Illness in the childcare setting happens every day, in spite of your best preventive efforts. Because children are different and express illnesses so individually, appropriate intervention is often challenging. Caregivers are constantly serving as gatekeepers, trying to be sensitive to a parent’s need not to miss work while assessing whether a mildly ill child should remain in care or return home.

Preschool children commonly experience mild illnesses, more often colds and occasional gastrointestinal upsets, as often as every other month. That translates into six or more tricky childcare situations per child per year. Illnesses occurring in the childcare setting mirror illnesses occurring in the community; what is seen in childcare programs is being seen at the same time in surrounding neighborhoods. More often than not, by the time the caregiver becomes aware that a child is ill, other children already have been exposed.

What To Do with Sick Children

Childcare programs can better handle illnesses and when to send children home with clear, written policies and procedures to guide the management of sick kids. When developing communicable disease policies in the childcare setting, a number of associated questions arise such as:

• If it is determined that a child must go home before the scheduled time, how is that child handled until the parent arrives?
• Is it sensible, or sensitive to the child, to separate the ill child from other children?
• Would it make more sense (and be more sensitive) to allow the ill child to remain in the program, resting on a mat or cot in a quiet corner, safe in familiar surroundings?
• What about adjusting plans for the day to entertain the other children away from this area?

Typically, quarantine at this point is ineffective and unnecessary. A child who is moved to an area away from the other children must be accompanied by an adult. That can result in an inappropriate staff/child ratio which may compromise the safety of other children.

It is critical to remember that if it appears a child has a life-threatening illness or injury, emergency help must be summoned immediately. Local emergency numbers should be ready at hand. Life-threatening emergencies could include seizures that last more than five minutes or that affect breathing; allergic reactions or asthma attacks that affect breathing in any way and that do not respond to medication or treatment; cardiac concerns; head injuries; a broken bone; bleeding that cannot be quickly stopped; disorientation or loss of consciousness; dehydration resulting in lethargy and lack of urine or tears; or any condition that seems beyond the staff’s skill to respond. Staff should practice responding to emergencies to ensure that everyone knows specific roles, whether as responder, caregiver for other children, parent contactor, etc.

Health Check

A brief “health check” when children arrive at the program often can prevent later problems. Take a moment, at child level, to note the overall mood and appearance of the child. Quickly assess breathing, looking for nasal drainage or a deep cough; observe the child’s skin color, temperature, and mood; and watch for rashes, obvious injuries or other abnormal marks.

At the same time, discuss with the parent how the child acted at home and if there is information you should know as a caregiver. Take advantage of the parent’s presence to discuss any concerns you have, and regularly confirm that you have correct parent contact numbers.

There are few hard and fast rules regarding whether an ill child should stay or go. However, most authorities agree that a child who has an illness requiring so much of a caregiver’s time that the care of the rest of the children is compromised should be at home. The same is true for a child whose illness prevents comfortable participation in daily activities. Children who exhibit cold symptoms or have a fever but who are behaving normally should not be sent home automatically.

The following specific conditions generally require exclusion:

• Change in temperature accompanied by behavior change.
• Lethargy, uncontrolled coughing, unexplained irritability or crying, difficulty breathing, wheezing, or other unusual signs of severe illness.
• Blood in stools.
• Diarrhea (watery, less formed, frequent stools) not explained by diet change or medication and that poses a risk to others because it cannot/may not be managed successfully by diapers or toilet use.
• Vomiting two or more times in a 24-hour period.
• Persistent abdominal pain.
• Mouth sores in a drooling child.
• Rash with fever or behavior change.
• Pus coming from the eyes (purulent conjunctivitis).
• Persistent honey-colored crusts (impetigo) on face or body.
• Chicken pox, even in a vaccinated child.

In addition, children who have been medically diagnosed with certain conditions should be excluded, and a note from the medical provider should be required before a child is allowed to return. Common diagnoses that are in this category include:

• Strep throat
• Tuberculosis
• Whooping cough (pertussis)
• Mumps
• Hepatitis A
• Measles
• Rubella
• Herpes Simplex

Remember, some communicable diseases, particularly some viruses, can be present with no observable symptoms. Children carrying CMV (cytomegalovirus), hepatitis B, or HIV infection should not be excluded. Precautions to prevent the spread of such diseases must be in place at all times for all children and staff. The responsibility for protection from disease spread begins with individual practice.

Janie Sailors, RN
Health Specialist, Training and Technical Assistance Services, Western Kentucky University

Resources

Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care, Second Edition, National Resource Center for Health and Safety in Child Care, UCHSC at Fitzsimons, Campus Mail Stop F541, PO Box 6508, Aurora, CO 80045-0508; 800-598-KIDS; nrc.uchsc.edu/SPINOFF/IE/ExcInc.htm.

Internet Resources

Keeping Kids Healthy, www.keepkidshealthy.com/welcome/infectionsguide/school_exclusion.html

Healthy Child Care America, www.healthychildcare.org/health_promotion.cfm