Sara Bode is associate director of the Community Pediatrics Training Initiative at the American Academy of Pediatrics (AAP); deputy editor of Pediatric Care online, incoming chair of the AAP Council on School Health; and author of the AAP’s current interim school guidance, which was being finalized as we went to press. Bode spoke with Contemporary Pediatrics® about what the 2021-2022 school year will look like as some (but not all) restrictions become more relaxed around COVID-19 protocols.

What do you consider the biggest challenges right now as children prepare to return to school this fall?

Bode: First, just as a background statement, the Council on School Health and the AAP have always had a strong statement about the goal being to get kids back to in-person learning. We knew that remote learning was not going to be ideal for both academic learning and social and emotional health, and that is still our North Star. It remains our focus: to continue to help schools work through what they need to do for every student and do it safely.

I think the biggest challenges different communities across the country are facing is changing their mandates around mitigation measures in public around masking and distancing. It is thinking about what that means for students back in the school environment, because they’re a unique group, especially for kids less than 12 years, who, right now, aren’t eligible for vaccines, as well as for older children who have special health care needs and can’t get vaccinated or may be at risk. How do we do all in-person learning safely?

How do we get schools back to all in-person learning but still maintain a safe environment?

Bode: One of the biggest things, which has already changed from last year, was physical distancing. As an example, the Centers for Disease Control and Prevention (CDC) recommendations started with 6 ft of physical distancing between students, and our concern from the Council on School Health was: [Is] that really prohibitive? So many schools just were not able to maintain that, so we had already worked in our recommendations to maintain 3 ft to get kids back. The CDC amended their recommendations to 3 ft. From our perspective, we are going to continue to try to maintain that physical mitigation strategy of 3 ft to the greatest extent possible.

Now, that’s important because there are some schools that can’t even get back to all in-person learning with 3 ft distancing. So from a mitigation strategy, it means thinking about what other layers we can add in to help keep kids safe.

We have put schools in a really tough position because in some communities, outside of the school setting, all mandates have been lifted. For example, I’m from Ohio, where there now are no more masking mandates, and they’ve left it up to individual organizations to put those back into place. And I can tell you from just what I’ve seen over the summer that there aren’t very many locations putting that in place. What that means is families are not masking anywhere in public. But then, when their child starts back in school in the fall, we’re going to say, “You know what? Even though they’re not wearing a mask anywhere else, it’s really important for them to come to school and wear a mask.”

And that is so hard for school districts. I think we’re putting them in a tough position because they’re getting a lot of strong opinions on both sides from their community.

Any thoughts or guidance on school cafeterias regarding lunchtime?

Bode: When you take away some mitigation measures, then you have to make sure you’re maintaining others. Eating lunch is a high-risk activity because, vaccinated or not, everybody’s masks are off. Often children are sitting together at social times and lunchtime. I would say that if you have other times of the school day when it’s challenging to maintain that physical distance, you want to really look at your opportunities to make sure kids are distanced farther apart while they’re eating lunch. It’s use of creative spaces, whether that’s staying in the classrooms to eat or, if it’s not inclement weather, going outside, staggering lunchtimes, those kinds of things. Schools have done a great job of using barriers and other strategies to protect students during that mealtime, so that’s going to be important to look at that as a separate consideration.

It’s impossible to maintain distance during contact sports, such as soccer and football. What does that mean for school sports programs?

Bode: The practicality of those decisions is to maintain the mitigation measures to the greatest extent that they can. We are recommending, particularly for sports, that when they’re not doing the vigorous physical activity— for example, when they come off the field or are on the sideline, all standing in a group—it would be important for them to either socially distance or put on their masks. But when you’re outside and you’re running and actively playing a sport, you may not be able to wear a mask.

Again, this isn’t zero risk. It’s balancing the risks and benefits of each activity. It’s thinking about what are the highest-risk periods and putting those mitigation layers into place while still being allowed to have the sport and play.

Much has been written about children who have fallen behind because of remote access.

Bode: I think this is going to be our biggest ongoing issue and will take continuous vigilance over the next several years. It is not only academic loss; it is also social and emotional. As schools get back to full-time, in-person learning, there will be children that have been really cut off over the past year, from both a peer perspective and an academic perspective. We will really need to think about what support must be put into place for the academic year to help provide the resources for the different levels of groups that need to be identified, for reading skills, math skills, who needs that remediation work, etc—who is ready to move on to the next level. We need to continue to keep the spotlight on as schools need resources for that.

You simply may not be able to, with 1 teacher and 30 students, provide the level of support needed for each student based on their level of academic loss.

Do you think that will translate into bills being put before Congress?

Bode: Yes. This is going to take additional government resources. I think it’s going to take ongoing funding, and not just from the perspective of setting up safety protocols in the school and getting kids back to in-school learning. Once they are there, what support will be needed from a mental health perspective and other behavioral health support? This will really require boots-on-the-ground staff that can help with this and academic learning as well.

What is the best advice that you can give to pediatricians right now as they see children to ready them for the school year?

Bode: So many things! First of all, vaccination, if they’re eligible. If it’s a younger patient, less than 12 years old, there needs to be an open conversation with the family about that back to in-person learning. What does that mean for the rest of the family? Do other high-risk individuals live in the house and have they been vaccinated, so that they are providing that layer of support? Ask questions about what the child has done in the past year. Have they had any in-person learning, or was it all virtual? Not just did they participate, but how many days? What did their attendance look like with virtual learning? What do the parents think about where their child is at in terms of academic levels? Many of our students were on an individualized education plan previously that stopped during the pandemic. Discussion of this will be important. Pediatricians might also talk with the patient’s school personnel early, and work with the teachers to get them any services they need quickly, at the beginning of the school year.

It’s also working with families to talk about how stretched schools have been and supporting the schools in this matter. For pediatricians, that may mean reaching out to teachers more this year than they did in the past. This is all 1 team.