Caring for Our Children (CFOC)

Chapter 3: Health Promotion and Protection

3.6 Management of Illness

3.6.2 Caring for Children Who Are Ill

3.6.2.1: Exclusion and Alternative Care for Children Who Are Ill


At the discretion of the person authorized by the child care provider to make such decisions, children who are ill should be excluded from the child care facility for the conditions defined in Standard 3.6.1.1. When children are not permitted to receive care in their usual child care setting and cannot receive care from a parent/guardian or relative, they should be permitted to receive care in one of the following arrangements, if the arrangement meets the applicable standards:

  1. Care in the child’s usual facility in a special area for care of children who are ill;
  2. Care in a separate small family child care home or center that serves only children with illness or temporary disabilities;
  3. Care by a child care provider in the child’s own home.
RATIONALE
Young children who are developing trust, autonomy, and initiative require the support of familiar caregivers and environments during times of illness to recover physically and avoid emotional distress (1). Young children enrolled in group care experience a higher incidence of mild illness (such as upper respiratory infections or otitis media) and other temporary disabilities (such as exacerbation of asthma) than those who have less interaction with other children. Sometimes, these illnesses preclude their participation in the usual child care activities. To accommodate situations where parents/guardians cannot provide care for their own children who are ill, several types of alternative care arrangements have been established. The majority of viruses are spread by children who are asymptomatic, therefore, exposure of children to others with active symptoms or who have recently recovered, does not significantly raise the risk of transmission over the baseline (2).
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
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
REFERENCES
  1. Crowley, A. 1994. Sick child care: A developmental perspective. J Pediatric Health Care. 8:261-67.
  2. 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.

3.6.2.2: Space Requirements for Care of Children Who Are Ill

Content in the STANDARD was modified on 8/9/2017.

Environmental space utilized for the care of children who are ill with infectious diseases and cannot receive care in their usual child care group should meet all requirements for well children and include the following additional requirements:

  1. Indoor space that the facility uses for children who are ill, including classrooms, hallways, bathrooms, and kitchens, should be separate from indoor space used with well children. This reduces the likelihood of mixing supplies, toys, and equipment. The facility may use a single kitchen for ill and well children if the kitchen is staffed by a cook who has no child care responsibilities other than food preparation and who does not handle soiled dishes and utensils until after food preparation and food service are completed for any meal;
  2. If the program for children who are ill is in the same facility as the well-child program, well children should not use or share furniture, fixtures, equipment, or supplies designated for use with children who are ill unless they have been cleaned and sanitized before use by well children;
  3. Children whose symptoms indicate infections of the gastrointestinal tract (often with diarrhea) should receive their care in a space separate from other children with other illnesses. Limiting child-to-child interaction, separating staff responsibilities, and not mixing supplies, toys, and equipment reduces the likelihood of disease being transmitted between children
  4. Children with chickenpox, pertussis, measles, mumps, rubella, or diphtheria, require a room with separate ventilation including fresh outdoor air (1);
  5. Each room/home that is designated for the care of children who are ill should have a handwashing sink that can provide a steady stream of clean, running water that is at a comfortable temperature at least for twenty seconds (2). Soap and disposable paper towels should be available at the handwashing sink at all times. A hand sanitizing dispenser is an alternative to traditional handwashing (3,4);
  6. ach room/home that is designated for the care of children who are ill and are wearing diapers should have its own diaper changing area adjacent to a handwashing sink and/or hand sanitizer dispenser.

 

RATIONALE
Transmission of infectious diseases in early care and education settings are influenced by the environmental sanitation and physical space of the facilities (5).
 
Handwashing sinks should be stationed in each room that is designated for the care of ill children to promote hand hygiene and to give the caregivers/teachers an opportunity for continuous supervision of the other children in care when washing their hands. The sink must deliver a consistent flow of water for twenty seconds so that the user does not need to touch the faucet handles. Diaper changing areas should be adjacent to sinks to foster cleanliness and to enable caregivers/teachers to provide continuous supervision of other children in care. 
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
3.2.2.5 Hand Sanitizers
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
5.4.1.10 Handwashing Sinks
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. Centers for Disease Control and Prevention. 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
  3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html.
  4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5

  5. American Academy of Pediatrics. Enterovirus D68 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: 331-334, 658, 692

  6. 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

NOTES

Content in the STANDARD was modified on 8/9/2017.

3.6.2.3: Qualifications of Directors of Facilities That Care for Children Who Are Ill


The director of a facility that cares for children who are ill should have the following minimum qualifications, in addition to the general qualifications described in Director’s Qualifications, Standards 1.3.1.1 and 1.3.1.2:

  1. At least forty hours of training in prevention and control of infectious diseases and care of children who are ill, including subjects listed in Standard 3.6.2.5;
  2. At least two prior years of satisfactory performance as a director of a regular facility;
  3. At least twelve credit hours of college-level training in child development or early childhood education.
RATIONALE
The director should be college-prepared in early childhood education and have taken college-level courses in illness prevention and control, since the director is the person responsible for establishing the facility’s policies and procedures and for meeting the training needs of new staff members (1).
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.3.1.2 Mixed Director/Teacher Role
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
REFERENCES
  1.  Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

3.6.2.4: Program Requirements for Facilities That Care for Children Who Are Ill


Any facility that offers care for the child who is ill of any age should:

  1. Provide a caregiver/teacher who is familiar to the child;
  2. Provide care in a place with which the child is familiar and comfortable away from other children in care;
  3. Involve a caregiver/teacher who has time to give individual care and emotional support, who knows of the child’s interests, and who knows of activities that appeal to the level of child development age group and to a sick child;
  4. Offer a program with trained personnel planned in consultation with qualified health care personnel and with ongoing medical direction.
RATIONALE
When children are ill, they are stressed by the illness itself. Unfamiliar places and caregivers/teachers add to the stress of illness when a child is sick. Since illness tends to promote regression and dependency, children who are ill need a person who knows and can respond to the child’s cues appropriately.
COMMENTS
Because children are most comfortable in a familiar place with familiar people, the preferred arrangement for children who are ill will be the child’s home or the child’s regular child care arrangement, when the child care facility has the resources to adapt to the needs of such children.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.6.2.2 Space Requirements for Care of Children Who Are Ill
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
3.6.4.3 Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
3.6.4.5 Death
10.5.0.1 State and Local Health Department Role

3.6.2.5: Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill


Each caregiver/teacher in a facility that cares for children who are ill should have at least two years of successful work experience as a caregiver/teacher in a regular well-child facility prior to employment in the special facility. In addition, facilities should document, for each caregiver/teacher, twenty hours of pre-service orientation training on care of children who are ill beyond the orientation training specified in Standards 1.4.2.1 through Standard 1.4.2.3. This training should include the following subjects:

  1. Pediatric first aid and CPR, and first aid for choking;
  2. General infection-control procedures, including:
    1. Hand hygiene;
    2. Handling of contaminated items;
    3. Use of sanitizing chemicals;
    4. Food handling;
    5. Washing and sanitizing of toys;
    6. Education about methods of disease transmission.
  3. Care of children with common mild childhood illnesses, including:
    1. Recognition and documentation of signs and symptoms of illness including body temperature;
    2. Administration and recording of medications;
    3. Nutrition of children who are ill;
    4. Communication with parents/guardians of children who are ill;
    5. Knowledge of immunization requirements;
    6. Recognition of need for medical assistance and how to access;
    7. Knowledge of reporting requirements for infectious diseases;
    8. Emergency procedures.
  4. Child development activities for children who are ill;
  5. Orientation to the facility and its policies.

This training should be documented in the staff personnel files, and compliance with the content of training routinely evaluated. Based on these evaluations, the training on care of children who are ill should be updated with a minimum of six hours of annual training for individuals who continue to provide care to children who are ill.

RATIONALE
Because meeting the physical and psychological needs of children who are ill requires a higher level of skill and understanding than caring for well children, a commitment to children and an understanding of their general needs is essential (1). Work experience in child care facilities will help the caregiver/teacher develop these skills. States that have developed rules regulating facilities have recognized the need for training in illness prevention and control and management of medical emergencies. Staff members caring for children who are ill in special facilities or in a get well room in a regular center should meet the staff qualifications that are applied to child care facilities generally.

Caregivers/teachers have to be prepared for handling illness and must understand their scope of work. Special training is required of caregivers/teachers who work in special facilities for children who are ill because the director and the caregivers/teachers are dealing with infectious diseases and need to know how to prevent the spread of infection. Each caregiver/teacher should have training to decrease the risk of transmitting disease (1).

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
10.5.0.1 State and Local Health Department Role
REFERENCES
  1. Heymann, S. J., P. Hong Vo, C. A. Bergstrom. 2002. Child care providers’ experiences caring for sick children: Implications for public policy. Early Child Devel Care 172:1-8.

3.6.2.6: Child-Staff Ratios for Facilities That Care for Children Who Are Ill


Each facility for children who are ill should maintain a child-to-staff ratio no greater than the following:

Age of Children

Child to Staff Ratio

3-35 months

3 children to 1 staff member

36-71 months

4 children to 1 staff member

72 months and older

6 children to 1 staff member
RATIONALE
Some states stipulate the ratios for caring for children who are ill in their regulations. The expert consensus is based on theories of child development including attachment theory and recognition of children’s temporary emotional regression during times of illness (1-3); the lowest ratios used per age group seem appropriate.
COMMENTS
These ratios do not include other personnel, such as bus drivers, necessary for specialized functions such as transportation.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
REFERENCES
  1. Davies, D. 1999. Child development: A practitioner’s guide. New York: The Guilford Press.
  2. Schumacher, R. 2008. Charting progress for babies in child care: CLASP center ratios and group sizes – Research based rationale. http://www.clasp.org/admin/site/babies/make_the_case/files/cp_rationale6.pdf.
  3. Crowley, A. A. 1994. Sick child care: A developmental perspective. J Pediatric Health Care 8:261-67.

3.6.2.7: Child Care Health Consultants for Facilities That Care for Children Who Are Ill


Each special facility that provides care for children who are ill should use the services of a child care health consultant for ongoing consultation on overall operation and development of written policies relating to health care. The child care health consultant should have the knowledge, skills and preparation as stated in Standard 1.6.0.1.

The facility should involve the child care health consultant in development and/or implementation, review, and sign-off of the written policies and procedures for managing specific illnesses. The facility staff and the child care health consultant should review and update the written policies annually.

The facility should assign the child care health consultant the responsibility for reviewing written policies and procedures for the following:

  1. Admission and readmission after illness, including inclusion/exclusion criteria;
  2. Health evaluation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance;
  3. Plans for health care and for managing children with infectious diseases;
  4. Plans for surveillance of illnesses that are admissible and problems that arise in the care of children with illness;
  5. Plans for staff training and communication with parents/guardians and primary care providers;
  6. Plans for injury prevention;
  7. Situations that require medical care within an hour.

RATIONALE: Appropriate involvement of child care health consultants is especially important for facilities that care for children who are ill. Facilities should use the expertise of primary care providers to design and provide a child care environment with sufficient staff and facilities to meet the needs of children who are ill (2,3). The best interests of the child and family must be given primary consideration in the care of children who are ill. Consultation by primary care providers, especially those whose specialty is pediatrics, is critical in planning facilities for the care of children who are ill (1).

RATIONALE
Appropriate involvement of child care health consultants is especially important for facilities that care for children who are ill. Facilities should use the expertise of primary care providers to design and provide a child care environment with sufficient staff and facilities to meet the needs of children who are ill (2,3). The best interests of the child and family must be given primary consideration in the care of children who are ill. Consultation by primary care providers, especially those whose specialty is pediatrics, is critical in planning facilities for the care of children who are ill (1).
COMMENTS
Caregivers/teachers should seek the services of a child care health consultant through state and local professional organizations, such as:
  1. Local chapters of the American Academy of Pediatrics (AAP);
  2. Local Children’s hospital;
  3. American Nurses Association (ANA);
  4. Visiting Nurse Association (VNA);
  5. American Academy of Family Physicians (AAFP);
  6. National Association of Pediatric Nurse Practitioners (NAPNAP);
  7. National Association for the Education of Young Children (NAEYC);
  8. National Association for Family Child Care (NAFCC);
  9. National Association of School Nurses (NASN);
  10. Emergency Medical Services for Children (EMSC) National Resource Center;
  11. State or local health department (especially public health nursing, infectious disease, and epidemiology departments).
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
REFERENCES
  1. Donowitz, L. G., ed. 1996. Infection control in the child care center and preschool, 18-19, 68. 2nd ed. Baltimore, MD: Williams and Wilkins.
  2. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child care centers. Infect Dis Clin North Am 11:347-65.
  3. Crowley A. A. 2000. Child care health consultation: The Connecticut experience. Matern Child Health J 4:67-75.

3.6.2.8: Licensing of Facilities That Care for Children Who Are Ill


A facility may care for children with symptoms requiring exclusion provided that the licensing authority has given approval of the facility, written plans describing symptoms and conditions that are admissible, and procedures for daily care. In jurisdictions that lack regulations and licensing capacity for facilities that care for children who are ill, the child care health consultant with the local health authority should review these plans and procedures annually in an advisory capacity.
RATIONALE
Facilities for children who are ill generally are required to meet the licensing requirements that apply to all facilities of a specific type, for example, small or large family child care homes or centers. Additional requirements should apply when children who are ill will be in care.

This standard ensures that child care facilities are continually reviewed by an appropriate state authority and that facilities maintain appropriate standards in caring for children who are ill.

COMMENTS
If a child care health consultant is not available, than the local health authority should review plans and procedures annually.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
10.2.0.1 Regulation of All Out-of-Home Child Care
10.3.1.1 Operation Permits

3.6.2.9: Information Required for Children Who Are Ill


For each day of care in a special facility that provides care for children who are ill, the caregiver/teacher should have the following information on each child:

  1. The child’s specific diagnosis and the individual providing the diagnosis (primary care provider, parent/guardian);
  2. Current status of the illness, including potential for contagion, diet, activity level, and duration of illness;
  3. Health care, diet, allergies (particularly to foods or medication), and medication and treatment plan, including appropriate release forms to obtain emergency health care and administer medication;
  4. Communication with the parent/guardian on the child’s progress;
  5. Name, address, and telephone number of the child’s source of primary health care;
  6. Communication with the child’s primary care provider.

Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (2). Confidentiality should be maintained at each step in compliance with any laws or regulations that are pertinent to all parties such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Insurance Portability and Accountability Act (commonly known as HIPAA) (2).

RATIONALE
The caregiver/teacher must have child-specific information to provide optimum care for each child who is ill and to make appropriate decisions regarding whether to include or exclude a given child. The caregiver/teacher must have contact information for the child’s source of primary health care or specialty health care (in the case of a child with asthma, diabetes, etc.) to assist with the management of any situation that arises.
COMMENTS
For school-age children, documentation of the care of the child during the illness should be provided to the parent to deliver to the school health program upon the child’s return to school. Coordination with the child’s source of health care and school health program facilitates the overall care of the child (1).
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
REFERENCES
  1. Beierlein, J. G., J. E. Van Horn. 1995. Sick child care. National Network for Child Care. http://www.nncc.org/eo/emp.sick.child
    .care.html.
  2. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.

3.6.2.10: Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill

Content in the STANDARD was modified on 8/9/2017.

Facilities that care for children who are ill who have conditions that require additional attention from the caregiver/teacher, should arrange for a clinical health evaluation prior to admission, by a licensed primary care provider, for each child who is admitted to the facility. A child care health consultant can assist in arranging the evaluation. Facilities who serve children who are ill should include children with conditions listed in Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children if their policies and plans address the management of these conditions, except for the following conditions which require exclusion from all types of child care facilities:

  1. A severely ill appearance. This could include lethargy or lack of responsiveness, irritability, persistent crying, difficulty breathing, or having a quickly spreading rash;
  2. Fever (temperature for an infant or child older than 2 months that is above 101° F [38.3° C] or, in infants younger than 2 months, a temperature above 100.4° F [38.0° F] by any method) and behavior change or other signs and symptoms;
  3. Diarrhea (Defined by stool that is occurring with more frequency or is less formed in consistency than usual in the child and not associated with changes in diet.) Exclusion is required for all diapered children whose stool is not contained in the diaper. For toilet-trained children, exclusion is required when diarrhea is causing “accidents”. Exclude children whose stool frequency exceeds 2 stools above normal frequency) and one or more of the following:
    1. Signs of dehydration, such as dry mouth, no tears, lethargy, sunken fontanelle (soft spot on the head);
    2. Blood or mucus in the stool until it is evaluated for organisms that can cause dysentery;
    3. Diarrhea caused by Salmonella, Campylobacter, Giardia, Shigella or E.coli 0157:H7 until specific criteria for treatment and return to care are met.
  4.  Vomiting 2 or more times in the previous 24 hours, unless vomiting is determined to be caused by a non-communicable or noninfectious condition and the child is not in danger of dehydration;
  5. Contagious stages of pertussis, measles, mumps, chickenpox, rubella, or diphtheria, unless the child is appropriately isolated from children with other illnesses and cared for only with children having the same illness;
  6. Untreated infestation of scabies or head lice; exclusion not necessary before the end of the program day;
  7. Untreated infectious tuberculosis;
  8. Undiagnosed rash WITH fever or behavior change;
  9. Abdominal pain that is intermittent or persistent and is accompanied by fever, diarrhea, vomiting, or other signs and symptoms;
  10. An acute change in behavior;
  11. Undiagnosed jaundice (yellow skin and whites of eyes);
  12. Upper or lower respiratory infection in which signs or symptoms require a higher level of care than can be appropriately provided; and
  13. Severely immunocompromised children and other conditions as may be determined by the primary health care provider and/or child care health consultant (1,2).
RATIONALE
These signs and symptoms may indicate a significant systemic infection that requires professional medical management and parental care (1,2). Diarrheal illnesses that require an intensity of care that cannot be provided appropriately by a caregiver/teacher could result in temporary exclusion (1,2).
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
3.6.1.1 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, pp. 43-48. 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 8/9/2017.