Excluding Children in Childcare Due to Illness

Four steps to a healthier program

1. Start the day with a health check. Perform a brief and casual assessment of each child every day upon arrival and before the parent leaves. You are familiar with what is typical for each child and can identify “red flags.” 

• 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. Observe 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.

2. Distribute and explain your exclusion policies to parents and staff. Have a clear, up-to-date exclusion policy for illness and provide parents with a copy. Ask your health consultant or a health professional to review it periodically. Writing a sound policy and enforcing it consistently will help reduce conflicts. Make sure all staff understand the policies and how to enforce them.

3. Understand the reasons for exclusion.

• The child doesn’t feel well enough to participate comfortably in routine activities.
• The ill child requires more care than staff are able to provide without compromising the health and safety of the other children.
• The illness is any of the specific list of diagnosed symptoms or conditions for which exclusion is recommended.

4. Notify parents. Inform parents of observed signs or symptoms, and promptly notify all families 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.

Conditions for which exclusion is not recommended:
Certain conditions, by themselves, do not require exclusion unless recommended by the child’s health care provider or the public health department. However, the reasons listed in step 3 still apply. 

1. Fever in the absence of any other signs or symptoms of illness.
2. Presence of germs in urine or stool in the absence of symptoms of illness. Exceptions include potentially serious organisms such as E. coli 0157:H7, shigella or salmonella.
3. Nonpurulent conjunctivitis, defined as a pink eye with a clear, watery discharge and without fever, eye pain, or eyelid redness.
4. Rash without fever and without behavior changes.
5. Diagnosed CMV infection.
6. Carrier of hepatitis B virus, if they have no behavioral or medical risk factors such as unusually aggressive behavior (biting), oozing rashes or bleeding.
7. HIV infection, provided the child’s health, immune status and behavior are appropriate as determined by that child’s medical provider.

Symptoms or conditions for which exclusion is recommended:
For some conditions, exclusion can significantly reduce the spread of infection or allow children time to recover to the point where you can safely care for them: 

1. Fever along with behavior change or other signs of illness such as sore throat, rash, vomiting, diarrhea, earache, etc. Fever is defined as having a temperature of 100º F or higher taken under the arm. Oral temperatures should not be taken on children younger than four years of age. Rectal temperatures are no longer recommended in the child care setting, and mercury-containing thermometers should be avoided. A temperature over 99º F (under the arm) in an infant under 4 months of age should be evaluated by a medical professional.
2. Symptoms and signs of possible severe illness such as unusual tiredness, uncontrolled coughing or wheezing, continuous crying, or difficulty breathing.
3. Diarrhea — runny, watery or bloody stools.
4. Vomiting — more than once in a 24-hour period.
5. Body rash with fever.
6. Sore throat with fever and swollen glands or mouth sores with drooling.
7. Eye discharge — thick mucus or pus draining from the eye. (Viral conjunctivitis usually has a clear, watery discharge
   and may not require medication or exclusion.)
8. Head lice or nits (eggs)
9. Severe coughing — child gets red or blue in the face, or makes high-pitched whooping sound after coughing.
10. Child is irritable, continuously crying, or requires more attention and care than you can provide without
    compromising the health and safety of the other children in your care.