Caring for Our Children (CFOC)

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 Ill Children

Content in the STANDARD was modified 04/16/2015, 8/2015, 4/4/2017, 5/21/2019 and 10/25/2022.

COVID-19 modification as of October 10, 2022.


After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

 

Adapted from American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.

Children in early care and education programs can often become ill. Most illnesses are mild and do not require dismissal or temporary exclusion from programs. But some infectious diseases do require temporary exclusion to control the spread of illness in the program.

Staff should work with a child care health consultant, local public health authority, or other licensed health expert to:

  • Develop policies and procedures for dismissal, temporary exclusion, and when to return to the program
  • Tell staff and families they are responsible for promptly reporting illness when their child has symptoms
  • Watch for and manage illnesses in the program
  • Understand when to report infectious illnesses to local public health authorities

Programs should prepare to manage illnesses by:1

  • Working with a child care health consultant to develop procedures for handling illnesses, including care plans for ill children and an inclusion and exclusion policy
  • Regularly reviewing the illness policy with staff and families; making it clear that the staff (not the families) will make the final decision about whether ill children may attend. The staff will decide based on the program’s illness guidelines, and their ability to care for the ill child¾while not taking away from the care of other children.
  • Encouraging families to have a backup plan for child care when their child cannot attend the program.
  • Doing daily health checks (see Standard 3.1.1.1) when children arrive and periodically through the day.
  • Discussing the child’s behavior with the family to decide if the child can take part in the program, and if excluded, when the child is well enough to return.

When children are ill, staff should:

  • Decide which children with mild illnesses can stay. For children whose symptoms do not need exclusion, verbal or written communication with the parent or guardian at the end of the day is fine.
  • Tell parent or guardian when a child has new signs of illness. Contact the parent or guardian immediately for emergencies or urgent issues.
  • Tell parents or guardians of children immediately if their child has symptoms that need temporary exclusion, so that they pick up their child as soon as possible.
  • Only ask for a healthcare provider’s note to return to the program if their advice is needed to decide:
    • If the child is a possible health risk to others
    • Or if the program needs more information about special care the child needs
Conditions That Do Not Require Exclusion1–2
Conditions Notes
Common cold, runny nose, and cough No exclusion regardless of color or consistency of nasal discharge.
For allergies that have similar symptoms to a common cold (e.g., runny nose, sneezing, cough), programs can encourage parents or guardians to get documentation from a healthcare provider to avoid unnecessary exclusions.
During outbreaks such as COVID-19, follow recommendations from the Centers for Disease Control and Prevention (CDC) or the local health department.
Cytomegalovirus infection (CMV) No exclusion required.
Diarrhea No exclusion if stool is contained in the diaper, there are no toileting accidents, and there are no more than 2 stools per day above the normal for that child.
Eye drainage No exclusion unless the child has watery discharge that is yellow or white; without fever, eye pain, or eyelid redness.
Fever Temperature above 100.4° F (38° C) (axillary, temporal, or oral) is a fever. Children over 4 months old without signs of illness do not need to be excluded. Only take a child’s temperature if the child seems ill. (During outbreaks such as COVID-19, follow CDC or local health department recommendations.)
Fifth’s Disease (Parvovirus B19 or slapped cheek disease) No exclusion for children who have normal immune systems and who don’t have an underlying blood disorder like sickle cell disease.
Hand, foot, and mouth (Coxsackie virus) No exclusion unless the child has a fever with symptoms, mouth sores, and constant drooling, or if recommended by public health authorities to control an outbreak.3
Hepatitis B virus, chronic No exclusion required.
HIV infection No exclusion required.
Impetigo Cover skin lesions until the end of the day if there is no fever or changes in behavior. If medical treatment starts before returning the next day, no exclusion is needed.
Lice or nits Treatment may start at the end of the day. If treatment starts before returning the next day, no exclusion needed.
“No-nit” policies are not effective in controlling spread of lice and are not recommended.2
Methicillin-resistant (MRSA) and methicillin-sensitive (MSSA) colonization Colonization is the presence of bacteria on the body without illness. Active lesions or illness may require exclusion.
Molluscum contagiosum No exclusion or covering of lesions is needed.
Pinkeye No exclusion needed if pink or red on the white of the eye with or without drainage, without fever or behavioral change.2
Rash without fever or behavior changes No exclusion necessary. Exception: Call EMS (911) for children who have a new rash with rapidly spreading bruising or small blood spots under the skin.
Ringworm Cover skin lesions until the end of the day. If medical treatment starts before returning the next day, no exclusion is needed.
Roseola No exclusion needed unless there is a fever and behavior changes.
Scabies Treatment may be delayed until the end of the day. As long as treatment starts before returning the next day, no exclusion is needed.
Thrush No exclusion needed. (The signs of thrush are white spots or patches in the mouth, cheeks, or gums.)

Conditions That Require Temporary Exclusion

Key Guidelines for Exclusion of Children Who Are Ill2
When a child becomes ill but does not need immediate medical help, programs should decide if the child should be sent home (temporarily excluded from the program). Most illnesses do not need exclusion.
Three main reasons to keep children at home:
  1. The child does not feel well enough to comfortably take part in usual activities (i.e., overtired, fussy, will not stop crying).
  2. A child needs more care than teachers and staff can give while still caring for the other children.
  3. The illness has a risk of spreading harmful disease to others as noted in Specific Conditions Needing Temporary Exclusion, below.
Specific Conditions Requiring Temporary Exclusion1-2
Conditions Notes
Abdominal pain Exclude with persistent or intermittent pain with fever, dehydration, or other signs or symptoms.
Chickenpox Exclude until all lesions have dried or crusted (usually 6 days after the start of the rash) and no new lesions have appeared for 24 hours.
COVID-19 Exclude according to current CDC guidelines.
Diarrhea Exclusion is needed for:
  • Diapered children whose stool is not contained in the diaper
  • Toilet-trained children when diarrhea causes “accidents” or when increased number of bowel movements are a risk for accidents and soiling of toileting areas
  • Children who have more than 2 stools per day above normal for that child while the child is in the program
  • Children whose stool contains blood or mucus
Children may return when the stool is contained in the diaper, or when toilet-trained children no longer have accidents or when they have no more than 2 stools above what is usual for the child.
For some infectious diarrheal illnesses, exclusion is needed until additional guidelines have been met and programs communicate  with healthcare providers and health departments. Children who have germs in their stool but no symptoms do not need to be excluded, except when infected with Shiga toxin-producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi.
Fever Exclude with behavior change or other symptoms. A temperature of 100.4° F (38° C) or above (from any site) in infants and children with behavior change. For infants younger than 2 months, a temperature of 100.4° F from any site) or above with or without a behavior change or other symptoms (e.g., sore throat, rash, vomiting, diarrhea) needs exclusion and immediate medical attention. (See Standard 3.6.1.3.)
Head lice
 
Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not had a medically approved treatment by the time they return.
Hepatitis A Exclude for 1 week after onset of illness or as directed by the health department.
Impetigo Exclusion is not needed before the end of the program day if impetigo lesions are covered, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Measles Exclude until 4 days after onset of rash.
Mouth sores Exclude children who have sores with drooling that a child is unable to control. Or exclude children who are unable to participate due to symptoms related to the mouth sores.
Mumps Exclude until 5 days after onset of parotid (salivary) gland swelling.
Pertussis (whooping cough) Exclude until treated with an appropriate antibiotic for 5 days, or 21 days from start of cough if untreated.
Rash with fever or behavior change Exclude until a healthcare provider decides the illness is not a harmful contagious disease.
Ringworm
 
Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Rubella Exclude until 7 days after onset of rash.
Scabies
 
Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Skin sores Exclude if the child has sores on an exposed body surface that are leaking fluid and cannot be covered with a waterproof dressing.
Streptococcal pharyngitis
(Strep throat, skin infections)
Exclude until treated with an appropriate antibiotic for 12 hours.
Tuberculosis (active) Exclude until the healthcare provider or local health department decides the child is no longer infectious.
Vomiting Exclude if the child vomits two or more times within 24 hours, unless vomiting is due to a noncontagious/noninfectious cause and the child can stay hydrated and take part in activities.
If a child with a recent head injury vomits, get emergency medical care.

When children need temporary exclusion, staff should1:

  • Ask parents or guardians to pick the child up as soon as possible following the program’s illness exclusion policies.
  • Let the child stay in the usual care setting/classroom (if symptoms allow) while waiting for pickup.
  • Move the child to a familiar and comfortable place, supervised by someone who knows the child well and who will continue to watch the child for new or worsening symptoms. If the child is coughing or sneezing, separate the child from other children and staff by at least 3 feet to help decrease exposure to others who were not in close contact with the child before. 
  • Make decisions on a case-by-case basis about giving care that is comfortable for the child while waiting for pickup. Consider the child’s age, surroundings, potential risk to others, and type and severity of symptoms. Staff should still appropriately tend to the child’s physical and emotional needs while waiting for pickup.
  • If the child-to-staff ratio cannot be met while caring for the ill child, extra staff may be needed to care for the other children until the child is picked up. Putting the ill child in the care of an unfamiliar caregiver or in a different space may make it difficult to care for the child and can expose other people to infectious illnesses.
  • Wash their hands, and continue to practice good hand hygiene if they (and other children) had contact with the ill child. Wash and sanitize toys, equipment, and surfaces used by the ill child after the child leaves.
  • Discuss illness signs and symptoms with the parent or guardian who is picking up the child. Review illness guidelines for return to child care. If needed, give the family written information that may be shared with a healthcare provider. The information should include when symptoms started, observations about the child, if a temperature was taken (e.g., temperature of 101.5° F at 10:30 am), any actions taken, and the time actions were taken (e.g., ½ tsp children’s acetaminophen given orally at 11:00 am).
  • Ask the parent or guardian to share written information from the child’s healthcare provider with staff. If more information is needed, ask for the parent’s or legal guardian’s written permission to contact the child’s doctor. Sharing health information with staff needs written consent from the parent or guardian.
  • Follow the medical advice (if the child saw a healthcare provider) for return to child care. When needed, let staff and families know about a possible exposure to an infectious disease.
  • Contact the local health department if a child or staff member might have a reportable or harmful infectious disease. If healthcare providers have different opinions about the care of a child with a reportable infectious disease, the health department has the legal authority to make a final decision.
  • Document any care for an ill child in the child’s file with date, time, symptoms, and actions taken (and by whom); sign and date the document.

For programs that routinely offer care for ill children in a space designed for such care: Follow special procedures for giving this service, as defined in CFOC Standard 3.6.2.2 (http://nrckids.org/CFOC).

If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for more information from the healthcare provider when the child returns to care. Children who have been sent home due to illness do not always need to see a healthcare provider.

Reportable/Notifiable Conditions1

The CDC has a list of infectious diseases that must be reported to public health authorities in the United States at the national level (see https://ndc.services.cdc.gov/search-results-year/). Other conditions may need to be reported to local, state, tribal, or territorial public health authorities. Although laboratories and healthcare providers are expected to report these notifiable diseases, their reporting may not alert health authorities that the child attends an early care and education program or is enrolled in school and may have exposed others. Delayed notification may delay quick responses to prevent illness among those exposed to the child in the group setting. If in doubt about whether to report, contact the local, state, tribal, or territorial health department.

Staff should contact the local health department:

  • When a child or staff member who is in contact with others has a reportable disease
  • If staff, children, or families in the program have a reportable illness
  • For help managing a suspected outbreak. An outbreak is 2 or more unrelated children (i.e., not siblings) with the same diagnosis or symptoms in the same group within 1 week. Clusters of mild respiratory illness, ear infections, and certain skin conditions are common and usually do not need to be reported.

Program staff 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.


COVID-19 modification as of October 10, 2022:

Children who are experiencing any of the symptoms/exposures/testing listed below should not enter the program.

  • COVID-19 symptoms most likely seen in children:
    • Congestion, runny nose or other allergy like symptoms
    • Sore throat
    • Headache
    • Fever (100.4o F/38o C or higher); feeling feverish (chills, sweating)
    • Refer to the complete list Symptoms of COVID-19 | CDC
  • Are waiting for results of a COVID-19 test
  • Have been recently diagnosed with COVID-19 and not yet cleared to discontinue isolation
  • If experiencing any of the COVID-19 symptoms above, get tested.

If a child shows symptoms or becomes sick during the day, program staff should:

  • Contact the child’s family and have a procedure in place for safe and accessible transport of the sick child.
  • Children who are sick should go home. Contact their healthcare provider for testing and care or go to a healthcare facility depending on how severe their symptoms appear.
  • If a child is ill, they should wear a mask.
  • Encourage families of children who are sick, or who have recently had close contact with a person with COVID-19, to contact their healthcare provider for testing. Follow CDC guidance.
  • Ensure families understand when their child can return to in-person care. Families should work with their health care provider and/or local health department.
  • Close off areas used by the sick child, increase ventilation, clean and disinfect surfaces.

If a child in care is confirmed to have COVID-19:

  • Follow the Cleaning and Disinfecting Your Facility
  • Ensure families understand their child cannot return to in-person care until they have met CDC’s guidance,
  • Maintain the sick child’s confidentiality, as required by the Americans with Disabilities Act (ADA), Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA).

Children or staff who arrive in the program with symptoms, or develop symptoms while in care should wear a well-fitting mask while in the building and be sent home and get tested. Children or staff expose to COVID-19 or develop symptoms, should be tested. 

Additional Resources:

Centers for Disease Control and Prevention


RATIONALE

Although young children often become ill, excluding children from early care and education programs can be stressful for families, and many exclusion decisions made by staff are not correct. Most infections in young children are mild and are spread by children who do not have symptoms. Excluding children with mild illnesses is unlikely to reduce the spread of most infections in early care and education settings. The most important reason for exclusion is if the child can’t take part in activities and the staff can’t care for the child. But exclusion is needed for some infectious diseases to control contamination and spread, and these diseases need criteria for a child’s return.2

COMMENTS

ADDITIONAL RESOURCES

For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 5th Edition, has educational handouts that programs can copy and distribute to parents and guardians, healthcare providers, and staff. This publication is available from the American Academy of Pediatrics at https://shop.aap.org/managing-infectious-diseases-in-child-care-and-schools-5th-ed-paperback/  

 

State-specific guidelines for licensing and regulations on exclusion and return to care are at https://licensingregulations.acf.hhs.gov/

 

For a more detailed rationale on inclusion and exclusion, return to care, when a health visit is needed, and health department reporting for children with specific symptoms, please see Appendix A: Signs and Symptoms Chart.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
3.1.1.1 Conduct of Daily Health Check
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Guidelines for Taking Children’s Temperatures
3.6.1.4 Infectious Disease Outbreak Control
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix A: Signs and Symptoms Chart
REFERENCES
  1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022

  2. American Academy of Pediatrics, Section 2 recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:116-126

  3. Centers for Disease Control and Prevention. Hand, foot, and mouth disease (HFMD) Causes & Transmission. CDC.gov Web site. Last reviewed February 2, 2021. Accessed August 8, 2022. https://www.cdc.gov/hand-foot-mouth/about/transmission.html

NOTES

Content in the STANDARD was modified 04/16/2015, 8/2015, 4/4/2017, 5/21/2019 and 10/25/2022.

COVID-19 modification as of October 10, 2022.

3.6.1.2: Staff Exclusion for Illness

Content in the STANDARD was modified on 4/5/2017.
COVID-19 modification as of August 10, 2022.


After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

Please note that if a staff member has no contact with the children, or with anything with which the children has come into contact, this standard does not apply to that staff member.

A facility should not deny admission to or send home a staff member or substitute with illness unless one or more of the following conditions exists:

  1. Influenza, until fever free for 24 hours. (Health care providers can use a test to determine whether an ill person has influenza rather than other symptoms. However, it is not practical to test all ill staff members to determine whether they have common cold viruses or influenza infection. Therefore, exclusion decisions are based on the symptoms of the staff member);
  2. Chickenpox, until all lesions have dried and crusted, which usually occurs by six days;
  3. Shingles, only if the lesions cannot be covered by clothing or a dressing until the lesions have crusted;
  4. Rash with fever or joint pain, until diagnosed not to be measles or rubella;
  5. Measles, until four days after onset of the rash (if the staff member or substitute has the capacity to develop an immune response following exposure);
  6. Rubella, until six days after onset of rash;
  7. Diarrheal illness, stool frequency exceeds two or more stools above normal for that individual or blood in stools, until diarrhea resolves, or until a primary care provider determines that the diarrhea is not caused by a germ that can be spread to others in the facility; For all cases of bloody diarrhea and diarrhea caused by Shiga toxin–producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi  I, exclusion must continue until the person is cleared to return by the primary health care provider. Exclusion is warranted for STEC, until results of 2 stool cultures are negative (at least 48 hours after antibiotic treatment is complete (if prescribed)); for Shigella species, until at least 1 stool culture is negative (varies by state); and for Salmonella serotype Typhi, until 3 stool cultures are negative. Stool samples need to be collected at least 48 hours after antibiotic treatment is complete. Other types of Salmonella do not require negative test results from stool cultures. Vomiting illness, two or more episodes of vomiting during the previous twenty-four hours, until vomiting resolves or is determined to result from non-infectious conditions;
  8. Hepatitis A virus, until one week after symptom onset or as directed by the health department;
  9. Pertussis, until after five days of appropriate antibiotic therapy or until 21 days after the onset of cough if the person is not treated with antibiotics;
  10. Skin infection (such as impetigo), until treatment has been initiated; exclusion should continue if lesion is draining AND cannot be covered;
  11. Tuberculosis, until noninfectious and cleared by a health department official or a primary care provider;
  12. Strep throat or other streptococcal infection, until twenty-four hours after initial antibiotic treatment and end of fever;
  13. Head lice, from the end of the day of discovery until after the first treatment;
  14. Scabies, until after treatment has been completed;
  15. Haemophilus influenzae type b (Hib), prophylaxis, until cleared by the primary health care provider;
  16. Meningococcal infection, until cleared by the primary health care provider;
  17. Other respiratory illness, if the illness limits the staff member’s ability to provide an acceptable level of child care and compromises the health and safety of the children. This includes a respiratory illness in which the staff member is unable to consistently manage respiratory secretions using proper cough and sneeze etiquette.

Caregivers/teachers who have herpes cold sores should not be excluded from the child care facility, but should:

 1. Cover and not touch their lesions;
 2. Carefully observe hand hygiene policies; and

   3. Not kiss any children.

 

COVID-19 modification as of August 10, 2022:

In response to the Centers for Disease Control and Prevention’s Guidance for Operating Child Care Programs during COVID-19, it is recommended that early childhood programs implement daily screening procedures for staff, or other support services, to self-screen with temperature checks at home or when they arrive to the program. Refer to COVID-19 modifications of CFOC Standard 1.7.0.2: Daily Staff Health Check.

Staff who are experiencing any of the symptoms/exposures/testing listed below should not enter the program:

  • COVID-19 symptoms
    • Fever (100.4o F/38o C or higher); feeling feverish (chills, sweating)
    • New cough
    • Fatigue
    • New loss of taste or smell
    • Sore throat
    • Headache
    • Runny or stuffy nose
    • Muscle pain or body aches
    • Nausea, vomiting or diarrhea

  • Have had close contact (within 6 feet for at least 15 minutes or more over a 24-hour period of time) with someone who is COVID-19 positive
  • Are waiting for the results of a COVID-19 test
  • If experiencing any of the COVID-19 symptoms above, get tested. 

Have been recently diagnosed with COVID-19 and not yet cleared to return to work.

If staff develop symptoms upon arrival or become sick during the day:

  • Immediately separate sick staff from others.
  • Use an isolation room or area with access to a separate restroom not used by others.
  • Send staff member home and encourage them to follow CDC guidance for caring for oneself and others who are sick.
  • Encourage sick staff to consult with their health care provider for care and testing.
  • Staff in contact with the sick individual should be protected with personal protective equipment (PPE) such as a well fitted facemask, eye protection, disposable gloves, and a gown.
  • Clean and disinfect the work area and any shared common areas (including restrooms) and any supplies, tools, or equipment handled by the sick staff member. Prior to cleaning, if possible, increase ventilation in the work area and any shared common areas.
  • Document who has been in close contact with the sick staff member to assist with future contact tracing efforts.

If the staff member is confirmed to have COVID-19:

  • Follow the Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes | CDC
  • Contact local public health authorities about contact tracing.
  • Maintain sick staff member’s confidentiality, as required by the Americans with Disabilities Act (ADA) and other applicable federal and state laws.
  • Work with local health officials to identify exposed and potentially exposed individuals, such as coworkers or enrolled children.
  • Refer to state and local agencies for guidance on when it is safe to discontinue self-isolation or end quarantine for staff or children who test positive or had close contact with an individual who tested positive for COVID-19.
  • Sick staff members should not return to work until they have met the CDC’s criteria to discontinue isolation.

Staff who have been close contacts (within 6 feet for a total of 15 minutes or more ) of an individual who tested positive for COVID-19 should not return to in-person work until they have completed their quarantine. Staff should follow CDC screening testing guidance for vaccinated and unvaccinated persons. COVID-19 Screening Testing identifies people with COVID-19, including those with or without symptoms who are likely to be contagious, so steps can be taken to prevent further spread of illness. At medium and high COVID-19 Community Levels, consider implementing screening testing in your ECE programs. 

 

Facilities are encouraged to develop policies that encourage sick employees to stay home without fear of negative consequences.

ADDITIONAL RESOURCES

Centers for Disease Control and Prevention

American Academy of Pediatrics 

 

RATIONALE
Most infections are spread by children who do not have symptoms.
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.
Adults are as capable of spreading infectious disease as children (1,2). Hand and personal hygiene is paramount in preventing transmission of these organisms. 
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.3.2 Cough and Sneeze Etiquette
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.4 Infectious Disease Outbreak Control
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. 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: 138-146


NOTES

Content in the STANDARD was modified on 4/5/2017.
COVID-19 modification as of August 10, 2022.

3.6.1.3: Guidelines for Taking Children’s Temperatures

Standard was last updated on September 13, 2022.


A normal body temperature is considered 98.6°F (37°C). A fever is a higher than normal body temperature. Body temperature increases in response to infection or other causes. In infants and children, a temperature of 100.4°F (38°C) or more from any area of the body is considered above normal.1,2 A child with a fever may feel warm, look flushed, sweat more than usual, be less active. Getting a correct temperature can help guide staff to make decisions about inclusion, temporary exclusion, or dismissal of children with a fever.

 When early care and education program staff suspect that a child has a fever, they should take a temperature with a digital thermometer. A digital thermometer does not have mercury and is not made of glass. Different types of digital thermometers measure temperature at different areas of the body.3 It is important to use the correct method based on the child’s age and to document the temperature, time the temperature was taken, and type of thermometer used. Do not adjust the temperature reading for the location in which the temperature was taken. Whatever method you use, it is also important to follow the manufacturer’s cleaning instructions for the thermometer before and after each use. Thermometers may include:

  • Tympanic (ear) thermometers. These may be used with children 6 months and older. Infants younger than 6 months have narrow ear canals, and tympanic thermometers can give inaccurate results. Tympanic thermometers need to be placed correctly in the child’s ear to be accurate. An accurate temperature depends on gently pulling the ear back before inserting the thermometer. A buildup of ear wax can make the temperature reading incorrect. Wait 15 minutes to take a temperature after being outside on a cold day, as that can cause an inaccurate low reading.

     

  • Oral (under the tongue) thermometers. These can be used for children 4 years old and older. Use individual plastic covers each time, or clean and sanitize these thermometers each time according to the manufacturer’s instructions. Once the thermometer is turned on, place the tip under the tongue. Make sure the child’s lips are sealed until the thermometer beeps. Do not use teeth to keep the thermometer in place. If the child has had a hot or cold drink, wait 30 minutes after the drink to use an oral thermometer.

     

  • Temporal artery (forehead) thermometers can be used for children of any age. This is the safest and most accurate way to get the temperature for a child under 6 months old in early care and education settings. Follow the manufacturer’s directions to know how and where to slide the thermometer across the forehead to make sure you get accurate results.


  • Axillary (armpit) thermometers. These can be used for a child of any age. Temperatures are only accurate when the thermometer stays in the child’s closed armpit for the time recommended by the manufacturer. This method can be fast, but armpit temperatures are the least accurate.

     

  • Rectal (in the bottom) thermometers. These are not recommended in early care and education programs due to health and safety concerns. A rectal thermometer could perforate (poke a hole) in the child’s rectum if not used properly. It could also pass germs from the stool, and if not properly cleaned, could spread illness among children and staff.
Armpit thermometers, pacifier thermometers, or fever strips are not accurate and not recommended. Glass or mercury thermometers should not be used in early care and education programs due to safety concerns.

 

RATIONALE

Taking an accurate temperature can guide staff as they make decisions about caring for children with a fever. If a child has a fever, early care and education program staff should prepare to manage the illness while keeping the child comfortable and safe. For more information, see 3.6.1.1 Inclusion/Exclusion/Dismissal of Children.

Safety and child abuse concerns may come up when using rectal thermometers. Early care and education program staff should be aware of these concerns. If rectal temperatures are taken, steps must be taken to make sure that all staff members are trained properly in this procedure and the opportunity for abuse is small  (e.g., make sure that more than one adult is present while taking the child’s temperature). Rectal temperatures should be taken only by staff with specific health training in performing this procedure, and parents/guardians must give permission.

Thermometers with mercury can easily break and release toxic levels of mercury fumes. To prevent mercury toxicity, the American Academy of Pediatrics (AAP) does not recommend using mercury or glass thermometers in early care and education programs.1 Many state or local agencies operate facilities that collect used mercury thermometers. For more information on hazardous waste collections in your area, contact your state environmental protection agency or your local public health department.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.1.1.1 Conduct of Daily Health Check
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
REFERENCES
  1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022.
  2. American Academy of Pediatrics. How to take a child’s temperature. Healthychildren.org Web site. Last reviewed October 12, 2020. Accessed April 27, 2022. https://www.healthychildren.org/English/health-issues/conditions/fever/pages/How-to-Take-a-Childs-Temperature.aspx

  3. American Academy of Pediatrics. Signs and symptoms of fever. Healthychildren.org Web site. Last reviewed November 21, 2015. Accessed April 27, 2022. https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Signs-and-Symptoms-of-Fever.aspx

NOTES

Standard was last updated on September 13, 2022.

3.6.1.4: Infectious Disease Outbreak Control


During the course of an identified outbreak of any reportable illness at the facility, a child or staff member should be excluded if the health department official or primary care provider suspects that the child or staff member is contributing to transmission of the illness at the facility, is not adequately immunized when there is an outbreak of a vaccine preventable disease, or the circulating pathogen poses an increased risk to the individual. The child or staff member should be readmitted when the health department official or primary care provider who made the initial determination decides that the risk of transmission is no longer present.
RATIONALE
Secondary spread of infectious disease has been proven to occur in child care. Control of outbreaks of infectious diseases in child care may include age-appropriate immunization, antibiotic prophylaxis, observing well children for signs and symptoms of disease and for decreasing opportunities for transmission of that may sustain an outbreak. Removal of children known or suspected of contributing to an outbreak may help to limit transmission of the disease by preventing the development of new cases of the disease (1).
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness
3.6.4.1 Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease
3.6.4.2 Infectious Diseases That Require Parent/Guardian Notification
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
REFERENCES
  1. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.

3.6.1.5: Sharing of Personal Articles Prohibited


Combs, hairbrushes, toothbrushes, personal clothing, bedding, and towels should not be shared and should be labeled with the name of the child who uses these objects.
RATIONALE
Respiratory and gastrointestinal infections are common infectious diseases in child care. These diseases are transmitted by direct person-to-person contact or by sharing personal articles such as combs, brushes, towels, clothing, and bedding. Prohibiting the sharing of personal articles and providing space so that personal items may be stored separately helps prevent these diseases from spreading.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
5.5.0.1 Storage and Labeling of Personal Articles