In Singapore and many other countries around the world, it's common for young children to wear masks against Covid-19 – but aside from the protection they provide against the virus, might they pose a risk to their longer-term development?

Like many children his age, three-year-old Eshan Evans is energetic and boisterous. But as soon as he has to put on a face mask at school, something changes. "You can see he's a different boy, much tamer and quieter," says his mother Herne.

In Singapore, where Eshan and his family live, children aged six and above are legally required to wear masks. But many kindergartens and pre-schools also strongly encourage the practice for younger children. It means that for roughly eight hours every weekday, except while eating, drinking, or napping, Eshan wears a disposable three-ply mask. 

The moment he's let out, however, he rips off his mask, shoving it into his pocket or thrusting into his grandmother's hands. Once, on a particularly bad day in July, he threw his mask on the ground and ran out the school gates.

"He hates it," says his mother, who doesn't make her son wear a mask outside of school. "I have nothing against masks... but we don't want to force it on him and know he's uncomfortable."

The decision of whether to mask young children is one that many parents and regulators around the world are facing as they try to prevent new waves of Covid-19, while also allowing children to develop, socialise and thrive emotionally. 

From a regulatory standpoint, as of early October, countries fall largely into three camps. Singapore and European countries such as France and Italy recommend masking up from the age of six. This is in line the World Health Organization's guidelines, which recommend that children over six wear masks in certain circumstances, for example when there is widespread transmission in their area. Some only apply the rule to specific indoor settings, such as school.  

Other regulatory bodies, including the Centers for Disease Control and Prevention in the United States, recommend mask-wearing for those aged two and older. And then there are those countries that have dropped requirements for in-classroom face coverings – for instance, in the UK, neither children nor their teachers are advised to wear masks to school.

The only globally accepted consensus is that babies and children under two should not wear masks, due to the risk of suffocation.

"The age limit for the use of masks by children is not yet a scientific definition," says Adamos Hadjipanayis, president of the European Academy of Paediatrics.

There have been relatively few studies investigating mask-wearing in children, due to ethical and logistical challenges. Those few studies, which focused on the physical impact of masks on breathing, did not find any harmful effects. But the debate around the wider pros and cons has been heated.

Proponents of mask-wearing argue that masks protect the wearer and those around them from Covid-19, and that the risk factors of the disease for young children should not be overlooked. Most countries do not vaccinate children under 12, or only in exceptional cases, which leaves them comparatively exposed. Serious cases of Covid-19 in young children are still relatively rare – according to a large UK study published this July, roughly one in 50,000 children with Covid end up in intensive care, and two in a million die. But the rapidly spreading Delta variant, which is at least twice as contagious compared with previous strains, is putting pressure on countries to contain and prevent outbreaks, including among children.

"Delta makes the situation far worse," says Deepti Gurdasani, a clinical epidemiologist at Queen Mary University of London. "Post-Delta, we're seeing a lot of outbreaks in schools all over the world."

The good news is that mask-wearing has been linked to lower rates of Covid-19 in schools. For example, in the US state of North Carolina, where masking is compulsory for students above six, schools reported extremely low transmission rates – although more than 7,000 children and staff attended school while carrying the virus between March and June 2021, only 363 Covid-19 cases were found to have been caused as a result.

In another survey involving 169 elementary schools in Georgia, researchers found that when teachers and staff were required to wear masks, reported Covid-19 cases were 37% lower compared to schools without a mask mandate.

"Masks provide an additional layer of protection against Covid-19 and have been shown to decrease the risk of getting the disease," says Annabelle de St. Maurice, an assistant professor of paediatrics at the University of California, Los Angeles. 

Of course, masking may not solely be responsible for reducing transmission. Other protective factors such as "personal hand hygiene, safe distancing, and whether an area is well-ventilated may play a part," says Mark Ng, an infectious disease specialist at Singhealth Polyclinics in Singapore.

But masks are an efficient and effective preventive measure, which is probably why many parents of young children in Singapore still stuck to it even after the island state raised the legal mask-wearing age to six last September. The initial ruling, imposed half a year earlier, required children over two to be masked. (Read more about how face masks reduce transmission.)

For Mimi Zainal, mother to two children aged three and five years old, the change in ruling made no difference. "I prefer the kids to wear masks... it gives me a peace of mind to know they are more protected," she says. 

The children struggled with wearing masks at first, Zainal admits, but she and her husband "hyped it up" into a fun activity that the family would do together before heading out. She bought a variety of patterns – astronauts, unicorns, and other colourful prints – for the children to choose from. Within a matter of weeks, the kids got used to their masks, she says.

Some argue that even the jolliest pattern can't change one fundamental problem with masks: they hide half the face, and may make it harder to decode people's moods and feelings.

Children begin to recognise basic emotions – happiness, sadness, fear, anger, and so on – from as early as 10 months of age, with development peaking around five or six years, says Kang Lee, a developmental psychologist at the University of Toronto.

Being able to see faces in their entirety is a key part of such development and masking can hinder that process, he says: "We learn emotions mostly through the face." (Read more about how the pandemic might be changing the world's children.)  

But other experts are skeptical of how much of an impediment masks really are. "Faces aren't necessarily the only or the most important cue to someone else's emotions," says Ashley Ruba, a postdoctoral researcher at the University of Wisconsin-Madison's Child Emotion Lab. There are other vital signals too, she says, "things like tone of voice, body posture, and overall social situation".

A 2012 study found that children under the age of nine could still correctly pinpoint the emotions of the faces they were viewing, even if they couldn't see their mouths. And in an experiment conducted last year, Ruba and her colleague discovered that while masks slightly impaired children's ability to recognise sadness, anger, and fear, the overall effect was the same with sunglasses.

"This is another piece of evidence to suggest that masks may not have such a negative impact on children's emotional development," she says. After all, people usually don't worry about wearing sunglasses around kids.

Eva Chen, a developmental psychologist at the Hong Kong University of Science and Technology, points out that in any case, people are not wearing masks or sunglasses all the time: "So children are not 100% deprived of facial information." And in places like China, South Korea, and Japan, where masking was commonplace even before the pandemic struck, children have developed normally, she adds.

One potentially greater area of concern may be the impact of masks on children's language development. Here, experts too are somewhat divided in their views, but they agree on one thing: there's a lot parents can do to bridge any budding problems.

"Children learn through observation," says Lynette Teo, who teaches childhood language and literacy development at Singapore's Ngee Ann Polytechnic. "They look at the movement of the mouth, and see the lips and tongue move. If you just think about the 'th' sound, the placement of the tongue is so important."

But parents shouldn't worry too much, says Lee. "Kids are very adaptable to the environment. If one channel is blocked, they will go to another channel." To help kids understand, he suggests teachers and parents enhance their speech, posture, body movement and gestures when speaking with them.

The situation for children with special needs is different, however, says Stephen Camarata, a professor of hearing and speech sciences at Vanderbilt University in Tennessee, who works extensively with such kids. "Children with disabilities, especially hearing loss, use facial features to fill in the information they're not hearing," he says. "They really need that visual information to understand what you're saying. With masks on, they're just not getting access to those cues."

He also expects masks to generally make it harder for young children to learn new words: "In the short term, in terms of comprehending new words and vocabulary, [masks are] going to have an attenuating effect."      

Zainal, the Singaporean mother of two, noticed such a potential lag in her own son, but was able to solve through additional support. Worried that the five-year-old "was a bit slow in learning his phonics," she sent him for extra classes at a tuition centre earlier this year. "I found that even though teachers had masks on, he was still able to pick up the sounds and learn."

Tammy Lim, a consultant with the Child Development Unit at Singapore's National University Hospital, agrees. She highlights how a local study found that two-year-olds were still able to learn and recognise words even when spoken from behind a mask. In her view, the impact of masks on children is negligible compared to the other ways in which Covid-19 has disrupted their lives. She's more worried about how increased screen time, for example, has displaced exercise, playtime, and other activities. Already, her unit has seen an increase in young patients with developmental delays and behavioural issues, which she partly ascribes to the lack of opportunities for free play and socialising.

By comparison, the lasting effects of masking, if any, may be trivial. "In the long run, I don't see any negative psychological effects on children," says Lee.

Chen takes a similar view. "Kids acclimatise surprisingly easily," she says. If parents are worried, she suggests the best solution is to spend as much time as possible with their kids. "There's plenty of research to show that it's really important to have a child feel securely attached to their parents – to have their parents listen to them and reflect their emotions back to them, and to communicate extensively with one another."

Creating those warm family moments may be the best way to weather the upheaval of pandemic-induced rules and disruptions.

For Zainal, that involved coming up with creative ways for her kids to have fun at home, such as picnicking on the balcony, having an indoor scavenger hunt, and doing weekly craft activities. Masks are annoying, she says, but there's still fun to be had indoors. And when they do venture out, masks provide "a sense of assurance to know that the kids are at least protected in a way, and can continue going to school and interacting with their friends".

BBC

More about: facemasks