Excluding Children Due to Illness

How do you decide if a child is too sick to be at childcare? Do you find yourself giving in to parents' pleas and letting children attend who seem too sick, or do you draw a firm line in the sandbox and refuse to care for children with even mild symptoms?

Deciding which children need to be excluded due to illness and when they can be readmitted after an illness is one of the most important decisions a childcare provider has to make--but it does not have to be the most difficult.

Why to Exclude

In general, there are three reasons to exclude sick children:

• The child does not feel well enough to participate comfortably in routine activities.
• The child requires more care than staff are able to provide without compromising the health and safety of the other children.
• The illness is on the list of diagnosed symptoms or conditions for which exclusion is recommended (see below), usually because of the chance of spreading.

The National Centers for Disease Control and Prevention recommends that children with the following conditions or symptoms should be excluded from childcare either to reduce the risk of spreading the infection, or to allow children time to recover to the point where you can safely care for them or both:

Conditions and Diseases

• Tuberculosis, until an appropriate health care provider or health official certifies that the child is in appropriate therapy and can attend care.
• Impetigo, until 24 hours after treatment has been initiated.
• Chickenpox (Varicella-Zoster), until all sores have dried and crusted (usually six days).
• Mumps, until nine days after an onset of parotid gland swelling.
• Hepatitis A virus, until one week after an onset of illness or jaundice or as directed by the health department.
• Measles, until four days after an onset of rash.
• Rubella, until six days after an onset of rash.

Signs and Symptoms

• Fever, when accompanied by behavior changes or other symptoms such as a sore throat, rash, vomiting, diarrhea, earache, etc. Fever means a temperature of 100°F or higher taken under the arm. Any elevated temperature in an infant under age four months should be referred to a physician for evaluation.
• Diarrhea-frequent, runny, watery stools.
• Blood in the stool not explained by dietary change, medication, or hard stool.
• Vomiting two or more times in a 24-hour period.
• Body rash with fever.
• Sore throat with fever and swollen glands or mouth sores with drooling.
• Eye discharge-thick mucus or pus draining from the eye.
• Scabies or head lice when apparently not being treated.
• Severe coughing with the child getting red or blue in the face or making a high-pitched whooping sound after coughing.
• Persistent abdominal pain (more than two hours) or intermittent pain with other signs and symptoms.
• Signs of possible severe illness such as irritability, unusual tiredness, or neediness that compromises your ability to care for other children.
• Uncontrolled coughing or wheezing, continuous crying, or difficulty breathing.

Conditions That Do Not Require Exclusion

Not all conditions and illnesses require that a child be excluded from childcare. Unless it is required by the child's health care provider, your public health department, or your licensing department, the conditions listed below do not require exclusion:

• Fever without other symptoms (except for infants less than four months of age)
• Pink eye (non purulent conjunctivitis) with a clear, watery discharge and without fever, eye pain, or eyelid redness.
• Rash without fever or behavior changes.
• Diagnosed CMV infection.
• Positive tuberculosis skin test in the absence of active tuberculosis disease.
• Presence of hepatitis B virus, if the child has no behavioral or medical risk factors such as unusually aggressive behavior (biting), oozing rashes, or bleeding.
• HIV infection, provided the child's health, immune status and behavior are appropriate as determined by that child's medical provider.
• Parvovirus B19 infection (fifth disease) in a person with a normal immune system.

Steps to a Healthier Program

There are simple steps you can take before children get sick in order to make it easier on everyone when illness does happen.

Start the day with a health check. Perform a brief and casual assessment of each child each day as they arrive and before the parent leaves. Listen to what the child and parent tell you about how the child is feeling. Is the child hoarse, having trouble breathing, or coughing? Did he or she eat breakfast? Look at children from their level. Look for signs of crankiness, pain, discomfort, or fatigue. Does the child look pale, have a rash, sores, or runny nose or eyes? Feel the child's cheek and neck with the back of your hand for warmth, clamminess, or bumps. Smell for unusual odors in their breath or diaper.

Notify parents of their child's symptoms. Tell parents when you see signs or symptoms of illness, and promptly let all families know when a diagnosed communicable condition arises. Post a notice that includes the signs and symptoms to watch for, what to do, and when children with the condition can return.

Every childcare provider including family programs should have a clear, up-to-date exclusion policy. To minimize confusion and misunderstanding, you should distribute and explain your exclusion policies to parents and staff. Ask your health consultant or a health professional to review the policy periodically. Writing a good policy and enforcing it consistently will help reduce conflicts. Make sure all staff understand the policies and how to enforce them.

Lyn Dailey, PHN
California Child Care Health Program

Caring for Our Children: National Health and Safety Performance Standards, Second Edition, 2002; nrc.uchsc.edu/CFOC/index.html

California Childcare Health Program, www.childcarehealth.org

Sample Daily health check form, www.childhealthonline.org/topicforms.htm

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