We have absolutely no idea whether putting masks on kids is net helpful or harmful, and here’s why.

Dr. Vinay Prasad is a UCSF heme/onc doc who specializes in clinical trials and medical decision-making. He is a regular on the show, check out all our episodes here.


Full Transcript Below

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– [Zubin] Dr. Vinay Prasad back on the show. We’re talking about kids and masks. Dude, there’s been a lot… Look, this is one of the most divisive things around. It’s one thing to put a mask on grownups, another thing to put a mask on a cute little wiggler who is apparently absorbing huge amounts of CO2 and is not learning language. And is there a benefit? And you’ve written about it in MedPage, dude. Enlighten us. Help us come up with an answer here.

– [Vinay] I got into this, because I saw that Twitter exploded last week. I said, “What the hell happened?” They said they did a mask study on kids and CO2. I said, I see.

– [Zubin] Oh, here we go.

– [Vinay] It was predictable that they did some study. And this study basically is that they had 45 kids, different ages, 6 to I think 17, use a mask. And they measured the concentration of CO2, I think, just in the dead space of the mask, the space between the nose and the mask itself. And that was a little bit on the high side, and higher than some of their occupational standards. And they said that this is potentially a risk to kids to wear this mask, hypercarbia.

– [Zubin] What kind of masks were they wearing?

– [Vinay] I believe in the study it was surgical masks.

– [Zubin] Okay, all right.

– [Vinay] Yeah, I think they had a couple of masks actually. But I didn’t concern myself too much, because you’ll see why-

– [Zubin] You’ll see why.

– [Vinay] You’ll see why, because I realized I was wasting my time to look into this too much. But then, of course, there were these lengthy rebuttals. It’s like, “I just read the study on the masks, and here’s 72 tweets why it sucks.” And they went through and a couple people had good points. One person’s point I thought was particularly good was whenever you wear a mask and you breathe in to take in air, some of that air you breathe is what’s in the mask. But most of the air you breathe is what’s beyond the mask getting sucked in through the mask, or around the mask, and into your lungs. And so the CO2 in your lungs is gonna be very different than whatever they find in the mask. Other people had qualms about was it the exhale breath or inhale breath, et cetera, et cetera, et cetera.

– [Zubin] So it’s equivalent of like a snorkel’s dead space. Like there’s always dead space, it can be full of CO2, but you’re pulling in a lot of-

– [Vinay] That’s a good analogy, yeah. And nobody ever snorkels, and then all of a sudden they, pop!

– [Zubin] Yeah, they just die. Although I’m sure now we’re gonna have a lot of reports. You know, my son-in-law-

– [Vinay] You never know.

– [Zubin] coated while snorkeling. Well, he was bitten by a jellyfish straight on the genitals.

– [Vinay] And that these mandatory snorkel laws are- So you know, I don’t know. So that was the lay of the land, and I saw that everyone was all fired up about it. And I guess I wanted to take a big picture look at this, which the big picture question is this, should kids wear a mask? And if so, when? And what’s the evidence for this kids wearing mask? And the one thing that first jumps out to you is that there is a difference in global international authorities on this issue. US CDC says if you’re two or older, mask up if you’re indoors in a public space. The WHO is different. WHO says if you’re under the age of five, they don’t recommend masking. And if you’re between, I think, 6 and 11, they say it depends on the kid, if you think that they can manage it appropriately. And I think some of the differences that exist between WHO and CDC, so I guess the clear difference is two to four: CDC says do it and WHO says don’t do it. And I think a lot of daycares take their cues from the US CDC, so it has real implications. What are the reasons you would do it? Well, it’s possible that the kids wearing the cloth mask… And I think for the most part kids wear cloth masks. I haven’t seen that many kids walking around with surgical masks.

– [Zubin] Surgical, yeah, no.

– [Vinay] But I have seen in the store that they’re actually manufacturing surgical masks in kid sizes, but I don’t see that many walking around. So it’s mostly cloth masks. So the potential benefit if you do is that there might be some reduction in SARS-CoV-2 spread for the children and for people around them. The potential decrements are there might be differences in language acquisition, in development, differences in speaking. I don’t know, I’ve worn the mask, but if you try to talk for a long period of time with a mask on, it kind of gets in your mouth. I mean, it starts to migrate. So it has decrements on speech. Potentially, there are other decrements involved. And of course, there is some risk, which is below a certain age, and if a child is asleep, there is a suffocation risk, which is why no guidelines say put it on a baby in their crib. Right?

– [Zubin] Right.

– [Vinay] So there’s some things that I think people agree has some common sense we won’t even try it.

– [Zubin] Right.

– [Vinay] So the question is, does it work? And if so, when? And the whole point of my essay, one of the first points, was that it’s so simplistic to think the answer is yes or no. Why can’t the answer be, the answer, I don’t know the answer, but the answer might be something like, “Oh, under some circumstances, yes.” So if community transmission is over 100 cases per 100,000. If you’re doing it for less than four hours. If you’re in an indoor closed space with less than five people. But maybe at some point, if eight kids are in a room with the teacher in a closed daycare setting, and you get to 8 hours or 10 hours, maybe it loses the benefit, because by that point all the air that is circulated in everyone’s lungs is all the same air at some point. You know?

– [Zubin] Right.

– [Vinay] It’s all sort of exchanged. Or maybe the answer is that if the case rate is less than 5 in 100,000, it doesn’t have a benefit. We all have seen. And maybe the answer is, it varies by age. Maybe it doesn’t work in two to three, or three to four, or four to five, but it works at some age, because we all have seen that young kid walking around the neighborhood and the mask is just snot. It’s just filled with secretions. And wearing a wet mask is not pleasant and probably not useful.

– [Zubin] It’s a face diaper.

– [Vinay] It’s literally a face diaper, which is what I think some people pejoratively call all masks.

– [Zubin] A face diaper, exactly.

– [Vinay] So I guess the real theme of the essay wasn’t that I can answer the question. It’s that first I point out that all the people who think they have the answer, they don’t, because they’re relying on really low quality evidence. And there is some retrospective observational study of very low quality comparing schools that mandated kids wear mask versus schools that didn’t mandate kids wear mask. So here we’re talking typically 6 to 11 kind of age groups, or 6 to 17. But the kind of schools that don’t mandate the masks and those that do are very different. They have different societal attitudes about how much to take SARS-CoV-2 to heart. In some of these places they just don’t take it seriously in other ways, and that might affect these outcomes.

– [Zubin] Huge confounders, yeah.

– [Vinay] Exactly, it’s just hopelessly confounded.

– [Zubin] Yeah.

– [Vinay] So I look to see, you know. And then there are of course the mechanistic people. They’re like, “Well, the size of the virus is sort of microns, and the size of the things is this, and…” If you think mechanistic science can answer these questions as to like what you ought to recommend to a group of young children, you haven’t studied behavioral science, or you haven’t really watched a bunch of kids.

– [Zubin] Yeah, like a dummy there with like little fake particles. Like yeah, that’s gonna apply to some kid who’s like picking his nose while… Yeah, exactly.

– [Vinay] Yeah, and so there’s this huge gap between, this is true in all science, between mechanistic science and actual empirical data on what actually works in the real world, and so this piece explores that. And then the final punchline of the piece is that nobody actually knows. We’ve gone the entire pandemic, and we don’t know if the WHO was right, or the CDC was right, and we’re not gonna know. No-one studied it. There’s not been a single study that actually looked at this question, and randomly assigned classrooms to different masking strategies or different rules, and measured transmission in those classrooms. No-one even did the experiment. And if you don’t do the experiment, you’ll never learn. And then the final punchline of the piece was we look back at the people who survived the plagues of Europe, and we think, “Look at those fools.” They didn’t know anything about how the virus was transmitted. They didn’t know anything about Yersinia pestis, fleas, rats, nothing. They didn’t know shit. And we will be looked at by future people as the same dummies. They masked their infant ch… No, not infant. They masked two-year-old, three-year-old children in one country, they didn’t do it in the other. They never studied it, they have no fucking clue, and they just wasted a year doing this. And I don’t know, to me that just… And the people on social media, they’re so fucking sure of themselves, like the people who know for sure it’s decremental and those who know for sure it’s beneficial. And they argue about this stupid CO2 study. And some of these people are like tooth and nail arguing that that doesn’t prove that it’s #They’re Safe, #MaskWear. You haven’t proven that they work. You haven’t proven that they’re safer than the alternative. And the same people on the other side who think it’s like child abuse, I don’t know what to say to those people. Obviously, there is worse forms of abuse than this.

– [Vinay] But I think it’s a shame that… I don’t know, I’m going on too much about it, but I guess I just wanna say one last thing. The people I really get angry with are these people, many of whom I know are professors and they claim to understand medical evidence. And very early on in the pandemic, they stopped asking the question of can we study masks? And they started tweeting incessantly that we know for sure they work for everybody, for all ages, for two and above, in all circumstances, always a cloth mask. Are they out of their fucking mind? I mean, maybe the answer was the person who’s cooking our food, they need to be in a ventilated kitchen, or wearing an N95, because they’re in close quarters. The person working in the factory slaughtering the animals, that feeding us, maybe they need to wear an N95. Maybe the cloth mask… It certainly doesn’t do anything outside. I certainly think that the data’s in on that, nobody thinks it’s doing much outside. And maybe when you wear it for these average little household chores, et cetera, who knows what it’s doing? No-one has studied it. That’s so embarrass… That’s so terrible that we didn’t study this at all. And everyone is so sure of this without any data that’s credible. They have all these retrospective flawed studies, which I could talk about, but they’re all flawed.

– [Zubin] So why don’t you just shut the hell up, Vinay Prasad, and follow the science? All right? #MaskUp. No, dude. I mean, I have nothing to add to that. I mean, that’s exactly right. That’s the rant that I would have given. We’ve studied it not at all. We’re gonna look like idiots in retrospect. People have tribalized the whole thing. It’s all politicized. Here in the fucking Bay Area where we don’t even have a mask mandate everybody is still wearing masks outside!

– [Vinay] Outside.

– [Zubin] Outside! Outside! And they look at you funny if you don’t wear a mask. When you walked in my building, we weren’t wearing masks. We got funny looks from the person in the lobby. It’s a conditioning, a culturalization. It has nothing to do with science. Anyone who says this has something to do with science is off their rocker, honestly.

– [Vinay] But that’s the weaponization of science. I mean, maybe we’ll touch on it in the other segment when we talk about vaccines. But some of these issues that used to be, like you used to be able to talk about whether or not a non-pharmacologic intervention would slow the spread of a respiratory virus. In fact, I remember, ’cause I used to teach a class, and one of the debates I think we did was on non-pharmacologic interventions for influenza. And we reviewed, I think, some of the meta-analytic work by, what’s the name? McAllister or something on masking. You can’t have that conversation anymore. It’s so polarized. The moment Trump didn’t wear it the moment the entire academy knew for sure it worked. They knew! He’s not doing it, it must work. And you can’t study in a randomized trial. It’s a parachute for fuck’s sake. They knew the moment he didn’t do it, which is so stupid.

– [Zubin] It’s the dumbest.

– [Vinay] If you tie yourself to someone you think is not very logical, you are just as illogical as they are. He didn’t do it for whatever reasons, whatever reasons he didn’t do it. But that doesn’t mean we couldn’t study it, and it doesn’t mean that it works under every circumstance. And in fact, if I were to put my cards down, I highly doubt that for these extremely low ages it actually offers net benefit. And I don’t doubt that because for any political reason, I just doubt that for the simple reason that like when you get below a certain age, executive function is not the same as an adult. And real-world usage and compliance is gonna diminish greatly, and secretions and all the sorts of other things that happen are probably gonna dwarf any potential efficacy signal. And the fact that the same kids in these daycares are brought together daily for extended periods of time, maybe 10 hours or more, the little cloth, I just can’t imagine in hour 11 it’s doing what it needs to do, you know what I mean?

– [Zubin] Oh, totally.

– [Vinay] It’s gotta do the work in hour 11 before they get parents pick them up, you know?

– [Zubin] Yeah, because transmission can occur at anytime.

– [Vinay] At anytime. You’re not trying to stop the first 90 minutes, you have a whole day to get through. And this thing at the end of the day, I doubt it. Is anyone really gonna get…? The other side, they’re worried about, what is this, growing bacteria and someone’s gonna get-

– [Zubin] Right.

– [Vinay] I was like, we haven’t seen an outbreak of mucormycosis from you know. That’s not gonna happen.

– [Zubin] Or impetigo.

– [Vinay] Or impetigo. I mean, I think but some people have gotten a few acne spots. Yeah?

– [Zubin] right.

– [Vinay] And I think those of us who lecture or talk a lot, and work, it’s not as pleasant to talk with. And the other thing is about subjective dyspnea. One thing we’re arguing so much about, O2 levels and CO2 levels, and all these people wasting their time. There is something called subjective shortness of breath. I had to carry a box of books to my fourth-floor office.

– [Zubin] Totally, with a mask.

– [Vinay] With a mask on. And I couldn’t do it. I was like, “Fuck the mask.” It’s subjective. And they’re running the Tour de France right now. They don’t make them wear it while they’re pedaling up the mountainside, they make them wear it when they’re doing their whatever, their show conference, which is probably also they’re vaccinated, so it’s a waste of time as well.

– [Zubin] It’s a waste of time. And that’s the other thing, the bottom line is, look, with kids, they’re not great transmission vectors, we think, from the data we’ve seen. Adults should just be vaccinated. Teachers should just be vaccinated. If they’re not vaccinated, they should wear a mask, and let’s move on.

– [Vinay] Let’s move on.

– [Zubin] But it’d be nice if we could have studied it. Now we can’t ’cause the transmission rates in the community are so low you’re not gonna get enough numbers to actually show any difference.

– [Vinay] You missed your window. And I think anyone… The people to blame are the people who are the most ardent proponents or opponents. The people in the middle who proposed equipoise and wanted to actually do something about it, those voices were squashed in this tribal polar world we live in.

– [Zubin] The Alt-Middle is always marginalized to the alt-side. It’s true, oh man. Guys, I’m gonna link to Vinay’s op-ed in MedPage. You know the drill: subscribe, like, comment. Leave a comment. It juices the algorithm, it gets this message out there. I’m gonna start really manipulating instead of using clickbait and all that garbage. I’m just gonna tell people, “Look, you want to get a good message out, just do these things.” Follow us, et cetera. And then if you want to step off the social media treadmill, go to locals.com, sign up for my tribe there. It’s totally off the ad grid. You can subscribe for like five bucks a month, and that way I’m in your pocket, forget about ads. It’s a beautiful community where we all kind of have this Alt-Middle perspective where we discuss things that we disagree about, and assume good intent.

– [Vinay] Who knew?

– [Zubin] Who knew? Who knew? Alt-Middle, man. All right, guys. We are out, peace.

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