Flying with Kids: Mask Selection and Risk Mitigation

With vaccinations on the rise, so are vacations and air travel. Many families are contemplating plans that involve flying with kids. This post presents mask information and risk management ideas related to flying with children. First we discuss how to select children’s face masks. Then we focus our attention on transmission risks specific to air travel, and the corresponding mitigation strategies.

Outline

Part 1: Masking Up Kids for Air Travel
Part 2: Risk Mitigation Strategies for Air Travel
Conclusion

The COVID-19 situation and each country’s travel guidelines will continue to change. Do check for the latest updates as you plan your travels. When planning your travel, check for:

Travel Advisories: Refer to the most up-to-date travel requirements and guidelines from both your local and destination city/country (e.g. US, Canada, UK). At the time of this writing, many countries continue to have strict travel requirements. In the United States, the CDC recommends delaying travel until you can get fully vaccinated, and still considers air travel a risk for COVID-19 transmission. CDC suggests safer travel ideas.
Masking Requirements: For example, the Centers for Disease Control and Prevention (CDC) issued an order on January 29, 2021 requiring masks for travelers on conveyances (e.g. airplane, ships, ferries, trains, subways, buses, taxis, ride-shares) and at public transportation hubs (e.g., airports, bus or ferry terminals, train or subway stations, seaports, ports of entry). On May 16, 2021 they clarified that even people that are fully vaccinated must continue masking on conveyances and at transportation hubs. Children under age 2 are exempt.
Airline requirements: Check with individual airlines for their minimum mask requirements.
Airport requirements: Check local and destination airport requirements.

Part 1: Masking Up Kids for Air Travel

Regardless of activity, masking must follow the golden rules of fit, filtration, and breathability. However, there are additional considerations when masking up children for air travel.

Illustration of a see-saw balancing fit, filtration, and breathability — **Figure 1**. A good mask must balance between fit, filtration, and breathability.

The best mask for children is the one they will keep on their face for the duration of the trip. Prior to the trip, help your child practice wearing the selected mask. Not only will it help your child gain confidence in wearing the mask, it will help you identify and address issues ahead of time–for example, adjusting ear loops, fixing the fit with ear loop extenders, figuring out the optimal way to wear long hair without interfering with the mask…etc.

When traveling, plan at least one mask every 4 hours, with extras to spare in case of mishaps such as broken straps and soiled masks. Change out masks when they get wet.

7 General Considerations for Masks for Kids

Maker Mask’s blog post “Masks for Children During the COVID-19 Pandemic” details special considerations for children’s masks which are summarized in the box below.

1) Select a proper child-size fit.

2) Use a nose wire for better fit and to reduce fogging up glasses.

3) Ensure breathability when choosing mask and mask materials. Compared to adults, children’s developing lungs breathe in a larger volume of air per body weight per day. A breathable mask is necessary to accommodate this higher respiratory rate.

4) Anyone who cannot remove a mask unassisted (e.g. infants and children under 2 years of age) should not wear a mask, as it may increase the risk of suffocation.

5) Use ear loops (instead of head ties) for very young children to help avoid potential strangulation hazards. Ear loop extenders, also called ear savers, can be used for comfort and to improve fit.

6) Children who are considered high-risk or severely immunocompromised are encouraged to wear a well-fitted medical mask (or similarly high performance mask) to provide the strongest filtration while maintaining breathability. [American Academy of Pediatrics (AAP)]

7) Avoid masks with valves.

Consider upgrading to a high performance children’s mask to further reduce COVID-19 exposure risk.

High Performance Children’s Masks for Air Travel (N95s, KF94s, and KN95s)

A high performance mask is one that provides high filtration efficiency while remaining breathable. Wearing a high performance mask not only protects others from our respiratory droplets, it can also protect the wearer from others’ respiratory droplets. Most importantly, a high performance mask must fit well on the face to achieve its filtration potential.

Beware that many unsafe masks are marketed and sold to the public as high performance masks. When selecting disposable high performance masks consider the 3 key considerations proposed by N95Decon in their informational report (see Section 3, page 6):

Stay with well-established, conventional designs
Select masks with credible test reports for filtration and breathability
Shop from reputable, authorized dealers.

Deeper Dive: Mask Designations

It can be very confusing for consumers trying to decipher the different FDA/NIOSH mask designations. Let’s review some of these terminologies.

“NIOSH does NOT approve any type of respiratory protection for children.” However, they maintain a list of NIOSH-approved respirators for adults. In cases where NIOSH-approved respirators are not available, the FDA maintains a list of imported non-NIOSH approved respirators for adults for consideration.
The FDA does NOT approve medical masks or respirators for adults or children. So if any mask claims to be “FDA-approved”, that should be a warning sign.
The FDA does regulate pediatric masks and maintains a list of children’s masks that have been “FDA-cleared” or “FDA-listed”. These masks are listed in the FDA device database as “pediatric/child facemasks” under the Product Code: OXZ (click here to for search the FDA’s list of child facemasks using the OXZ product code). The table below includes select examples of “FDA-Listed” children’s masks (manufactured in North America) from the FDA’s database along with the testing performance listed on the manufacturer’s website:

FDA-Listed Pediatric Masks*	Ages	Style	BFE (3um)	PFE (0.1um)	Breathability (mm H2O/cm2)
Halyard Child’s Mask (USA)	4-12	Pleated	≥ 98%	≥ 99%	< 2.0
Armbrust Child’s Mask (USA)	Not specified	Pleated	≥ 99%	≥ 99%	< 5.0**
Medicom Pediatric Mask (Canada and USA): ASTM F2101 (Level 1)	4-12	Pleated	≥ 98%	≥ 99%	< 5.0
Lutema Kids M95c (USA)***	< 12	Fitted	99.9%	99.8%	Tested using a different metric
Lutema Kids M3PFMC (USA) : ASTM F2101 (Level 3)***	4 – 14	Pleated	99.9%	99.8%	4.8
* Select North American Mask Manufacturers listed in the FDA’s “Establishment Registration and Device Listing” database for pediatric/child mask (Product Code: OXZ) Armbrust includes this testing information for their adult masks at: https://www.armbrustusa.com/pages/surgical-mask-lab-results * Additional testing data available on manufacturer’s website

Based on these criteria, consider the following disposable high performance masks for children:

N95: Any valveless NIOSH-approved (U.S.) respirator (consider for adolescents only; not available in children’s sizes)
KF94: Any Korean-made KF94 or higher-class respirator (children’s sizes available)
KN95 and FFP2: Carefully evaluated KN95 and FFP2 or higher respirators (children’s sizes available)

Each of these styles will be discussed in detail below. If none of these options work for your child, consider disposable medical masks (e.g. surgical and procedural style masks) or custom-made reusable cloth masks with high performing materials, also discussed below.

N95 (Good Quality Control, Consider for Adolescents only). A NIOSH-approved N95 respirator filters 95% of 0.3 micron particles. An N95 has undergone rigorous inspection and certification set by the National Institute for Occupational Safety and Health (NIOSH). N95’s are not manufactured for children, neither are they recommended for young children due to the extremely tight fit on the face which can cause discomfort and strangulation hazard. Some N95s come in different sizes, and size small may fit adolescents who can safely and correctly follow donning (put on) and doffing (take off) procedures.

Note: N95’s are important Personal Protective Equipment (PPE) for healthcare workers and front line workers in high risk settings–only purchase from retailers that prioritize distribution to healthcare workers or vulnerable populations.
3M clearly stated that their respirators (P2 or N95 models) are not manufactured nor tested for children’s use. If parents decide to use respirators on their children, they should accept the associated risks.

Deeper Dive: Studies on N95 Use and Kids

From existing studies, no adverse physiological effects were found in children wearing masks or N95-like respirators. However, evidence-based studies on the impact of face masks on children are limited.

Eberhart, 2021 This mini-review only found two studies on masks for children. Goh et al, 2019 and Smart et al, 2020. However, both were limited studies:
- Goh et al., 2019 showed that healthy 7-14 year old children did not experience any harmful physical effects wearing N95 respirators while performing daily activities like reading and brisk walking, based on physiological data including heart rate, respiratory rate, oxygen and carbon dioxide levels. This study was limited in that the duration of these activities were short (5 minutes each), therefore no conclusion on the long term effects can be reached.
- Smart et al., 2020 assessed the wearability of three different N95-filtration level masks on children aged 8-11 years. This limited study did not measure physiological parameters, and only reported subjective reviews from the participants. When the children were running, no subjective impact on breathing was reported. The main complaint from the participants was feeling hot when wearing the mask.
Holm et al., 2021 This narrative review focused on the effects of wildfire smoke on children, and included reviews of the use of respirators/masks by children. Based on various masks and N95 studies on adults, there is no evidence of adverse physiological effects. They conclude, “Nothing about pediatric physiology would make one concerned that children are at higher risk than adults for adverse cardiopulmonary effects. Thus, in individuals capable of removing a respirator should they get uncomfortable, concerns over physiologic effects should not prevent the general public from using respirators.” Fitting respirators on children may be difficult due to variation in facial sizes. However, adolescence face sizes are within the range of adult size respirators so fit for adolescents is less likely to be an issue.
Van de Sande et al, 2008 showed that adult-sized N95 respirators were effective in filtering particles for children ages 5-11, despite imperfect fit.

KF94 (Good Quality Control, Comfortable, Children’s Sizes). KF94 combines the comfort and breathability of a lightweight structured mask with high filtration capability of/near an N95. South Korea’s Ministry of Food and Drug Safety rigorously tests and oversees KF94’s manufacturing and distribution. KF94 comes in various children’s sizes. The 3-dimensional shape of a KF94 provides plenty of mouth space and is comfortable for extended wear. KF94 typically comes in ear loops instead of head straps. To improve the seal around the face, consider adding an ear loop extender (ear saver) to secure the ear loops behind the head.

Figure 2 shows a 10 year old wearing a KM’s Dr. Puri KF94 size small. In the left photos, the KF94 was worn without an ear loop extender. There is a noticeable gap around the nose and on the side cheek. In the right photo, an ear loop extender is used to tie the ear loops behind the head, anchored by a ponytail, removing the nose gap and side cheek gap, and significantly improving the fit.

Child wearing a KF94 mask — **Figure 2**. **Modifications on Dr. Puri KF94 (size small) to improve fit.** This Dr. Puri KF94 is selected based on the three considerations discussed above: 1) KF94 is a well established design. 2) This mask has credible test reports for filtration and breathability that are verified by other sources, including the South Korean government’s rigorous KF94 certification and distribution control, a test report by CDC’s National Personal Protective Technology Laboratory (NPPTL), and a review and test by US mask manufacturer Armbrust. 3) This mask is purchased directly from the manufacturer’s US distributor KM.

KN95 (Beware of Quality Control, Comfortable, Children’s Sizes). A KN95 mask is a cross between a respirator and a face mask that meets the KN95 (GB2626-2019) standard regulated by the Chinese government. KN95 comes in children’s sizes. Unfortunately, quality control for KN95 does not appear to be uniform, and NIOSH reported that some KN95s might not meet the actual KN95 standard. During the pandemic, the FDA granted Emergency Use Authorization to some of these KN95 respirators/masks listed in the FDA EUA Appendix A. Due to quality concerns, only shop for KN95s from this FDA EUA list, and only from reputable, authorized dealers. Additional concerns for using this FDA EUA list:

A mask must be searched under the manufacturer’s name, not the brand name.
Often retailers only list the brand name in their online product description, not the manufacturer.
It is not uncommon for a given brand to use different manufacturers for the adult size mask and the child size mask. In that case, even if the adult size mask is listed on the FDA EUA list, the child size mask may not.
Some of the more reliable KN95 brands do not come in children’s sizes.

Because of the complexity in searching for a reliable KN95, some families prefer KF94 for children’s masks.

Medical Masks (Loose Fitting, Children’s Sizes)

If you cannot locate a N95, KF94, or KN95 that fits your child, consider a disposable child’s size medical mask (surgical and procedural style masks). Look for a medical mask with ASTM labeling to ensure it meets the minimum criteria for breathability and filtration set by the ASTM F2100 standard. Unlike an N95, KF94, or KN95, medical masks are not designed for a tight seal around the face. This can result in a significant drop in its effectiveness for filtration during use. The Clapp et al study and the CDC guidance show that upon slight modifications, filtration improves for adults. The following modifications can be adapted for children:

Ear loop extender (ear saver): By securing the ear loops to the back of the head through an ear loop extender, or even a hair clip, the mask can be sealed tighter to the face. Leakage around the nose is very common even upon using an ear loop extender. To further improve seal, consider tying up long hair into a high ponytail and securing the ear loops + ear loop extenders above the ponytail for a better angle and leverage.
Twist and Tuck plus ear loop extender: This method uses a slightly wider mask to create more space between the mask and the mouth. Twist the ear loops before securing them behind the head with an ear loop extender. Tuck extra fabric on the side of the mask to remove side gaps. Tucks become undone easily with movements–consider securing the tucks with stitches ahead of time.
Double masking is not recommended for children due to breathability concerns.
Mask fit considerations: Medical masks are available in children’s sizes. Medical masks vary in their construction and fit. It may take trial and error to get to the right fit. Moreover, how well a medical mask fits depends on the child’s facial structure. On some, even with modifications, the mask may gap and slip. On others, the pleated style of the mask creates very little space between the mask and the mouth. This may result in discomfort, and a child may end up chewing the mask which creates a transmission pathway for pathogens.

Figure 3 shows a 10 year old wearing an Armbrust medical face mask in child size (blue) and in adult size (light gray). In the left photo, the child size mask was worn using ear loops, with significant gaps observed all around the edges. In the middle photo, an ear loop extender was used to secure the ear loops behind the head, anchored by a ponytail, resulting in an improved fit with minimal gaps on the side and around the nose. On the righthand photo, a wider mask (adult size) was used with the twist and tuck modification along with an ear loop extender, creating more mouth room while minimizing gaps around the edges. The subject reported the child and adult masks with these modifications were comfortable and breathable.

Child wearing a medical style mask — **Figure 3.** **Modifications on Armbrust’s Child Medical Mask to improve fit.** This Armbrust child size medical face mask was selected based on the three considerations discussed above: 1) The surgical style is a well established design. 2) This mask has credible test reports for filtration and breathability. It has gained the ASTM F2100 Level 3 certification. It is USA made and FDA listed. It was also independently tested by trusted third party labs. 3) This mask is purchased directly from the manufacturer’s website.

Deeper Dive: Studies on Medical Masks and Kids

From limited evidence-based studies on pediatric face mask use, no adverse physiological effects were found in children wearing masks.

Lubrano, et al., 2021 This study found that the use of surgical face masks among children aged 4 months to 12 years did not affect their oxygen level, and was not associated with episodes of oxygen desaturation or the development of clinical signs of respiratory distress. The limitation of this study was that children were only wearing masks for 30 minutes, plus 12 minutes of walking for children older than 24 months.

Reusable Children’s Cloth Masks with High Performing Materials

If you cannot find any high performance masks that fit well and comfortably on your child, consider a fabric mask made of high performing materials, such as spunbound non-woven polypropylene (NWPP), which balances breathability and filtration. Maker Mask has tested two fabric mask combinations that have passed the ASTM F3502 Barrier Face Covering standard:

Mask with 3 layers of spunbound nonwoven polypropylene (NWPP x 3)
Mask with a 3-layer combination of cotton and spunbound NWPP (cotton-NWPP-cotton)

Figure 4 shows a 10 year old wearing two different styles of custom-made fabric masks, both of which were tied with elastics that go behind the crown of the head and the neck, creating a very comfortable and secure tight fit, with minimal gap all around. Both were constructed with 2 layers of 68 gsm NWPP and an innermost layer of quilting cotton, adopted from the World Health Organization (WHO)’s fabric mask recommendation. This exact fabric combination was not included in the Maker Mask testing, but it could be deduced from the test report that the filtration and breathability would be somewhere in between those two tested combinations, implying that this combination would likely pass the ASTM F3502 Barrier Face Covering standard.

Photo of a child wearing custom-made fabric masks — **Figure 4.** **Custom-made mask with high performing materials, head strap secure fit.** Custom 1 source: Sophie Passmore 3D/Boxy NWPP Mask. (Size: As shown in the video). Custom 2 source: Iris Luckhaus’ Hybrid Cloth Mask. (Size: Width XS and height S).

Part 2: Risk Mitigation Strategies for Air Travel

While wearing a high performance mask is helpful in reducing transmission, it is most effective when combined with other mitigation strategies. In this section, we will review the COVID-19 transmission risks associated with air travel, and investigate the corresponding mitigation strategies.

Virologist Ian M. Mackay suggested a layered approach to risk mitigation known as the Swiss Cheese Respiratory Virus Pandemic Defence. While each layer alone is insufficient (it has holes) the combined effect of many layers (masks, distancing, etc.) results in a considerable reduction of risk.

The Swiss Cheese Model of Disease Transmission — **Figure 5. Swiss Cheese Model. Source**

Is the Airport/Airplane a High Risk Environment?

A common flying-related question is whether the airport and the airplane are high risk environments. The answer is nuanced.

Studies have shown that airports and airlines have adopted layered risk mitigation strategies to reduce COVID-19 transmission on the aircraft and in the airports. Most aircraft are designed to effectively maintain clean air through the use of HEPA filters, mixing in fresh outside air, vertical top-to-bottom airflow, and fast cabin air exchange rate. A study stated that airports have been proactive in implementing layered mitigation measures, including interventions that address ventilation, disinfection, cleaning, face mask usage, hand hygiene, and physical distancing. Combined together, these measures contribute to the reduction of COVID-19 transmission.

However, these mitigation strategies have limitations (swiss cheese with holes). For example, the HEPA ventilation system is often not running during boarding/deplaning, and smaller regional aircraft may not be equipped with a HEPA ventilation system. Many airlines are slowly relaxing back to pre-pandemic protocols. Furthermore, passengers could be unmasked for an extended amount of time, and you have no control over the behaviors of other passengers.

A recent COVID-19 outbreak at the Singapore Changi Airport serves as a reminder that despite all these mitigation strategies, COVID-19 transmission is a possibility during air travel, especially in vulnerable spots like the food court where people are unmasked. This airport outbreak began with a fully vaccinated worker who was believed to have contracted the more transmissible Indian variant B.1.617 virus from travelers, and subsequently transmitted to other co-workers and passengers in the food court. The airport responded by imposing stricter mitigation strategies

Deeper Dive: Studies on Airport/Airline Safety

The Aviation Public Health Initiative (APHI) study examined current aircraft, airline, and airport practices and their impact on public health during the COVID-19 pandemic. Phase 1 of the study found that the layered approach of Non-Pharmaceutical Interventions (NPI) instituted on commercial aircrafts are effective in diluting and removing pathogens, and in combination with face masks, results in low COVID-19 transmission risk on an aircraft. Phase 2 of the study concluded that airports have been proactive in implementing layered mitigation measures, which significantly contribute to reduction of COVID-19 transmission in airports.

An article from MIT Medical summarized how aircraft designs are effective in achieving good air quality. Cabin air is exchanged every two to four minutes. Vertical airflow from overhead vents to floor-level intakes reduces row-to-row air exchange. In addition, commercial aircrafts use HEPA (high-efficiency particulate air) filters with 99.97% efficiency and mix the filtered air with fresh outside air before sending it back into the cabin. The article recommended a few tips:

1) Window seats reduce exposure paths.

2) Face coverings reduce transmission risk.

3) Even with all the precautions, a relatively short domestic flight “still carries moderate risks and should not be undertaken lightly.”

Bielecki, et al., 2020 provided a narrative review regarding air travel and COVID-19 prevention. Risk of in-flight transmission is considered to be very low, estimated at one case per 27 million travellers. Despite high-efficiency filtering on aircrafts, there is some evidence that passengers within two rows of an infected passenger are at higher risk. Given the difficulty of airborne infection transmission in-flight because of the efficient HEPA ventilation systems, contact with contaminated surfaces of infected person when boarding, moving, or deplaning may play a critical role in inflight transmission.

What Can You Do to Reduce Risk?

Given the limitations of the mitigation strategies implemented on the airplane and in the airport, travelers should incorporate additional mitigation layers to further reduce risk (more slices of cheese). We will use the Bazant et al., 2021 study to identify factors that affect indoor transmission risk, and recommend corresponding mitigation strategies.

Bazant et al., 2021 presented a theoretical model to quantitatively assess COVID-19 airborne transmission risks in indoor settings such as airports and airplanes. The paper and the accompanying interactive tool COVID-19 Indoor Safety Guideline provide insight on how indoor transmission risk is linked to exposure time, occupancy, volume of the indoor space, ventilation and filtration rate, face-mask usage, respiratory activities, and risk tolerance.

To limit COVID-19 exposure during air travel, these are the factors from Bazant’s model that are within the passenger’s control:

Vaccination: By waiting until you are fully vaccinated before traveling, you can withstand a much higher risk tolerance for COVID-19 transmission. This is a very powerful layer of risk mitigation (CDC Science Brief, Table 2).
Limit exposure time: If possible, plan short trips and limit stops/layovers. Choose a window seat to reduce exposure to passengers. Avoid high exposure areas in the airport (e.g., food courts, crowded areas), and look for quiet corners or outdoor rest areas. When boarding, get seated as soon as possible and limit movement around the cabin. Limit overhead bin luggage to reduce standing time. When deplaning, stay seated until it is time to leave.
Face-mask usage: Select a high performance mask that fits well. Limit unnecessary eating and drinking to reduce unmasked time.
Occupancy: You may be able to minimize crowds by picking a less busy airport or quieter time of day to travel.
Ventilation and filtration rate: If possible, choose larger commercial aircraft with good HEPA ventilation systems. On the airplane, switch the overhead air vent to maximum to direct airflow vertically downward to reduce row-to-row air exchange.
Respiratory activities: Limit conversations with passengers around you to minimize respiratory droplets produced by both parties. Talking, especially loud talking, produces more respiratory droplets than breathing only.

Special Considerations for Kids

Keep all the mitigation strategies in mind when customizing your travel procedures to incorporate the children’s needs. Here are some child-friendly suggestions to get you started:

Encouragement: Traveling is exciting but adhering to new procedures could be stressful. Plan for fun and creative ways to encourage the children’s cooperation–for example, practice ahead of time, create games and rhymes for these procedures, model behaviors, practice with a favorite doll, add a fun small sticker to the side of the mask that doesn’t affect airflow, engage them with travel games/puzzle.
Mask Fit Check: Help children check that the mask is fitting properly on the face, fully covering the nose and mouth, and with no gap on the sides. Create a game/rhyme out of mask fit checks.
Brief Mask Breaks: Children may need brief mask breaks. Plan for safe moments and locations to incorporate these short breaks—for example, in a quiet corner in the airport standing under the air vent, or outdoor while waiting for transit.
Snack/Drink Procedure: Minimize unmasked time by limiting the frequency of drinking and eating. Use a water bottle with straw to minimize mask disruption. Pack neat and easy-to-consume snacks to minimize unmasked time. Wash/sanitize hands thoroughly before removing the mask. Place the removed mask in a clean bag to prevent contamination from other surfaces. After snacking, put the mask back on and sanitize hands again.
Sanitize surfaces: Current studies suggest that fomite (surface) is unlikely the main mode of transmission. However, it is a good practice to further reduce risk by wiping down surfaces that children may touch such as seats, seat belt, armrest, seat control buttons, overhead controls, TV screen, seat tray, bathroom surfaces…etc.

By implementing these mitigation strategies, it is like adding more slices of swiss cheese into the Swiss Cheese Model to further reduce COVID-19 risk.

Conclusion

Inevitably, air travel comes with COVID-19 exposure risks as we mingle with other travelers in indoor spaces for extended amounts of time. In this post, we offered tips on selecting high performance children’s masks as one of the mitigation measures. In addition, we evaluated transmission risk involved in air travel, and risk mitigation strategies. Families should consult local and destination updates when planning their travel.

Plan wisely. Be safe. And bon voyage (when the time is right)!

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Flying with Kids: Mask Selection and Risk Mitigation