Caring for Our Children (2019) recommends the following criteria for excluding a child from child care. Talk with your administrator about your program’s policy on exclusion for illness.

Key Criteria for Exclusion of Children Who Are Ill

When a child becomes ill but does not require immediate medical help, a determination should 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:

1. Prevents the child from participating comfortably in activities
2. Results in a need for care that is greater than the staff can provide without compromising the health and safety of other children
3. Poses a risk of spread of harmful diseases to others

If any of these criteria are met, the child should be excluded, regardless of the type of illness. Decisions about providing care that is comfortable for the child while awaiting parent/guardian pickup should be made on a case-by-case basis, considering factors such as the child’s age, surroundings, potential risk to others, and 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 his or her usual care setting while awaiting pickup, 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 who were not previously in close contact with the child. All who have been in contact with the ill child should 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:

1. The illness prevents the child from participating comfortably in activities.
2. 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.
3. A severely ill appearance—this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash.
4. Fever (temperature >101°F [38.3°C] by any method) with a behavior change in infants older than 2 months. For infants younger than 2 months, a fever (temperature >100.4°F [38°C] by any method) with or without a behavior change or other signs and symptoms (eg, sore throat, rash, vomiting, diarrhea) requires exclusion and immediate medical attention. When taking temperatures remember that:
   • The amount of temperature elevation varies at different body sites.
   • The height of the temperature does not indicate a more- or less-severe illness. The child’s activity level and sense of well-being are far more important that the temperature reading.
   • If a child has been in a very hot environment and heatstroke is suspected, a higher temperature is more serious.
   • The method chosen to take a child’s temperature depends on the need for accuracy, available equipment, the skill of the person taking the temperature, and the ability of the child to assist in the procedure.
   • Oral temperatures are difficult to take for children younger than 4 years.
5. Diarrhea is defined by stools that are more frequent or less formed than usual for that child and not associated with changes in 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 “accidents.” In addition, diapered children with diarrhea should be excluded if stool frequency exceeds 2 stools more than typical for that child during the time in the program day, because this may cause too much work for the caregivers/teachers, or if stools contain blood or mucus. 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 not having “accidents,” and when stool frequency is no more than 2 stools more than typical for that child during the time in the program day.

Special circumstances that require specific exclusion criteria include the following¹:

1. A health care professional should clear the child or staff member for readmission for all cases of diarrhea with blood or mucus. Readmission can occur following the requirements of the local health department authorities, which may include testing for a diarrhea outbreak in which the stool culture result is positive for Shigella, Salmonella serotype Typhi and Paratyphi, or Shiga toxin–producing Escherichia coli (STEC). Children and staff members with Shigella should be excluded until diarrhea resolves and test results from at least 1 stool culture are negative (rules vary by state). Children and staff members with STEC should be excluded until test results from 2 stool cultures are negative at least 48 hours after antibiotic treatment is complete (if prescribed). Children and staff members with Salmonella serotype Typhi and Paratyphi are excluded until test results from 3 stool cultures are negative. Stool should be collected at least 48 hours after antibiotics have stopped. State laws may govern exclusion for these conditions and should be followed by the health care professional who is clearing the child or staff member for readmission.
2. Vomiting more than 2 times in the previous 24 hours, unless the vomiting is determined to be caused by a noninfectious condition and the child remains adequately hydrated.
3. Abdominal pain that continues for longer than 2 hours or intermittent pain associated with fever or other signs or symptoms of illness.
4. Mouth sores with drooling that the child cannot control unless the child’s primary health care provider or local health department authority states that the child is noninfectious.
5. Rash with fever or behavioral changes, until the primary health care provider has determined that the illness is not an infectious disease.
6. Active tuberculosis, until the child’s primary health care provider or local health department states child is on appropriate treatment and can return.
7. Impetigo, only if the child has not been treated after notifying family at the end of the prior program day. Exclusion is not necessary before the end of the day as long as the lesions can be covered.
8. Streptococcal pharyngitis (ie, strep throat) until at least 12 hours after treatment has been started.^1,2
9. Head lice, only if the child has not been treated after notifying the family at the end of the prior program day. Note: Exclusion is not necessary before the end of the program day.
10. Scabies, only if the child has not been treated after notifying the family at the end of the prior program day. Note: Exclusion is not necessary before the end of the program day.
11. Chickenpox (varicella), until all lesions have dried or crusted (usually 6 days after onset of rash and no new lesions have appeared for at least 24 hours).
12. Rubella, until 7 days after the rash appears.
13. Pertussis, until 5 days of appropriate antibiotic treatment.
14. Mumps, until 5 days after onset of parotid gland swelling.
15. Measles, until 4 days after onset of rash.
16. Hepatitis A virus infection, until 1 week after onset of illness or jaundice if the child’s symptoms are mild or as directed by the health department. Note: Protection of the others in the group should be checked to be sure everyone who was exposed has received the vaccine or receives the vaccine immediately.
17. Any child determined by the local health department to be contributing to the transmission of illness during an outbreak.

REFERENCES

1. Aronson, S. S., Shope, T. R., eds. (2019). Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. 5th ed. American Academy of Pediatrics.
2. Kimberlin, D. W., Brady, M. T., Jackson, M. A., Long, S. S., eds. (2021). School health. In:  Red Book: 2021–2024 Report of the Committee on Infectious Diseases. 32nd ed. pp. 136–138. American Academy of Pediatrics.
3. Kimberlin, D. W., Brady, M. T., Jackson, M. A., Long, S. S., eds. (2021). Children in out-of-home child care. In: Red Book: 2021–2024 Report of the Committee on Infectious Diseases. 32nd ed. p.122. American Academy of Pediatrics.

See Caring for Our Children at https://nrckids.org/CFOC/Database/3.6.1.1 for more information.