Visitor restriction during the respiratory viral season is a common practice among children’s hospitals. Specific visitor limitations vary by institution but often include a reduction in the total number of adult visitors a patient may have, restriction of visitation by children younger than a particular age, and restriction of all visitors with respiratory symptoms. ^{Reference Pong, Beekmann, Faltamo, Polgreen and Shane1} In a study prior to the coronavirus disease 2019 (COVID-19) pandemic, a policy of visitor restriction was associated with a >50% decreased risk of hospital-acquired respiratory viral infections. ^{Reference Forkpa, Rupp and Shulman2}

In the era of COVID-19, the critical importance of social distancing to decrease transmission has required a reduction in the numbers of people present in hospitals and clinics. As a result of physical distancing, the common spaces of hospitals (eg, cafeterias, waiting rooms, and elevators) cannot support pre–COVID-19 volumes, so many members of the healthcare team and support staff have transitioned to remote work arrangements. Many adult hospitals have banned all visitation and have increased the capability for videoconferencing and telephone contact among patients, families, and the healthcare team. ^{Reference Hart, Turnbull, Oppenheim and Courtright3}

Parents and guardians are not merely ‘visitors’ of pediatric patients. They are essential members of the care teams for pediatric patients, providing comfort, reassurance, and support, to their children in addition to assisting with feeding, bathing, toileting, and diaper changes. ^{Reference Lulgjuraj and Maneval4} They are also involved in the clinical decision-making process with the primary team. Therefore, restriction of parental visitation could negatively affect the child’s care and well-being; such restrictions have also been shown to increase stress levels for the parents. ^{Reference Kirschbaum5} For children with complex healthcare needs, parent or guardian involvement is crucial to ensuring a safe hospitalization and discharge for the child. Infection prevention and control programs are responsible for the safety of patients, visitors, and healthcare workers, and decisions around visitation must consider all these groups. ^{Reference Virani, Puls, Mitsos, Longstaff, Goldman and Lantos6,Reference Antommaria, Monhollen and Schaffzin7} Recommendations for mitigating COVID-19 transmission risk will continue to evolve as prevalence fluctuates in communities, as variants emerge, and as vaccination becomes widely available, including for children.

Parents and guardians most often share the same household as the hospitalized child and therefore have similar COVID-19 exposure risk. ^{Reference Laws, Chancey and Rabold8} Parents and guardians of children hospitalized with COVID-19 have already been exposed (or potentially have already been infected), and the incremental increased risk of SARS-CoV-2 transmission with their continued presence with the patient is unknown, but it is likely to be low in most circumstances. ^{Reference Lee, Kim and Chang9} It is useful to consider the patient and parent or guardian as a ‘family unit’ of exposure to the healthcare system and to plan risk mitigation strategies accordingly (Table 1).

Table 1. COVID-19 Risk Mitigation Strategies For Visitors of Hospitalized Pediatric Patients

Limiting exposure of the ‘family unit’ to other patients and visitors in the hospital or clinic can be accomplished (1) by requiring parents or guardians to remain in the patient’s room; closing or limiting access to common areas (eg, family kitchens, lounges, and child life spaces); (2) by having a program for symptom screening; and (3) by enforcing masking and social distancing when interacting with the healthcare team and when entering and exiting the facility. If age- and developmentally appropriate, pediatric patients should wear masks if they need to leave their rooms for a medical procedures and at discharge. Appropriate use of personal protective equipment (PPE) by healthcare workers can prevent transmission of COVID-19, and PPE can be tailored to the risk of COVID-19 of the ‘family unit.’ For example, if the parent of a patient has been exposed to COVID-19 and is under quarantine, the ‘family unit’ should be placed on appropriate COVID-19 isolation and workflows while in the hospital or clinic.

Many of these mitigation recommendations presume private patient rooms. The risk–benefit ratio of parent or guardian visitation changes when other patients and families are at risk of exposure. The Centers for Disease Control and Prevention (CDC) recommends at least 1 m between patient beds, ^{Reference Siegel, Rhinehart, Jackson and Chiarello10} so social distancing may not be feasible in all shared rooms. Hand hygiene, mask use by parents or guardians, and physical barriers (eg, curtains) should be emphasized. Perinatal transmission of SARS-CoV-2 infection is very infrequent ^{Reference Shalish, Lakshminrusimha, Manzoni and Keszler11} ; thus, there is little concern about patient-to-patient transmission in the neonatal intensive care unit, even if there is an open pod with multiple patients. Parents and guardians and healthcare workers are the primary risk factor for acquisition of COVID-19 infection for these vulnerable patients; therefore, basic prevention measures focusing on parents or guardians and healthcare workers are most important.

The presence of parents or guardians at the bedside facilitates delivery of family-centered care. ¹² Multiple mitigation strategies have been applied to maintain family communication remotely, although this can be logistically complicated for both care teams and families. ^{Reference Hart, Turnbull, Oppenheim and Courtright3} Clear communication regarding visitor restrictions and expectations is critical and should ideally be communicated to families prior to planned visits and hospitalizations, and as early as possible within an unplanned or emergent visit. Policing and enforcing policies can be an additional stressor on our already overextended clinical workforce. There will always be need for situation-based exemptions, and teams can work with their local infection prevention and control teams to minimize risk to patients, families, and the healthcare team. Possible scenarios include end-of-life care, developmental-delay or complex-care planning, and education at discharge (Table 1). A formal escalation process for visitor policy exceptions to ensure standardization and equity should also be considered.