There are unanswered questions and concerns around the subject of compulsory mask-wearing in primary-age children at school. Wearing a face mask can result in increased air hunger and feelings of claustrophobia. Moreover, there are potentially serious long-term consequences for health that must be considered.
In April 2021, scientists in Germany published a comprehensive review of 178 clinical studies. Their article, “Is a Mask That Covers the Mouth and Nose Free from Undesirable Side Effects in Everyday Use and Free of Potential Hazards?” examines short and long-term effects of mask wearing in adults and children. It’s authors, Kai Kisielinski and colleagues, draw from the literature to explain in detail the challenges to breathing caused by mask wearing (surgical, disposable and fabric masks), and the potential impact this has on other systems in the body.
In terms of breathing, a mask increases the volume of dead space. This results in rebreathing of carbon dioxide (CO2), which causes breathing to speed up. When the breathing speeds up, breathing muscles must work harder, increasing oxygen demand and consumption. In essence, the mask throws breathing out of balance, increasing both the respiratory rate and heart rate. Any change to breathing is likely to be more pronounced in children with a tendency towards asthma, anxiety, or panic disorder — and it is not recommended that children with these conditions wear a mask at all (Goh et al., 2019). But for any child, fast, shallow breathing can activate a stress response, and prolonged wearing of a mask may lead to breathing pattern disorders including habitual mouth breathing.
The German review mentions “overall impaired cognitive abilities” and an impact on behavior, mood, thought and perception. Changes in levels of oxygen and carbon dioxide, it states, can cause “clinically relevant psychological and neurological effects.”
Fast, hard breathing not only causes confusion and tiredness. It impacts sleep quality, cognitive function, and anxiety states, and promotes open mouth breathing. When mouth breathing during childhood becomes habitual, it contributes to adverse effects on health into adulthood, including sometimes irreversible abnormalities to the growth of the face, teeth, and airways. Children who breathe through an open mouth are likely to experience cognitive and behavioral disorders and problems with memory, concentration, attention, and learning ability (Catalano 2018). Open mouth breathing also contributes to sleep disorders. Children with sleep-disordered breathing at the age of 8 years are 40% more likely to develop special educational needs (Boyd et al., 2013).
The German scientists explain that children are particularly vulnerable to the effects of mask wearing and may be more likely to be harmed by it. “It can be assumed,” say the authors, “that the potential adverse mask effects described for adults are all the more valid for children.”
Children have a higher metabolic oxygen demand than adults, and a greater susceptibility to hypoxia (low blood oxygen). They have smaller airways and experience more resistance to breathing. The review points out that the masks currently provided for children are adult masks, designed in a smaller size. They have not been tested or approved for children to use (Smart et al., 2020).
There are psychological concerns too. Masks cause fear in 46% of children (Forgie et al., 2009). An observational study of nearly 26,000 children identified problems from learning difficulties (38%) to headaches (53%), difficulty concentrating (50%) and “joylessness” (49%). A quarter of the children had new onset anxiety and others had nightmares. These issues were in addition to physical symptoms including cracked and bloodied lips, migraine attacks and impaired vision (Schwartz at al., 2021). In another study, fewer than 10% of mask wearing children surveyed had a stress level lower than 8 out of a possible 10 (Prousa et al., 2020).
Masks also block interpersonal and emotional communication. This negatively affects learning, and it deprives children of the positive effects of laughing, smiling and emotional mimicry (Spitzer et al., 2020).
The adverse changes caused by mask wearing are initially quite minor. But over long periods, repeated exposure will cause problems, just as repeated exposure to mouth breathing results in serious health and development issues, and untreated breathing pattern disorders lead to chronic health conditions. As Kisielinski and colleagues state, “Long-term disease-relevant consequences of masks are to be expected.”