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Child Care Illness Exclusion Guidelines Not Being Followed,Taking Toll on Parents, Children, Caregivers and Physicians


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A study led by a physician at Cincinnati Children's Hospital Medical Center and published in the November issue of Pediatrics indicates that parents, child care providers and physicians are unfamiliar with national guidelines on excluding children from child care based on illness.

Kristen Copeland, MD, a physician in the Division of General and Community Pediatrics and lead author of the study, discovered that many children are excluded from child care when they shouldn't be, forcing parents to take time away from work. For every child appropriately excluded from child care, there are at least six children that child care providers exclude who do not meet criteria for exclusion, according to Dr. Copeland.

"Inappropriate exclusions from child care place a heavy burden on working parents, who often struggle to find alternate last-minute child-care arrangements" says Dr. Copeland. "In some cases, parents risk losing their jobs if forced to miss work to care for a child who has been excluded from child care."

The researchers surveyed 215 pediatricians, 223 parents and 192 child care providers between January and July 2004. The surveys contained six case scenarios depicting common child care illnesses: upper respiratory infection (a cold), conjunctivitis (pink eye), gastroenteritis (stomach flu), mild fever, ringworm and eczema.

The researchers asked whether children should be excluded immediately from child care based on each scenario. Responses were compared to national illness exclusion guidelines, which were jointly published by the American Academy of Pediatrics and the American Public Health Association in 1992 and revised in 2002.

Child care providers complied with national illness exclusion guidelines in 60 percent of cases, parents in 61 percent of cases and pediatricians in 74 percent of cases. Only 23 percent of child care providers and pediatricians indicated they were familiar with national guidelines by name, and only 17 percent of parents were familiar with national guidelines.

After their children are excluded from child care, parents often ask pediatricians for a note so their children can be readmitted, and pediatricians tended to allow children to return to care before they were able to participate fully in planned child care activities. "Allowing these children to remain in care could divert caregiver attention away from other, healthy children in the child care setting," says Dr. Copeland.

Temporary exclusions are designed to prevent the spread of disease and enable children to obtain the care and attention they need. The guidelines define three conditions for exclusion:

  • Inability of the child to participate in program activities
  • Caregiver inability to provide care for the child without compromise of care for the other children in the group
  • Specific symptoms and diseases that warrant temporary exclusion from child care

"The most common mistake that parents and child care providers made was to say that ringworm needed to be sent home immediately," says Dr. Copeland. "Sixty-three percent of parents we surveyed believed that, as did 79 percent of child care providers. In fact, the guidelines recommend that this wait until the end of the day. The most common mistake that pediatricians made (36 percent) was to leave children in child care who were miserable due to eczema and unable to participate in normal activities.

"All three groups seemed to be unaware that clear eye discharge (allergic conjunctivitis) does not warrant exclusion. In addition, the groups did not consistently answer in line with the recommended guidelines for fever (a temperature over 100°, measured in the armpit). National guidelines state that a child must have a fever over 100° and associated symptoms or behavioral changes in order to warrant exclusion," says Dr. Copeland.

Pediatricians were more likely to comply with national guidelines than child care providers or parents for colds, pinkeye and ringworm. The three groups had similar compliance rates for stomach flu, fever and eczema, according to Dr. Copeland.

Dr. Copeland suggests that parents seeking child care for their children ask about the center's sick policies and whether they comply with national guidelines. These guidelines are available from the National Resource Center for Health and Safety in Child Care web site. Parents also should obtain a copy of a child care center's exclusion policies upon enrolling their children, says Dr. Copeland.

Approximately one of every three children from birth to age 6 spends time in a child care center, and 57 percent of children between the ages of 3 and 6 attend a child care center. Infections in child care are common. Studies have estimated the cost to society at more than $1.8 billion. The inclusion or exclusion of ill children not only affects parents' absenteeism from work but also the utilization of health care resources: Many centers require a readmission note from the child's doctor stating that the child is safe to return to child care and no longer contagious.

Cincinnati Children's is a 475-bed institution devoted to bringing the world the joy of healthier kids. Cincinnati Children's is dedicated to transforming the way health care is delivered by providing care that is timely, efficient, effective, family-centered, equitable and safe. Cincinnati Children's ranks second nationally among all pediatric centers in research grants from the National Institutes of Health. It is a teaching affiliate of the University of Cincinnati College of Medicine. The Cincinnati Children's vision is to be the leader in improving child health.

Contact Information

Jim Feuer, 513-636-4656, jim.feuer@cchmc.org