How do you decide if children can play together again?


As some parts of the country "open up" and families venture beyond their households, parents are faced with hard decisions about what children can do. There are no official guidelines, so I asked smart and experienced pediatricians from around the country what questions they are getting from parents, and how they're answering them. Spoiler alert: There are no easy answers.

"I'm getting it every day in my office" said Dr. Sally Goza, the president of the American Academy of Pediatrics, who is a primary care private practice pediatrician in Fayetteville, Georgia. "I try to explain to parents, this virus is not gone, it's still here, we need to be smart in how we go about being around other people."

Despite the "novelty" of the virus, these dilemmas are not entirely new — this is what parents do: weigh risks, look at what the experts say, figure out where your own level of comfort is, and then make decisions that affect the health and safety of the people you love best.

Making these decisions is going to involve choosing other families you feel you can trust. "There's a certain amount of selecting out families with the same level of risk aversion," said Dr. David Rubin, director of PolicyLab at the Children's Hospital of Philadelphia.

"People are wondering how they sort of stick their toe in the water and try to re-engage outside of their homes," said Dr. Terri McFadden, associate professor of pediatrics at Emory School of Medicine and medical director for primary care at Hughes Spalding Hospital in Atlanta. "I'm getting that especially for teens — the teens feel invincible, they don't feel like they're in any danger at all, and they're itching to get out and interact with their peers.

Still, she said in an email, "I caution families to be very careful about potentially exposing their children or themselves to Covid-19 while infection rates remain high. This is especially true for high risk groups that have been disproportionately affected, which is many of my patients: African Americans, Hispanics and families with preexisting conditions or elderly caregivers."

If you are contemplating a play date, taking into account all these risks, you will need good communication with the other parents. "A start would be, hi, our kids have been asking about getting together, and as you know, this is a complicated conversation right now," said Dr. Dipesh Navsaria, an associate professor of pediatrics at the University of Wisconsin School of Medicine and Public Health. A parent could continue, "I wanted to start with an open conversation, see where you are, tell you where I am, and see if it's possible to send a consistent message to our kids."

And then you can get down to the details: indoors, outdoors, duration of contact, masks, food and drink, parental supervision to make sure that rules are observed. "I'm less worried about a parent or a business getting all the rules right, because we don't know what 'right' is," Navsaria said, "and more concerned about them being intentionally thoughtful."

It's not so different, he said, from the conversations that pediatricians advise parents to have with other parents about whether there are unsecured firearms in the house, or whether the pool is fully fenced and locked; it's basically a conversation about whether you feel your child is safe at someone else's home, in someone else's care.

Don't frame it so that the more restrictive parent is the bad guy, and try for an honest conversation that respects differences of opinion. Remember that other parents may have reasons you don't know about to be more wary of possible infections. That's what it means to present a consistent message to a child: This is about keeping everyone safe, and sometimes that means waiting a little longer. And if there's going to be a play date with limitations, make sure the child understands what those limitations are, and rehearse the possible activities.

Families should not feel pressure to change their rules, even if they are living in areas that are opening up. If there is a vulnerable adult — or child — in the home, they may want to be more strict, rather than less strict, as others relax their restrictions. And not all children — or adolescents — are necessarily pushing for those in-person social contacts. We need to give each other time, and treat each other gently.

Take it step by step, Goza said. Start with carefully chosen contacts, and don't jump right to large gatherings. "You spent all this time trying to isolate and social distance," she said. "You don't want to go out there and just blow it all." The parents she's talked to, she said, have been very conscientious, planning out social encounters with neighbors getting together outside for a barbecue.

Goza advised that parents encourage children to spend their time together outside, she said, to wear masks, to wash their hands regularly. Pools are probably relatively safe, she said, according to current thinking about transmission, but supervision is important, both because of water safety and to try to prevent kids from being too close together.

What about when family and friends disagree? "I say, if they don't wear masks, I would try not to be in an enclosed place," Goza said. "Wear a mask yourself, say, 'I respect your opinion but we feel like we want to keep a bit of distance.'"

To reduce risk, everyone's No. 1 piece of advice is that if there is going to be socializing, keep it outdoors as much as possible. Keep the time periods limited — maybe a short session outside in the afternoon, rather than a sleepover. Encourage hand-washing, send children with hand sanitizer, and yes, make it clear beforehand that masks are to be worn. If there's going to be a meal together, meaning that masks will come off, kids need to be sitting far enough apart.

But if you decide you're ready to relax your isolation, don't expect the impossible. Navsaria cautioned parents "not to expect 100% hand hygiene and proper mask use, because children are children, and even older kids that quote unquote should know better."

Rubin said, "It's a good moment for teaching kids individual responsibility." That includes asking older kids to be honest if they have relaxed the rules, which may mean, he said, that parents will want to practice some social distancing at home around adolescents who may be taking risks.

With adolescents, it's important to review your family stands on alcohol and other substance use, and the ways they can affect judgment, and to talk frankly about sex in the context of social distancing.

Talk to your children about why this all matters, Goza said. "Give them science so they can understand why it's so important, to protect them, protect their friend, protect their parents and grandparents and their friend's parents and grandparents."

"Not every lapse of self-protection activity is going to necessarily mean that the worst is going to happen," Navsaria said. "We need to teach and redirect and guide with kindness and compassion, including our own kids, because everyone is doing the best they can."

Pediatricians are also concerned that with children looking for summer recreation, but not supervised in camps or formal programs, there may be a higher risk of injuries, including bicycle-related accidents and trampoline mishaps, and especially drownings. No activities are completely risk-free, but taking precautions (bike helmets, locked gates around pools, proper adult supervision) and talking things through with your children can make everyone safer.

So here we all are, parents and pediatricians, trying to keep children as safe as possible, while letting them take some steps out into the world.

"Summer is going to be different," Goza said. "We just need to be kind to each other — people are going to have different ideas, and we need to try to be considerate about what other people think, knowing we have to do what's right for our families."

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