Caring for Our Childen, 3rd Edition (CFOC3)

Chapter 3: Health Promotion and Protection

3.6 Management of Illness

3.6.1 Inclusion/Exclusion Due to Illness

3.6.1.1: Inclusion/Exclusion/Dismissal of Children

Content in the STANDARD was modified on 04/16/2015, on 8/2015, and on 4/4/2017.


(Adapted from: Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.)

Preparing for managing illness:

Caregivers/teachers should:

  1. With a child care health consultant, develop protocols and procedures for handling children’s illnesses, including care plans and an inclusion/exclusion policy.
  2. Review with all families the inclusion/exclusion criteria. Clarify that the program staff (not the families) will make the final decision about whether children who are ill may attend. The decision will be based on the program’s inclusion/exclusion criteria and their ability to care for the child who is ill without compromising the care of other children in the program.
  3. Encourage all families to have a backup plan for child care in the event of short- or long-term exclusion.
  4. Consider the family’s description of the child’s behavior to determine whether the child is well enough to return, unless the child’s status is unclear from the family’s report.
  5. A primary health care provider’s note may be required to readmit a child to determine whether the child is a health risk to others, or if guidance is needed about any special care the child requires.

Daily health checks as described in Standard 3.1.1.1 should be performed upon arrival of each child each day. Staff should objectively determine if the child is ill or well. Staff should determine which children with mild illnesses can remain in care and which need to be excluded.
Staff should notify the parent/guardian when a child develops new signs or symptoms of illness. Parent/guardian notification should be immediate for emergency or urgent issues.
Staff should notify parents/guardians of children who have symptoms that require exclusion and parents/guardians should remove the child from the child care setting as soon as possible.
For children whose symptoms do not require exclusion, verbal or written notification of the parent/guardian at the end of the day is acceptable.
Most conditions that require exclusion do not require a primary health care provider visit before reentering care.

Conditions/symptoms that do not require exclusion:

  1. Common colds, runny noses (regardless of color or consistency of nasal discharge)
  2. A cough not associated with fever, rapid or difficult breathing, wheezing or cyanosis (blueness of skin or mucous membranes)
  3. Pinkeye (bacterial conjunctivitis) indicated by pink or red conjunctiva with white or yellow eye mucous drainage and matted eyelids after sleep.  This may be thought of as a cold in the eye. Exclusion is no longer required for this condition. Health professionals may vary on whether or not to treat pinkeye with antibiotic drops. The role of antibiotics in treatment and preventing spread of conjunctivitis is unclear. Most children with pinkeye get better after 5 or 6 days without antibiotics. Parents/guardians should discuss care of this condition with their child’s primary care provider, and follow the primary care provider’s advice. Some primary care providers do not think it is necessary to examine the child if the discussion with the parents/guardians suggests that the condition is likely to be self-limited. If no treatment is provided, the child should be allowed to remain in care.  If the child’s eye is painful, a health care [provider should examine the child.  If 2 or more children in a group develop pinkeye in the same period, the program should seek advice from the program’s health consultant or a public health agency.
  4. Watery, yellow or white discharge or crusting eye discharge without fever, eye pain, or eyelid redness
  5. Yellow or white eye drainage that is not associated with pink or red conjunctiva (i.e., the whites of the eyes)
  6. Fever without any signs or symptoms of illness in children who are older than four months regardless of whether acetaminophen or ibuprofen was given. For this purpose, fever is defined as temperature above 101 degrees F (38.3 degrees C) by any method. These temperature readings do not require adjustment for the location where they are made. They are simply reported with the temperature and the location, as in “101 degrees in the armpit/axilla";
Fever is an indication of the body’s response to something, but is neither a disease nor a serious problem by itself. Body temperature can be elevated by overheating caused by overdressing or a hot environment, reactions to medications, and response to infection. If the child is behaving normally but has a fever, the child should be monitored, but does not need to be excluded for fever alone. For example, an infant with a fever after an immunization who is behaving normally does not require exclusion.

  1. Rash without fever and behavioral changes. Exception: call EMS (911) for rapidly spreading bruising or small blood spots under the skin.
  2. Impetigo lesions should be covered, but treatment may be delayed until the end of the day. As long as treatment is started before return the next day, no exclusion is needed;
  3. Lice or nits treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed;
  4. Ringworm treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed;
  5. Scabies treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed;
  6. Molluscum contagiosum (does not require covering of lesions);
  7. Thrush (i.e., white spots or patches in the mouth or on the cheeks or gums);
  8. Fifth disease (slapped cheek disease, parvovirus B19) once the rash has appeared;
  9. Methicillin-resistant Staphylococcus aureus, or MRSA, without an infection or illness that would otherwise require exclusion. Known MRSA carriers or colonized individuals should not be excluded;
  10. Cytomegalovirus infection;
  11. Chronic hepatitis B infection;
  12. Human immunodeficiency virus (HIV) infection;
  13. Asymptomatic children who have been previously evaluated and found to be shedding potentially infectious organisms in the stool. Children who are continent of stool or who are diapered with formed stools that can be contained in the diaper may return to care. For some infectious organisms, exclusion is required until certain guidelines have been met. Note: These agents are not common and caregivers/teachers will usually not know the cause of most cases of diarrhea;
  14. Children with chronic infectious conditions that can be accommodated in the program according to the legal requirement of federal law in the Americans with Disabilities Act. The act requires that child care programs make reasonable accommodations for children with disabilities and/or chronic illnesses, considering each child individually.

Key criteria for exclusion of children who are ill:
When a child becomes ill but does not require immediate medical help, a determination must be made regarding whether the child should be sent home (i.e., should be temporarily “excluded” from child care). Most illnesses do not require exclusion. The caregiver/teacher should determine if the illness:

  1. Prevents the child from participating comfortably in activities;
  2. Results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;
  3. Poses a risk of spread of harmful diseases to others. 

If any of the above criteria are met, the child should be excluded, regardless of the type of illness. Decisions about caring for the child while awaiting parent/guardian pick-up should be made on a case-by-case basis providing care that is comfortable for the child considering factors such as the child's age, the surroundings, potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in their usual care setting while awaiting pick-up, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children not previously in close contact with the child. All who have been in contact with the ill child must wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and disinfected after the child leaves.
Temporary exclusion is recommended when the child has any of the following conditions:

  1. The illness prevents the child from participating comfortably in activities;
  2. The illness results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;
  3. A severely ill appearance - this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash;
  4. Fever (temperature above 101°F [38.3°C] by any method) with a behavior change in infants older than 2 months of age. For infants younger than 2 months of age, a fever (above 100.4°F [38°C] by any method) with or without a behavior change or other signs and symptoms (e.g., sore throat, rash, vomiting, diarrhea) requires exclusion and immediate medical attention;
  5. Diarrhea is defined by stools that are more frequent or less formed than usual for that child and not associated with changes in diet. Exclusion is required for all diapered children whose stool is not contained in the diaper and toilet-trained children if the diarrhea is causing ”accidents”. In addition, diapered children with diarrhea should be excluded if the stool frequency exceeds two stools above normal for that child during the time in the program day, because this may cause too much work for the caregivers/teachers, or those whose stool contains blood or mucus. Readmission after diarrhea can occur when diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children are not having “accidents” and when stool frequency is no more than 2 stools above normal for that child during the time in the program day;

Special circumstances that require specific exclusion criteria include the following (2):
A health care provider must clear the child or staff member for readmission for all cases of diarrhea with blood or mucus. Readmission can occur following the requirements of the local health department authorities, which may include testing for a diarrhea outbreak in which the stool culture result is positive for Shigella, Salmonella serotype Typhi and Paratyphi, or Shiga toxin–producing E coli. Children and staff members with Shigella should be excluded until diarrhea resolves and test results from at least 1 stool culture are negative (rules vary by state). Children and staff members with Shiga toxin–producing E coli (STEC) should be excluded until test results from 2 stool cultures are negative at least 48 hours after antibiotic treatment is complete (if prescribed). Children and staff members with Salmonella serotype Typhi and Paratyphi are excluded until test results from 3 stool cultures are negative. Stool should be collected at least 48 hours after antibiotics have stopped. State laws may govern exclusion for these conditions and should be followed by the health care provider who is clearing the child or staff member for readmission.

  1. Vomiting more than two times in the previous twenty-four hours, unless the vomiting is determined to be caused by a non-infectious condition and the child remains adequately hydrated;
  2. Abdominal pain that continues for more than two hours or intermittent pain associated with fever or other signs or symptoms of illness;
  3. Mouth sores with drooling that the child cannot control unless the child’s primary care provider or local health department authority states that the child is noninfectious;
  4. Rash with fever or behavioral changes, until the primary care provider has determined that the illness is not an infectious disease;
  5. Active tuberculosis, until the child’s primary care provider or local health department states child is on appropriate treatment and can return;
  6. Impetigo, only if child has not been treated after notifying family at the end of the prior program day. Exclusion is not necessary before the end of the day as long as the lesions can be covered;
  7. Streptococcal pharyngitis (i.e., strep throat or other streptococcal infection), until the child has two doses of antibiotic (one may be taken the day of exclusion and the second just before returning the next day);
  8. Head lice, only if the child has not been treated after notifying the family at the end of the prior program day.  (note: exclusion is not necessary before the end of the program day);
  9. Scabies, only if the child has not been treated after notifying the family at the end of the prior program day. (note: exclusion is not necessary before the end of the program day);
  10. Chickenpox (varicella), until all lesions have dried or crusted (usually six days after onset of rash and no new lesions have appeared for at least 24 hours);
  11. Rubella, until seven days after the rash appears;
  12. Pertussis, until five days of appropriate antibiotic treatment;
  13. Mumps, until five days after onset of parotid gland swelling;
  14. Measles, until four days after onset of rash;
  15. Hepatitis A virus infection, until one week after onset of illness or jaundice if the child’s symptoms are mild or as directed by the health department. (Note: Protection of the others in the group should be checked to be sure everyone who was exposed has received the vaccine or receives the vaccine immediately.);
  16. Any child determined by the local health department to be contributing to the transmission of illness during an outbreak.

Procedures for a child who requires exclusion:
The caregiver/teacher will:

  1. Make decisions about caring for the child while awaiting parent/guardian pick-up on a case-by-case basis providing care that is comfortable for the child considering factors such as the child’s age, the surroundings, potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in their usual care setting while awaiting pick-up, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children not previously in close contact with the child. All who have been in contact with the ill child must wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and  disinfected after the child leaves;
  2. Discuss the signs and symptoms of illness with the parent/guardian who is assuming care. Review guidelines for return to child care. If necessary, provide the family with a written communication that may be given to the primary care provider. The communication should include onset time of symptoms, observations about the child, vital signs and times (e.g., temperature 101.5°F at 10:30 AM) and any actions taken and the time actions were taken (e.g., one children’s acetaminophen given at 11:00 AM). The nature and severity of symptoms and or requirements of the local or state health department will determine the necessity of medical consultation. Telephone advice, electronic transmissions of instructions are acceptable without an office visit;
  3. If the child has been seen by their primary health provider, follow the advice of the  provider for return to child care;
  4. If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for further information from the health professional when the child returns to care. Children who had been excluded from care do not necessarily need to have an in-person visit with a health care provider;
  5. Contact the local health department if there is a question of a reportable (harmful) infectious disease in a child or staff member in the facility. If there are conflicting opinions from different primary care providers about the management of a child with a reportable infectious disease, the health department has the legal authority to make a final determination;
  6. Document actions in the child’s file with date, time, symptoms, and actions taken (and by whom); sign and date the document;
  7. In collaboration with the local health department, notify the parents/guardians of contacts to the child or staff member with presumed or confirmed reportable infectious infection.

The caregiver/teacher should make the decision about whether a child meets or does not meet the exclusion criteria for participation and the child’s need for care relative to the staff’s ability to provide care. If parents/guardians and the child care staff disagree, and the reason for exclusion relates to the child’s ability to participate or the caregiver’s/teacher’s ability to provide care for the other children, the caregiver/teacher should not be required to accept responsibility for the care of the child.
Reportable conditions:
The current list of infectious diseases designated as notifiable in the United States at the national level by the Centers for Disease Control and Prevention (CDC) are listed at https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/infectious-diseases/.
The caregiver/teacher should contact the local health department:

  1. When a child or staff member who is in contact with others has a reportable disease;
  2. If a reportable illness occurs among the staff, children, or families involved with the program;
  3. For assistance in managing a suspected outbreak. Generally, an outbreak can be considered to be two or more unrelated (e.g., not siblings) children with the same diagnosis or symptoms in the same group within one week. Clusters of mild respiratory illness, ear infections, and certain dermatological conditions are common and generally do not need to be reported.

Caregivers/teachers should work with their child care health consultants to develop policies and procedures for alerting staff and families about their responsibility to report illnesses to the program and for the program to report diseases to the local health authorities.

RATIONALE
Most infections are spread by children who do not have symptoms. Excluding children with mild illnesses is unlikely to reduce the spread of most infectious agents (germs) caused by bacteria, viruses, parasites and fungi. Exposure to frequent mild infections helps the child’s immune system develop in a healthy way. As a child gets older s/he develops immunity to common infectious agents and will become ill less often. Since exclusion is unlikely to reduce the spread of disease, the most important reason for exclusion is the ability of the child to participate in activities and the staff to care for the child.
The terms contagious, infectious and communicable have similar meanings. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts. Hand and personal hygiene is paramount in preventing transmission of these organisms. Written notes should not be required for return to child care for common respiratory illnesses that are not specifically listed in the excludable condition list above.
For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 4th Edition has educational handouts that can be copied and distributed to parents/guardians, health professionals, and caregivers/teachers. This publication is available from the American Academy of Pediatrics (AAP) at http://www.aap.org.
For more detailed rationale regarding inclusion/exclusion, return to care, when a health visit is necessary, and health department reporting for children with specific symptoms, please see Appendix A: Signs and Symptoms Chart.
State licensing law or code defines the conditions or symptoms for which exclusion is necessary. States are increasingly using the criteria defined in Caring for Our Children and the Managing Infectious Diseases in Child Care and Schools publications. Usually, the criteria in these two sources are more detailed than the state regulations so can be incorporated into the local written policies without conflicting with state law.
COMMENTS
When taking a child’s temperature, remember that:
  1. The amount of temperature elevation varies at different body sites;
  2. The height of fever does not indicate a more or less severe illness. The child’s activity level and sense of well-being are far more important that the temperature reading;
  3. If a child has been in a very hot environment and heatstroke is suspected, a higher temperature is more serious;
  4. The method chosen to take a child’s temperature depends on the need for accuracy, available equipment, the skill of the person taking the temperature, and the ability of the child to assist in the procedure;
  5. Oral temperatures are difficult to take for children younger than four years of age;
  6. Rectal temperatures should be taken only by persons with specific health training in performing this procedure and permission given by parents/guardians, however this method is not generally practiced due to concerns about proper procedure and risk of accusations of sexual abuse;
  7. Axillary (armpit) temperatures are accurate only when the thermometer remains within the closed armpit for the time period recommended by the device;
  8. Any device used improperly may give inaccurate results; and
  9. Only digital thermometers, not mercury thermometers, should be used.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.1.1 Conduct of Daily Health Check
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.1.4 Infectious Disease Outbreak Control
Appendix A: Signs and Symptoms Chart
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
  2. American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 122-123

  3. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 140-141

NOTES

Content in the STANDARD was modified on 04/16/2015, on 8/2015, and on 4/4/2017.