August 1998
VIENNA, Va. - When children are excluded from day care for common childhood illnesses such as fever, rhinorrhea, conjunctivitis and head lice, the financial burdens to both the parent and the heath care community can be high. The costs of excluding children from day care centers becomes notable, though, when the standards for exclusion among centers vary to the point of conflicting with the standards of common medical practice.
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In 1996, 310 day care centers directors throughout Virginia were sent a questionnaire by researchers from the University of Virginia's department of pediatrics. The survey tried to assess the exclusion policies of day care centers in Virginia regarding common childhood illnesses.
Of these surveys, 183 were studied for analysis, representing centers from rural to urban areas. All the facilities accepted children from 2-5 years old, and about one-third accepted children less than 2 years old.
The majority (57.9%) of facilities reported that their policies for exclusion and return to day care following common pediatric illnesses derived directly from the Virginia Child Day Care Council exclusion policies. These policies say that a child may not attend day care (unless otherwise instructed by the child's health care provider) if he has a temperature greater than 100° F, recurrent vomiting or diarrhea, or a communicable disease requiring exclusion according to the Virginia Department of Heath's communicable disease chart. Yet in practice, these guidelines prove to be vague, and leave day care centers with the burden of making unqualified medical decisions which more often than not result in the exclusion of children.
"When you look at [the state policies], they're not bad; they simply leave a lot of room for interpretation, because they are not specific," said Richard H. Schwartz, MD, Inova Hospital for Children in Falls Church, Va., and a member of the editorial board of Infectious Diseases in Children
"Many pediatricians deal with a lot of unnecessary visits," he said. As an example, many day care centers don't specify the method that should be used to measure temperature, or whether degrees should be added to an axillary temperature. "This can lead to many different interpretations of what the state policies really are."
According to the study, almost 10% of centers considered lower temperatures of 99°-99.9° F to represent fever while slightly more than 10% considered only higher temperatures of 101° F to constitute fever for purposes of exclusion.
For a child with a low-grade fever, as is defined by each separate center, 43.2% reported a policy of immediate exclusion. A majority (79.2%) of day care centers will allow a child with fever to return when the fever is gone, but 37.2% require only that the child be free of fever for at least 24 hours.
The study showed that exclusion for other common illnesses such as rhinorrhea, conjunctivitis and head lice infestation also showed a lack of uniformity. "From the day care standpoint, centers have a fear of getting into trouble by underdiagnosing. Often, they unnecessarily feel that the child will be a contagious risk," said Schwartz. "Keeping children in day care would probably not change the infectivity of the vast majority of upper respiratory illnesses," he said.
Most (82%) day care centers reported that they do not exclude or isolate children with clear or white nasal discharge, but if the nasal discharge becomes yellow or green, 37.7% of centers will exclude these children immediately, even though there is no rational basis for this decision.
The study pointed out that an exclusion policy based on the color of nasal discharge may unintentionally cause parents to equate colored nasal discharge with a diagnosis of acute sinusitis for which antimicrobial therapy may be useful. This type of policy may result in unnecessary physician visits and parental demand for inappropriate antimicrobial treatment.
Over 80% of day care centers reported exclusion of children for eye discharge. Almost 50% of centers required children with yellow or green discharge to see a physician before return to day care, and 37.7% required a doctor visit and a statement that the child is no longer contagious. Several (12.6%) centers required antibiotic therapy before allowing a child to return to day care.
According to the study, the American Academy of Pediatrics (AAP) Red Book guidelines suggest day care exclusion of children with purulent conjunctivitis until the child has been examined by a physician and approved for readmission with treatment. Exclusion is not suggested, however, for a child with nonpurulent conjunctivitis. While purulent discharge is observed more commonly with bacterial conjunctivitis, it can be seen in almost half of children with viral conjunctivitis as well. "Whether there is pus or not really shouldn't matter," said Schwartz. "Unless it's epidemic conjunctivitis, leaving older kids in day care represents very little threat to others."
For children sent home with head lice, day care centers reported a variety of policies concerning when the child may return. About one-quarter require that all signs of lice and nits are gone and that bedding and clothing have been cleaned; while 23.5% require only that all signs of lice and nits are gone; 22.4% require a doctors note of adequate treatment; and 17.5% simply require one head lice treatment before return.
Almost half of all surveyed day care centers required removal of all nits before return, although nit removal after treatment is not considered necessary to prevent spread to others; nits located further than 1 cm from the scalp are typically empty egg casings. Even with the availability of over-the-counter treatments such as permethrin, 22.4% of centers reported requiring a doctor's note of adequate treatment before return to day care, according to the study.
The social, economic and medical costs of day care exclusion policies can pile up quickly. Since many day care centers often cannot or will not accommodate the needs of a sick child, parents must miss work or make alternative arrangements when their children are sick.
Physicians are now subjected to increased parental and day care center pressure to treat a child's illness so that they may return to day care. As a result, children may be subjected to unnecessary antibiotic therapy, with increased risks of adverse drug reactions and antibiotic resistance in the child and community. New policies "would save a lot on medical costs and time spent in certifying that kids can return to school, and would avoid a lot of unnecessary prescriptions," said Schwartz.
According to the study, what is needed is exclusion and return criteria that more accurately reflect what is known about common childhood illnesses and when exclusion is medically indicated. With recommendations in place that include a standardized definition of fever and exclusion policies for the more common childhood conditions, the costs of exclusion would drop.
For more information:
- Pappas, DE, Schwartz, RH, Hayden, GF. Day care exclusion policies: Who's in and who's out? Presented at the Pediatric Academic Societies annual meeting. May 1-5. New Orleans.
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