Medical Exclusion of Sick Children From Child Care Centers
Medical Exclusion of Sick Children From Child Care Centers
Background: Policies for excluding ill children from child care can affect parental absenteeism from the workplace and the utilization of pediatric health care resources.
Methods: We surveyed a representative sample of 310 child care centers throughout Virginia to assess policies for excluding children with fever, common upper respiratory tract illnesses, or head lice.
Results: Of the 183 center directors (59%) who returned completed surveys, 119 (69%) considered a temperature of 100.0°F to 100.4°F to represent fever, but methods for measuring temperature varied widely. Most centers excluded children with low-grade fever, even in the absence of changes in their behavior. Other low-threshold policies could exclude afebrile children with white nasal or eye discharge and children with hair nits, even after treated with a pediculicidal shampoo.
Conclusions: Exclusion policies among child care centers in Virginia vary widely and often are inconsistent with current standards of medical practice. More uniform implementation of exclusion policies established by national consensus panels of experts is needed to reduce unnecessary exclusion of children from child care centers.
In 1995, 19% of the population less than 5 years of age were enrolled in child day-care centers. Such centers often will not allow mildly ill children to remain with their group, requiring parents to leave their workplace early and/or miss work the following day. Forty percent of parental absenteeism from the workplace has been attributed to the illness of a child. Center policies that require a physician examination before an ill child may return to child care can increase family expenditures and utilization of health care resources even further. The direct and indirect costs incurred because of common infections in toddlers attending child care centers can exceed $500 per child per year. Parents may then pressure physicians to prescribe antibiotics to treat self-limiting viral infections so that the child can return to child care in the briefest possible time. In summary, overly stringent exclusion policies can be associated with high social, economic, and medical costs.
The problem is substantial because of the increasing number of children in child care and their more frequent infections compared with children cared for at home. The American Academy of Pediatrics (AAP), the American Public Health Association (APHA), and the Federal Bureau of Maternal and Child Health have collaborated to develop health and safety standards for child care centers, including criteria for the exclusion and return of sick children. According to these standards, most children with mild illnesses should not be excluded from their regular child care program. Exclusion is indicated if (1) the child's minor illness precludes comfortable participation in group activities, (2) the illness necessitates greater care than the child care center staff can provide, (3) other children are likely to become ill because of a significant risk of contagion, or (4) the child has signs or symptoms suggesting more serious illness that requires medical attention. Additional guidelines and implementation tools have been published, but there have been few published studies of actual exclusion practices.
In Virginia, the Department of Social Services has the authority to inspect and license child care centers and family child care homes. Currently, there are more than 2,288 licensed child care centers in Virginia, and according to state regulations, children may not attend child care (unless otherwise instructed by the child's health care provider) if they have (1) a temperature >100.0°F (the regulations provide no guidance on the type of thermometer or anatomic location for measuring temperature); (2) recurrent vomiting or diarrhea; or (3) a communicable disease necessitating exclusion according to the Virginia Department of Health. The purpose of this study was to assess whether there is significant variability in the policies used to determine exclusion of children from licensed child care centers in Virginia because of fever, nasal or eye discharge, or head lice.
Background: Policies for excluding ill children from child care can affect parental absenteeism from the workplace and the utilization of pediatric health care resources.
Methods: We surveyed a representative sample of 310 child care centers throughout Virginia to assess policies for excluding children with fever, common upper respiratory tract illnesses, or head lice.
Results: Of the 183 center directors (59%) who returned completed surveys, 119 (69%) considered a temperature of 100.0°F to 100.4°F to represent fever, but methods for measuring temperature varied widely. Most centers excluded children with low-grade fever, even in the absence of changes in their behavior. Other low-threshold policies could exclude afebrile children with white nasal or eye discharge and children with hair nits, even after treated with a pediculicidal shampoo.
Conclusions: Exclusion policies among child care centers in Virginia vary widely and often are inconsistent with current standards of medical practice. More uniform implementation of exclusion policies established by national consensus panels of experts is needed to reduce unnecessary exclusion of children from child care centers.
In 1995, 19% of the population less than 5 years of age were enrolled in child day-care centers. Such centers often will not allow mildly ill children to remain with their group, requiring parents to leave their workplace early and/or miss work the following day. Forty percent of parental absenteeism from the workplace has been attributed to the illness of a child. Center policies that require a physician examination before an ill child may return to child care can increase family expenditures and utilization of health care resources even further. The direct and indirect costs incurred because of common infections in toddlers attending child care centers can exceed $500 per child per year. Parents may then pressure physicians to prescribe antibiotics to treat self-limiting viral infections so that the child can return to child care in the briefest possible time. In summary, overly stringent exclusion policies can be associated with high social, economic, and medical costs.
The problem is substantial because of the increasing number of children in child care and their more frequent infections compared with children cared for at home. The American Academy of Pediatrics (AAP), the American Public Health Association (APHA), and the Federal Bureau of Maternal and Child Health have collaborated to develop health and safety standards for child care centers, including criteria for the exclusion and return of sick children. According to these standards, most children with mild illnesses should not be excluded from their regular child care program. Exclusion is indicated if (1) the child's minor illness precludes comfortable participation in group activities, (2) the illness necessitates greater care than the child care center staff can provide, (3) other children are likely to become ill because of a significant risk of contagion, or (4) the child has signs or symptoms suggesting more serious illness that requires medical attention. Additional guidelines and implementation tools have been published, but there have been few published studies of actual exclusion practices.
In Virginia, the Department of Social Services has the authority to inspect and license child care centers and family child care homes. Currently, there are more than 2,288 licensed child care centers in Virginia, and according to state regulations, children may not attend child care (unless otherwise instructed by the child's health care provider) if they have (1) a temperature >100.0°F (the regulations provide no guidance on the type of thermometer or anatomic location for measuring temperature); (2) recurrent vomiting or diarrhea; or (3) a communicable disease necessitating exclusion according to the Virginia Department of Health. The purpose of this study was to assess whether there is significant variability in the policies used to determine exclusion of children from licensed child care centers in Virginia because of fever, nasal or eye discharge, or head lice.
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