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As many parts of the country have started to re-open, there is one question that pediatricians have been asked over and over again these last few weeks: “Is it safe to send my kid to daycare right now?”

I’ll be honest with you—I’ve dragged my feet on writing this article for a while. Why? Because I pride myself on being able to weed through complex medical issues and giving clear, concise answers. But to the question of whether it’s safe to send kids to daycare during COVID, the best, most honest answer we can currently give is:

Probably. Maybe. We think.

At issue is the challenge of trying to marry data that looks very reassuring with questions about applying that data to communities across the United States, some of which are currently seeing their COVID numbers skyrocketing upward.

And yet through it all, millions of parents are faced with the unfair burden of trying to figure out whether they can feel comfortable about daycare as their jobs begin calling them back to work—and for many, it’s not even a choice, but a necessity whether they feel comfortable with it or not.

So here is what we know so far—evidence on the safety of daycare for young kids, some practical challenges to that data, and things you’ll want to see your daycare doing if you do send your child in.

WHY WE THINK DAYCARE MAY BE SAFE FOR YOUNG KIDS

Our understanding of how children are affected by this virus and what their role is in spreading it has evolved over the last several months. This shift in thinking is the result of teams around the world compiling and analyzing data as it comes, plus the experiences of regions that have either reopened daycare and schools or never shut them down in the first place.

The result is a picture that leans toward suggesting that daycare is indeed safe for young kids.

So what’s led to that suggestion?

1. Kids May Be Less Susceptible to COVID-19 Infection

Something that had baffled scientists in the early months of the pandemic was the strange fact that children weren’t making up a significant portion of the people getting sick. Initially, the thought was that they must be more likely to have mild or no symptoms and, therefore, are less likely to get tested and recognized as being infected. Essentially, if a child doesn’t seem sick, we won’t know that she is. This is still thought to be true, but the numbers show that there’s likely more at play.

Looking at data from around the world, kids under 18 make up about 2% of the world’s cases of COVID-19 infections. In South Korea, kids under 9 were just 1% of cases, whereas kids 10-19 were over 5%. Random sampling in Iceland and parts of Italy found no cases in kids under 10. And research by the London School of Hygiene and Tropical Medicine has shown that people under the age of 20 are about half as likely to get infected as those over 20.

Why are so few kids getting sick? The current thought is that their cells simply don’t allow the virus in. COVID-19 latches onto a protein called ACE2—a protein present on many different cells in the human body—and uses it as a gateway into the cells. But children under 10 years old don’t have as much ACE2 on their cells as older kids and adults—making it harder for the virus to get in.

This doesn’t mean kids can’t get sick—it’s important to point that out, as some people have mistakenly claimed that kids are “immune,” which simply isn’t true. But the low prevalence of ACE2 in young kids is why Edmund Goossens, coordinator of the EU task force researching COVID-19, has suggested that kids under the age of 12 can safely go back to school and daycare.

2. Kids May Not Spread COVID-19 Very Much

When the pandemic first started to spread, we thought that the fact that kids were more likely to have mild or no symptoms meant that they were probably super-spreaders, silently getting the adults in their lives sick.

Now, however, we don’t think that’s likely the case. A study in Iceland found multiple examples of parents infecting kids, but only two examples of kids infecting their parents. And while France saw 70 new infections in schools within a week of their reopening, most of those were in adults who were believed to have gotten sick from someone at home, not from the students.

The result of all of this is the current belief that it’s much more likely that kids aren’t strong spreaders of COVID-19—and that instead, it’s adults who infect both kids and other adults.

3. Experiences at U.S. Daycares and Schools Abroad Have Been Positive

If children under 10 are both less susceptible to COVID-19 infection and less likely to spread it, then there shouldn’t be many outbreaks in primary schools or daycares—and on the most part, that’s what has been observed.

Brown University economist Emily Oster has been compiling data on child care centers and has so far found that only about 1% of daycare providers have turned up positive, and only 0.15% of children.

In New York City, the original epicenter of the epidemic in the United States, tens of thousands of children of essential workers continued to go to daycares run by the YMCA and the city’s Department of Education through the peak of the city’s infections. Both organizations reported to NPR that they experienced zero outbreaks—even as the virus raged across the city at the time.

And similar experiences have borne out abroad. Denmark, Austria, Norway, Finland, Singapore, Australia, New Zealand have reopened classrooms without outbreaks in schools or daycares. Areas of the world that have faced challenges reopening schools have primarily seen infections rise amongst middle and high schoolers, not as many amongst younger children.

WHY WE CAN’T COMPLETELY RULE OUT RISK

So with all of this reassuring data indicating that daycare is likely safe during the pandemic, why did I say my answer when asked is “Probably. Maybe. We think?”

The challenge lies in taking an interpretation of cold data to try and make a blanket statement meant to apply to a variety of real life situations.

These are the potential issues in doing so:

1. We Don’t Know If the Data We’re Using Is Applicable to the General U.S. Population Right Now

Perhaps the biggest challenge to some of the information we’re using is the question of how well it translates to your particular family’s situation right now—a time when some U.S. communities’ COVID numbers are fairly flat, while others are steadily picking up steam.

The first issue is that many of the countries that have successfully reopened schools and daycares have sophisticated contact tracing systems in place—something we don’t have on a grand scale here just yet. Essentially, contact tracing would impact daycares in that if someone in your household is exposed to someone else with COVID-19, then everyone in your household—including your daycare-aged child—would stay home until it’s clear that your family has either contracted the virus or not. In the successfully reopened countries, good contact tracing could, theoretically, have helped them limit spread in schools and daycares—and without equivalent contact tracing on board here, there is a chance that our daycare infection numbers might turn out to be different from those in Europe.

In addition to more centralized governments and good contact tracing, many of those same countries—if we were to make a broad generalization—also have cultures that prize following the rules for the greater good. Nearly half of all adults in Denmark, for example, ride bikes to work every day because it’s good for both the environment and the community. The polarization of the simple act of wearing a mask shows that we in the U.S. just aren’t quite there yet. And as a pediatrician, I routinely see young kids midday who were initially sent to daycare with a dose of Tylenol masking a fever they woke up with—something that can’t be tolerated during COVID, but that I worry would happen more often than it should.

Most importantly, those countries that successfully reopened did so when their rates of COVID-19 infection were relatively low. If infection rates are low in a community, rates of spread in a portion of that community—i.e., daycares—will likely be low, too. So in order to get a clear sense of how much kids in daycare may spread the virus, we’d need to see what happens in daycares where community infection rates are high.

So while the numbers from New York are reassuring, the picture in Texas—which barreled through reopening despite skyrocketing infection numbers—is looking fairly bleak. Between mid-May and July 6^th, cases in Texas daycares spiraled upward from 59 to 1,335, with one third of those cases occurring in children. And until Texas has good contact tracing protocols in place, it will remain unclear what portion of those new infections are from exposure at home versus daycare.

Emily Oster’s data is also quite reassuring, but she notes it has a potential flaw—that because the data is based only on those daycares who willingly responded to the surveys and is also unable to account for asymptomatic kids, it likely “somewhat understates COVID-19 cases.” Luckily, there is more detailed data on the way.

Ultimately, the data generally looks really good—good enough for most families to feel comfortable sending their kids—but we’re just not going to know how well all of this information translates to the average U.S. daycare until more daycares open.

2. The Safety of Adults Isn’t Discussed Enough in Daycare Conversations

The adult provider is an important, crucial component in daycares—and conversations about daycare safety tend to revolve only around the children.

Even if young kids may not be great spreaders of COVID-19, we know that adults are. This means that protocols must be in place to keep daycare providers healthy—for their own benefit, as well as that of the children and other adults at the daycare.

3. In Science, You Can Never Say Never

When it comes to assessing risk, it’s important to remember that “low risk” doesn’t mean “no risk.”

Just because kids under 10 are less susceptible to contracting COVID-19 doesn’t mean they can’t (in fact, as of July 1^st, kids under 10 were the fastest growing infected age group in Oregon). And just because they seem less likely to spread it doesn’t mean they can’t.

Many adults drive cars even though motor vehicle accidents are a leading cause of death in the United States. We balance the benefit we get with accepting some risk, and we try and minimize that risk even further by taking certain precautions, like wearing a seatbelt and stopping at stop signs.

The same is true with COVID and daycare. I can’t in good conscience tell you that there is absolutely no risk, but the data in areas with low transmission generally looks pretty good—and you can minimize that risk even further by making sure your daycare is taking smart precautions.

YOU’LL WANT YOUR DAYCARE TO TAKE THESE PRECAUTIONS

Daycare centers (and schools this fall) will be choosing from a buffet-style list of possible precautions and protocols. As fellow pediatrician Cara Natterson puts it: Think of it as like legs on a stool—the more legs a stool has, the less likely it is to tip over. So, the more safeguards a daycare takes, the better.

You’ll want to find out the specific plans that your daycare has made. Some daycares are posting their plans online, but leaving many sections vague (i.e., stating that the number of kids per class will be “per local government guidelines”) with the expectation that situations may change over time. But as a parent and pediatrician, I’d prefer to know their exact plans. For example, will they max out groupings of kids at the local government maximum, which may be as many as 8 or 10 or more? Or will they be keeping kids to groups of, say, 4? Those sorts of details will help you make the decision.

Ideal protocols will include:

• Pickup & dropoff outside the building—it might be no fun for little ones, but minimizing the number of adults stepping foot into the building will help minimize infections
• All adults will wear masks 100% of the day—adults are the major spreaders, not the kids
• It’s going to be a challenge for kids to wear a mask, but kids who are over 3 and able to do so should attempt to do so if possible
• Staff, parents, and children will be assessed for fever at drop off
• Parents should sign a daily affidavit stating that no one in the home is sick—I appreciate work requirements, but giving a child a dose of Tylenol in the morning and shipping her off to daycare just can’t be tolerated right now
• Small groupings of kids (4-6 or less would be ideal, but local recommendations may allow for higher numbers), and groups don’t inter-mingle
• Emphasis on good handwashing throughout the day
• As much outdoor time as possible—we know that transmission outdoors is lower than in enclosed spaces
• Unfortunately for staff, it’s best to have as little mingling between adult staff as possible
• Plans for closure or required absences/quarantine for kids and providers who are sick or have exposure to sick family members, as well as for kids and providers who were exposed to that child in the daycare. The details of how long they’ll need to be out are a little murky and may vary by local health department guidelines—this will also get hairy in the fall and winter when common childhood illnesses abound.

SO WHAT TO DO?

Every family’s blend of risks, benefits, and needs is unique right now, making it hard to give a blanket recommendation—which is part of why it’s taken me so long to approach this topic.

If you live in an area of the country that is seeing COVID numbers rapidly rising, or if your kids are fairly happy at home and you’re able to get your work done with them there—essentially, if there isn’t a strong need for your kids to go right now—it may simply be best to stay home. Texas is currently proving that without adequate contact tracing to prove that kids are getting sick from family exposure not from daycare, the spectre of risk at daycare remains, even if just for the adult providers.

But if your region is seeing COVID numbers flatlining or falling; if you or your kids are showing signs of mental health stresses with prolonged isolation; or if family dynamics, job requirements, or finances simply require that your kids be in daycare—then you can take comfort in knowing that the majority of the information we have so far points to daycare being low-risk for young kids.

This is a time steeped in uncertainty—about the course of the pandemic, the consequences of infection, the impact on our families. These uncertainties have made it difficult to know exactly how much risk there is and how much risk is worth taking.

But there are precautions we can take as families, that daycares can take as institutions, and that our governments can take to lead the way and help slow the spread and minimize any risk we and our kids might face.

In fact, the best way to eradicate any worries about transmission is for all of us to take the simplest of steps—wearing a mask in public, keeping physical distance from those not in our “circle,” simple handwashing—to put a major dent in how much virus is out there in the first place.

By taking wise steps, and by working together and for each other, then we can feel most confident about the health, safety, and well-being of our kids.

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Dr. Steve Silvestro is a pediatrician and consultant. He hosts The Child Repair Guide Podcast, and can be found on Instagram, YouTube, and Facebook.