The updated “Managing Infectious Diseases in Child Care and Schools” (Elk Grove Village, Ill.: American Academy of Pediatrics, 2008), also recommends against exclusion for the following conditions that often incite red flags, according to Dr. Jana:
* Hand, foot, and mouth disease. “Children should not be excluded unless they have sores in their mouth with drooling or if the rash is associated with fever or behavior change,” Dr. Jana explained. “Good hygiene is the best way to minimize the opportunity for the spread of this common virus.”
* Fifth disease. Because there is little virus present when the telltale rash appears, exclusion has no preventive benefit.
* Draining skin infection, including methicillin-resistant Staphylococcus aureus (MRSA) infection. “Because of the media attention surrounding MRSA, there’s a lot of anxiety about this, but the reality is, these children should be excluded only if the infection is accompanied by fever, pain, or behavior change,” said Dr. Jana. “There is no need for the caregiver to request a culture, because it won’t affect how the infection will be handled. Some kids without symptoms have MRSA, and there is no good way to eradicate the germ yet from individuals, families, or classrooms.”
* Diarrhea. According to the revised guidelines, diapered children with diarrhea may remain in care if the diarrhea is contained in the diaper and the child has no more than two stools above normal baseline. “This is a departure from the previous recommendation that all diapered children be excluded until the diarrhea resolves or is deemed noninfectious,” said Dr. Jana. Children who are able to use the toilet may remain in care with good hand washing, as long as they don’t have accidents. “Exclusion is appropriate for children with blood in their stool not explained by medication, hard stool, or diet,” she said.
* Vomiting. Exclusion is recommended for a child who has had two or more episodes of vomiting in the previous 24 hours and continuing exclusion until the vomiting resolves or a health care provider determines the cause is not contagious.
* Fever. “Children with fever should not be excluded automatically, unless the fever is accompanied by behavior change or other signs or symptoms of illness,” explained Dr. Jana. The exception to this is children younger than 4 months old with unexplained fever.
* Respiratory illness. Most respiratory illnesses do not require exclusion; however, a child with persistent coughing or trouble breathing should be evaluated for pneumonia, asthma, or serious respiratory infection, such as whooping cough.
* Earache, no fever. “This child should be excluded if he or she requires more care than the staff can reasonably provide,” said Dr. Jana. “Often, these kids are in a lot of pain and cannot participate in routine activities.”
* Lice. “Lice are a nuisance, but they’re not a health hazard,” said Dr. Jana. “Children with lice should be excluded, but they don’t have to be sent home right away. It can wait until the end of the day, and they can return once treatment occurs,” she said.
“Of course, all of these are recommendations, and while they are based in evidence, they are not binding,” Dr. Jana concluded.