Excluding Children in Childcare Due to Illness (page 2)
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.
- Fever in the absence of any other signs or symptoms of illness.
- 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.
- Nonpurulent conjunctivitis, defined as a pink eye with a clear, watery discharge and without fever, eye pain, or eyelid redness.
- Rash without fever and without behavior changes.
- Diagnosed CMV infection.
- Carrier of hepatitis B virus, if they have 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.
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:
- 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.
- Symptoms and signs of possible severe illness such as unusual tiredness, uncontrolled coughing or wheezing, continuous crying, or difficulty breathing.
- Diarrhea — runny, watery or bloody stools.
- Vomiting — more than once 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. (Viral conjunctivitis usually has a clear, watery discharge
and may not require medication or exclusion.)
- Head lice or nits (eggs)
- Severe coughing — child gets red or blue in the face, or makes high-pitched whooping sound after coughing.
- 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.
What to do when a child becomes ill in your program
- Attempt to keep the child from intimate contact with other children and staff. Remove and sanitize toys and other items they may have put into their mouth. WASH HANDS!
- Contact the parents to have the child picked up as soon as possible. Make the child as comfortable as possible. Do not isolate them in such a way that you cannot provide supervision at all times.
- Continue to observe the child for new or worsening symptoms.
- If the child does not respond to you, is having trouble breathing, or is having a seizure, call 9-1-1.
- Document your actions in the child’s file with date, time, symptoms, actions taken, by whom, and be sure to add your signature.
When to get immediate help
Some conditions require immediate medical help. If the parent can be reached, tell them to come right away and to notify their medical provider. If the parent or the child’s medical provider is not immediately available, call 9-1-1 (EMS) for immediate help.
Tell the parent to come right away, and get medical help immediately, when any of the following things happen:
- An infant under four months of age has an axillary (“armpit”) temperature of 100° F or higher (A child over four months of age has an axillary temperature of 105° F or higher).
- An infant under four months of age has two or more forceful vomiting episodes (not the simple return of swallowed milk or spit-up) after eating.
- A child looks or acts very ill, or seems to be getting worse quickly.
- A child has neck pain when the head is moved or touched.
- A child has a stiff neck or severe headache.
- A child has a seizure for the first time.
- A child acts unusually confused.
- A child has uneven, different-sized pupils (black center spots of the eyes).
- A child has a blood-red or purple rash made up of pinhead-sized spots or bruises that are not associated with injury.
- A child has a rash of hives or welts that appears quickly.
- A child breathes so fast or hard that he or she cannot play, talk, cry or drink.
- A child has a severe stomach ache that causes the child to double up and scream.
- A child has a stomach ache without vomiting or diarrhea after a recent injury, blow to the abdomen or hard fall.
- A child has stools that are black or have blood mixed through them.
- A child has not urinated in more than eight hours, and the mouth and tongue look dry.
- A child has continous, clear drainage from the nose after a hard blow to the head.
Caring for Our Children, National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs. Washington, D.C.: American Public Health Association and American Academy of Pediatrics (1992).
Keeping Kids Healthy: Preventing and Managing Communicable Disease in Child Care. CA Department of Education (1994).
Reprinted with the permission of the California Childcare Health Program.
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