As schools reopen, the United States is being forced to reckon with a new "bottleneck" in its coronavirus testing: Few places will test children, making the isolation and contract tracing of infected or exposed children difficult, Sarah Kliff and Margot Sanger-Katz report for the New York Times' "The Upshot."

The 3 biggest questions about Covid-19 testing, answered

Few sites test children

Many testing sites set age limits on whom they will test for the novel coronavirus or they explicitly decline to test any children at all, Kliff and Sanger-Katz report. These restrictions vary widely from provider-to-provider: Walgreens, for example, doesn't test children at its drive-thru clinics, and CVS Health is imposing an age minimum of 12.

States and cities appear to have similarly varying age restrictions: Dallas, for instance, tests only patients ages five or older, while San Francisco—which previously tested only adults—recently set its minimum coronavirus testing age at 13.

Meanwhile, in the District of Columbia, public testing sites will not accept children younger than six because children have nearly universal health care coverage in the city—which means they should technically be able to be tested at a pediatrician's office. However, pediatricians' offices in the city seem to have limited testing capacity, Kliff and Sanger-Katz report.

For example, Audrey Blute's two-year-old son George developed a runny nose in July, and she wanted to get him tested for the coronavirus. She turned to her son's pediatrician's office after learning that the District's public testing sites don't accept child patients. However, her pediatrician's office did not have the necessary capacity to test her son.

As a result, Blute said, "We were told to assume that everyone in the household has it, which didn't seem like the best information—we're both big believers in contributing to the data pool." Blute added, "We think that's really important."

Ultimately, Blute and her husband never got George tested for the coronavirus and elected to keep him isolated while they worked full-time from home, Kliff and Sanger-Katz report.

Why the age limits?

According to Kliff and Sanger-Katz, the age restrictions on testing seem to stem from a variety of concerns, including different rules on medical privacy, variations in health insurance, gaps in testing approval, and provider discomfort or concern with treating younger patients.

In addition, at the start of the coronavirus pandemic, public health officials were not as concerned about children as an at-risk population, since comparatively few minors required hospitalization for Covid-19, the disease caused by the virus. As a result, testing among children wasn't as prioritized in America, particularly given limited testing capacity in the country overall, Kliff and Sanger-Katz report.

Now, however, "[t]here is no good reason not to do [coronavirus tests] in kids. It's a matter of people not being comfortable with doing it," Sean O'Leary—a pediatrician in Colorado who is on the American Academy of Pediatrics' committee on infectious diseases—said.

In fact, according to pediatricians, coronavirus tests are performed the same whether administered to adults or children, although tests for children can occasionally require additional supplies, such as smaller swabs, as not all coronavirus tests have been evaluated for safety among pediatric patients.

As for concerns that children may resist the tests, Joe Little, clinical supervisor for coronavirus testing at AllCare Family Medicine and Urgent Care, said, at his clinic, children "generally tolerate it pretty well."

Why limited testing among children is a problem

Limiting testing of children creates a bottleneck that could hamper parents' and schools' abilities to test and conduct contact tracing for  both symptomatic and asymptomatic children infected with the novel coronavirus as schools and child-care centers reopen this fall—and that's an especially significant concern now that research indicates children can become infected with and transmit the virus to others, Kliff and Sanger-Katz report.

Nir Menachemi, a professor of health policy and management at Indiana University, said the lack of coronavirus testing among children is critical flaw undermining schools' attempts to reopen and efforts to better understand how the coronavirus spreads. "Having a blind spot makes you not able to respond from a public health perspective, either with the correct messaging or with the right policies to put into place to protect the people who are vulnerable," Menachemi explained.

Thankfully, some areas are starting to test more children, Kliff and Sanger-Katz report. Florida's Division of Emergency Management, for example, last month said it will "prioritize" testing children, though just 25% of its 60 testing sites see children of all ages.

"When we first started, and there was a lack of access to testing, this kind of triage might have made sense," Daniella Levine Cava, a commissioner of Florida's Miami-Dade County, said. "Clearly it doesn't make sense in the current environment. We know that children contract the disease, we know that children spread the disease, and just because they are less likely to show symptoms, that doesn't mean they pose any less of a risk to others."

Similarly, CVS, which initially tested only adults, recently opted to lower its age limit from 16 to 12. "Because we use self-administered swabs, we've been evolving our testing protocols as we learn more about what's possible," William Durling, a spokesperson for CVS, said. "Twelve years old is the age that our team felt a child could likely swab themselves."

And CORE, a nonprofit in Atlanta, runs clinics that provides no-cost testing for anyone ages two and up. Olivia Boyd, who helps run CORE's testing program, said she started to get several calls about testing for children as schools and camps started to open. "'I heard you test under 18. Is that true?'" Boyd said, recollecting the queries she often receives. "And we'd say yes. Then, 'Thank goodness'" (Kliff/Sanger-Katz, "The Upshot," New York Times, 9/8).