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

Tuesday, May 17, 2005

CINCINNATI -- Studies by a physician at Cincinnati Children's Hospital Medical Center indicate that parents, child care providers and physicians are unfamiliar with national guidelines on excluding children from child care based on illness.

As a result, many children are excluded from child care when they shouldn't be, forcing parents to take time away from work. In addition, some children who meet guideline exclusion criteria remain in child care, possibly exposing other children to illness and diverting caregivers' attention from other, healthy children while attending to ill children.

"Child care providers tend to over-exclude, sending home too many children with ringworm, non-bacterial pink eye, mild stomach aches and runny noses," says Kristen Copeland, MD, a physician in the Division of General and Community Pediatrics at Cincinnati Children's and the lead author of these studies. "On the other hand, pediatricians seemed to be less sensitive to the burden that many of these common childhood ailments impose on child care providers. For instance, they send too many children back to child care with diarrheal illnesses that not only may be infectious but also may place unrealistic demands on child care providers."

Dr. Copeland's studies will be presented May 17 at the annual Pediatric Academic Societies meeting in Washington, D.C.

Temporary exclusions are designed to prevent the spread of disease and enable children to obtain the care and attention they need. The American Academy of Pediatrics and the American Public Health Association jointly published national illness exclusion guidelines in 1992 and revised them in 2002. These guidelines stipulated when sick children must be sent home from child care centers and were based on the best available scientific evidence and expert opinion from the pediatric, infectious disease and early childhood education communities. Yet, in a survey that Dr. Copeland conducted in the state of Maryland, only 23 percent of pediatricians and parents, and 29 percent of child care providers, report that they were familiar with these guidelines.

Dr. Copeland looked at six case scenarios depicting common ailments: upper respiratory illness (a cold), conjunctivitis (pink eye), gastroenteritis (stomach flu), mild fever, ringworm and eczema. Pediatricians correctly identified when exclusion is warranted in each of these scenarios from 64 to 81 percent of the time; parents from 37 to 74 percent of the time, and child care providers from 21 to 74 percent of the time.

"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 (32 percent) was to leave children in child care who were miserable due to eczema and unable to participate in normal activities.

"Overall, alignment with guidelines varied by provider and disease type, adds Dr. Copeland. "Exclusion differences among pediatricians, parents and child care providers may be explained by varying perceptions of disease severity and communicability. This suggests that educational campaigns to increase guideline awareness and compliance should focus on the different health belief and guideline misperceptions among groups. Child care providers often take the heat, but our research suggests that pediatricians need to be educated as well."

In general, children were more likely to be excluded from child care if they had a high fever, if they were felt to require more care than a caregiver could reasonably provide, or if the decision-maker thought that exclusion would prevent the spread of the condition, according to Dr. Copeland.

Approximately one of every three children from birth to age 6 spends time in a child care center, and 55 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 423-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. It ranks third nationally among all pediatric centers in research grants from the National Institutes of Health. The Cincinnati Children's vision is to be the leader in improving child health.

Contact Information

Jim Feuer,, 513-636-4656