At-home COVID-19 test kits say they’re not for kids under 2. So how do I test my toddler?

Navigating the COVID-19 pandemic as the parent of a toddler hasn’t been easy: They are too young to be vaccinated and can’t keep on a mask, but at the same time turn into drool and snot zombies in the winter, with a mission to contaminate anyone who comes in their wobbly path.

The rules about social distancing, masking, and quarantining after exposure change so often it seems many people have given up trying to keep up, which makes things even more complicated for parents trying to protect unvaccinated children from getting sick.

Add to the list: If your infant or toddler is exposed to someone with COVID-19, or you’re just worried that those sniffles are more than the ever-present toddler cold, getting them tested isn’t so straightforward.

I found that out when my 16-month-old daughter needed a COVID-19 test to return to day care after an exposure in her classroom the previous week. My husband and I planned to take her to a nearby test site that does both antigen and PCR tests on children (not all sites test young children), but our appointment was canceled by the weekend snowstorm.

Instead, we dug out the at-home test kit we’d bought as backup and started to read the directions.

“Do not use on anyone under 2 years of age,” I read from the side of the box.

A negative COVID-19 test is a requirement for many young children to return to day care after an exposure in the classroom, yet rapid at-home antigen tests — the most easily accessible option for busy families — specify they’re not to be used on infants and toddlers.

Why? And what should parents of young children do when they need a test urgently and can’t get an appointment at a clinic or pediatrician’s office?

“The only reason they say it’s for children above age 2 is because they only did studies in children above age 2,” said Mario Maffei, primary care doctor with Virtua Primary Care in Voorhees. “It’s a very safe procedure to do. The test accuracy is just as good, if you do it the right way.”

Or, as my colleague, Inquirer science reporter Tom Avril put it when I posed the question on Twitter: “Betting that under-2 snot is functionally equivalent to over-2 snot.”

An important caveat about the accuracy of at-home tests for young children is that they have to be done correctly, which is no small feat when dealing with toddlers, said Azmat Husain, an emergency physician and medical director of Personic Health Care, which operates test sites in Delaware County.

“You run into challenges with the sampling — keeping a child calm so the swab can stay in long enough to get a sample,” said Husain, which is why he recommends PCR tests for children under age 2.

Most rapid antigen tests call for users to swirl a cotton swab in each nostril for a total of 10 seconds.

PCR tests are also done with a nasal swab, but are more sensitive because they detect the virus’ genetic material, which means they are more likely than antigen tests to return accurate results with even a partial sample.

“Although it’s recommended to have the swab in for 10 seconds ... the reality is the PCR swab will detect very small levels of virus molecules, and so it’s able to pick it up even if you do it for less than 10 seconds,” Husain said.

Collecting samples from unwilling toddlers can be so challenging that not all public test sites will accept young children. Personic specially trains its medical technicians on how to swab children using two medics — one to hold the child’s head steady and another to swab the nose.

Though PCR tests are considered to be the gold standard for COVID-19 tests, one shortcoming is that people can test positive for months after their infection is no longer contagious, Maffei said.

Meanwhile a false positive result is extremely unlikely with a rapid antigen test (though false negatives can happen when the test is done too soon after an infection, before the viral load is large enough to detect).

At-home rapid tests are also more practical for busy families, and appointments at test sites can be hard to come by. Our pediatrician’s office is so slammed, they are not offering COVID-19 testing to children seeking one because of an exposure.

Maffei offered some advice to caregivers for getting a good sample from a squirmy child:

My husband and I decided to go ahead with the at-home rapid test for our daughter because the director at her day care center told us that a negative result from any COVID-19 test was acceptable. We also figured that we could schedule a new clinic test for her if I learned while reporting this article that the at-home tests were ineffective for children her age.

She sat in my lap with a blanket wrapped around her torso like a baby straitjacket, while I hugged her with one arm and held the side of her head against my chest with the other. My husband breathed a deep inhale and exhale before taking the plunge, first into her right and then left nostril.

“Done!” he said excitedly to our screaming toddler. “That’s it! Done!”

Unsure whether she should forgive us, she reluctantly accepted our peace-offering popsicle to eat while we waited for her results: negative.