Caring for our Children

A new Cincinnati Children's Hospital Medical Center study shows that parents, pediatricians and child care providers are equally unknowledgeable about guidelines that recommend whether children should be excluded from child care due to particular illnesses.

As a result, children may be excluded for harmless conditions that do not meet national criteria, such as colds and allergic conjunctivitis, while being allowed to return to child care for some conditions that warrant staying home, such as uncontrolled coughing or persistent diarrhea, according to Kristen Copeland, M.D., a pediatrician at Cincinnati Children's and lead author of the study.

The study, published in the November-December issue of Ambulatory Pediatrics, found that child care providers, parents and pediatricians knew guideline recommendations for 12 common childhood ailments only 60 percent of the time.

"Inappropriate exclusions from child care can have a significant economic impact," says Dr. Copeland. "When their child attending child care becomes ill, parents have limited options. It's easy to see how exclusion can become a contentious issue between parents who may think child care providers are inconsistent and unreasonable in their application of guidelines and those child care providers who resent some parents' attempts to subvert the guidelines."

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.

The guidelines list 28 specific symptoms and diseases that warrant temporary exclusion from child care and seven symptoms and diseases that do not. Most states require centers only to abide by state licensing standards and not to model their sick policies on these national guidelines.

"If acted upon, misconceptions about these guidelines could lead to inappropriate exclusions and unnecessary work absences for parents," says Dr. Copeland. "On the other hand, some misconceptions, particularly among pediatricians, could lead to inappropriate inclusions that could delay medical evaluation and treatment and reduce the quality of child care for other children due to the special demands of an ill child."

To conduct the Ambulatory Pediatrics study, Dr. Copeland and her colleagues surveyed pediatricians, parents and child care providers in the Baltimore area between May and June 2000. While child care providers, parents and pediatricians all had poor knowledge of the guidelines, they had very different beliefs about exclusions, their effectiveness and how consistently they are implemented.

For example, 81 percent of pediatricians thought that current child care exclusion practices result in too many exclusions, while 44 percent of child care providers thought current practices result in too few exclusions. Seventy-eight percent of parents of children in child care were happy with the frequency of exclusions.

More than 80 percent of child care providers, 70% of parents thought that child care providers use good judgment when excluding a child, follow the written guidelines closely and are consistent about which children need to be excluded. Only about a third of pediatricians agreed. Likewise, 70 percent of child care providers and 60 percent of parents felt that sick children should be excluded because child care providers may be held legally responsible for a child's detriment. Only 33 percent of pediatricians felt this way.

"All three groups -- but especially child care providers and parents -- were over-confident about the ability of exclusion to prevent disease spread," says Dr. Copeland. "Because the period of infectivity precedes the manifestation of symptoms for so many of these common childhood viral illnesses, most of the other children and staff in the center have already been exposed once the child becomes ill. Routine hand-washing and sanitation procedures are much more effective than exclusion at preventing disease spread within child care centers."

The guidelines are available as a part of a larger (over 400 page) document detailing health and safety performance standards for child care programs entitled "Caring for our Children", and are available on the internet at http://nrc.uchsc.edu/CFOC/index.html.