Some Guidelines for DayCare & PreSchool Facilities for Ill Children
September 21, 2019
Category: Pediatric Illness


I recently came accross the 3rd edition of "Caring for Our Children: National Health and Safety Performance Standards" from 2011_ a very comprehensive listing of Health and Safety Standards for facilities caring for our children <>.  Below are a few standards that relate to criteria for inclusion and exclusion from daycares and preschools of infants, toddlers and young children who are ill or recovering from illness. 

I found the informatin on fever in an otherwise well child and diarrhea especially helpful.

Dr. T


National Health and Safety Performance Standards;

Guidelines for Early Care and Education Programs, Third Edition


3.6 Management of Illness

3.6.1 Inclusion/Exclusion Due to Illness

STANDARD Inclusion/Exclusion/Dismissal of Children

(Adapted from: Aronson, S. S., T. R. Shope, eds. 2009.

Managing infectious diseases in child care and schools: A quick reference guide, 39-43. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.)

Preparing for managing illness:

Caregivers/teachers should:

a) Encourage all families to have a backup plan for child care in the event of short or long term exclusion;

b) Review with families the inclusion/exclusion criteria and clarify that the program staff (not the families) will make the final decision about whether children who are ill may stay based on the program’s inclusion/exclusion criteria and their ability to care for the child who is ill without compromising the care of other children in the program;

c) Develop, with a child care health consultant, protocols and procedures for handling children’s illnesses, including care plans and an inclusion/exclusion policy;

d) Request the primary care provider’s note to readmit a child if the primary care provider’s advice is needed to determine whether the child is a health risk to others, or if the primary care provider’s guidance is needed about any special care the child requires (1);

e) Rely on the family’s description of the child’s behavior to determine whether the child is well enough to return, unless the child’s status is unclear from the family’s report.

Daily health checks as described in Standard should be performed upon arrival of each child each day. Staff should objectively determine if the child is ill or well.

Staff should determine which children with mild illnesses can remain in care and which need to be excluded.


Staff should notify the parent/guardian when a child develops new signs or symptoms of illness. Parent/guardian notification should be immediate for emergency or urgent issues. Staff should notify parents/guardians of children who have symptoms that require exclusion and parents/guardians should remove the child from the child care setting as soon as possible. For children whose symptoms do not require exclusion, verbal or written notification of the parent/

guardian at the end of the day is acceptable. Most conditions that require exclusion do not require a primary care provider visit before reentering care.


Conditions/symptoms that do not require exclusion:

a) Common colds, runny noses (regardless of color or consistency of nasal discharge);

b) A cough not associated with an infectious disease (such as pertussis) or a fever;

c) Watery, yellow or white discharge or crusting eye discharge without fever, eye pain, or eyelid redness;

d) Yellow or white eye drainage that is not associated with pink or red conjunctiva (i.e., the whites of the eyes);

e) Pink eye (bacterial conjunctivitis) indicated by pink or red conjunctiva with white or yellow eye mucous drainage and matted eyelids after sleep. Parents/guardians should discuss care of this condition with their child’s primary care provider, and follow the primary care provider’s advice. Some primary care providers do not think it is necessary to examine the child if the discussion with the parents/guardians suggests that the condition is likely to be self-limited.

If two unrelated children in the same program have conjunctivitis, the organism causing the conjunctivitis may have a higher risk for transmission and a child health care professional should be consulted;

f) Fever without any signs or symptoms of illness in children who are older than six months regardless of whether acetaminophen or ibuprofen was given.

Fever (temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method) is an indication of the body’s response to something, but is neither a disease nor a serious problem by itself. Body temperature can be elevated by overheating caused by overdressing or a hot environment, reactions to medications, and response to infection.

If the child is behaving normally but has a fever of below 102oF per rectum or the equivalent, the child should be monitored, but does not need to be excluded for fever alone;

g) Rash without fever and behavioral changes;

h) Lice or nits (exclusion for treatment of an active lice infestation may be delayed until the end of the day);

i) Ringworm (exclusion for treatment may be delayed until the end of the day);

j) Molluscum contagiosum (do not require exclusion or covering of lesions);

k) Thrush (i.e., white spots or patches in the mouth or on the cheeks or gums);

l) Fifth disease (slapped cheek disease, parvovirus B19) once the rash has appeared;

m) Methicillin-resistant Staphylococcus aureus, or MRSA, without an infection or illness that would otherwise require exclusion. Known MRSA carriers or colonized individuals should not be excluded;

n) Cytomegalovirus infection;

o) Chronic hepatitis B infection;

p) Human immunodeficiency virus (HIV) infection;

q) Asymptomatic children who have been previously evaluated and found to be shedding potentially infectious organisms in the stool. Children who are continent of stool or who are diapered with formed stools that can be contained in the diaper may return to care. For some infectious organisms, exclusion is required until certain guidelines have been met.

Note: These agents are not common and caregivers/teachers will usually not know the cause of most cases of diarrhea;

r) Children with chronic infectious conditions that can be accommodated in the program according to the legal requirement of federal law in the Americans with Disabilities Act. The act requires that child care programs make reasonable accommodations for children with disabilities and/or chronic illnesses, considering each child individually.


Key criteria for exclusion of children who are ill:

When a child becomes ill but does not require immediate medical help, a determination must be made regarding whether the child should be sent home (i.e., should be temporarily “excluded” from child care). Most illnesses do not require exclusion. The caregiver/teacher should determine if the illness:

a) Prevents the child from participating comfortably in activities;

b) Results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;

c) Poses a risk of spread of harmful diseases to others. If any of the above criteria are met, the child should be excluded, regardless of the type of illness. Decisions about caring for the child while awaiting parent/guardian pick-up should be made on a case-by-case basis providing care that is comfortable for the child considering factors such as the child’s age, the surroundings, potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in their usual care setting while awaiting pick-up, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children not previously in close contact with the child. All who have been in contact with the ill child must wash their hands. Toys, equipment and surfaces used by the ill child should be cleaned and disinfected after the child leaves. Temporary exclusion is recommended when the child has any of the following conditions:

a) The illness prevents the child from participating comfortably in activities;

b) The illness results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;

c) An acute change in behavior - this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash;

d) Fever (temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method) and behavior change or other signs and symptoms (e.g., sore throat, rash, vomiting, diarrhea). An unexplained temperature above 100°F (37.8°C) axillary (armpit) or 101°F (38.3°C) rectally in a child younger than six months should be medically evaluated. Any infant younger than two months of age with any fever should get urgent medical attention. See COMMENTS Below for important information about taking temperatures;

e) Diarrhea is defined by watery stools or decreased form of stool that is not associated with changes of diet. Exclusion is required for all diapered children whose stool is not contained in the diaper and toilet-trained children if the diarrhea is causing soiled pants or clothing. In addition, diapered children with diarrhea should be excluded if the stool frequency exceeds two or more stools above normal for that child, because this may cause too much work for the caregivers/teachers. Readmission after diarrhea can occur when diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children are continent.


Special circumstances that require specific exclusion criteria include the following (2):

1) Toxin-producing E. coli or Shigella infection, until stools are formed and the test results of two stool cultures obtained from stools produced twenty-four hours apart do not detect these organisms;


2) Salmonella serotype Typhi infection, until diarrhea resolves. In children younger than five years with Salmonella serotype Typhi, three negative stool cultures obtained with twenty-four-hour intervals are required; people five years of age or older may return after a twenty-four-hour period without a diarrheal stool. Stool cultures should be collected from other attendees and staff members, and all infected people should be excluded;

f) Blood or mucus in the stools not explained by dietary change, medication, or hard stools;

g) Vomiting more than two times in the previous twenty-four hours, unless the vomiting is determined to be caused by a non-infectious condition and the child remains adequately hydrated;

h) Abdominal pain that continues for more than two hours or intermittent pain associated with fever or other signs or symptoms of illness;

i) Mouth sores with drooling unless the child’s primary care provider or local health department authority states that the child is noninfectious;

j) Rash with fever or behavioral changes, until the primary care provider has determined that the illness is not an infectious disease;

k) Active tuberculosis, until the child’s primary care provider or local health department states child is on appropriate treatment and can return;

l) Impetigo, until treatment has been started;

m) Streptococcal pharyngitis (i.e., strep throat or other streptococcal infection), until twenty-four hours after treatment has been started;

n) Head lice until after the first treatment (note: exclusion is not necessary before the end of the program day);

o) Scabies, until after treatment has been given;


p) Chickenpox (varicella), until all lesions have dried or crusted (usually six days after onset of rash);


q) Rubella, until six days after the rash appears;


r) Pertussis, until five days of appropriate antibiotic treatment;


s) Mumps, until five days after onset of parotid gland swelling;


t) Measles, until four days after onset of rash;


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