3.6.1.1: Inclusion/Exclusion/Dismissal of Ill Children

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

 

Adapted from Shope, T.R., Hashikawa, A.N. (2023). Managing Infectious Disease in Child Care and Schools: A Quick Reference Guide, 6th Edition. American Academy of Pediatrics.

Children in early care and education programs can often become ill. Most illnesses are mild and do not require dismissal or temporary exclusion from programs. But some infectious diseases do require temporary exclusion to control the spread of illness in the program.

Staff should work with a child care health consultant, local public health authority, or other licensed health expert to:

• Develop policies and procedures for dismissal, temporary exclusion, and when to return to the program
• Tell staff and families they are responsible for promptly reporting illness when their child has symptoms
• Watch for and manage illnesses in the program
• Understand when to report infectious illnesses to local public health authorities

Programs should prepare to manage illnesses by:¹

• Working with a child care health consultant to develop procedures for handling illnesses, including care plans for ill children and an inclusion and exclusion policy
• Regularly reviewing the illness policy with staff and families; making it clear that the staff (not the families) will make the final decision about whether ill children may attend. The staff will decide based on the program’s illness guidelines, and their ability to care for the ill child¾while not taking away from the care of other children.
• Encouraging families to have a backup plan for child care when their child cannot attend the program.
• Doing daily health checks (see Standard 3.1.1.1) when children arrive and periodically through the day.
• Discussing the child’s behavior with the family to decide if the child can take part in the program, and if excluded, when the child is well enough to return.

When children are ill, staff should:

• Decide which children with mild illnesses can stay. For children whose symptoms do not need exclusion, verbal or written communication with the parent or guardian at the end of the day is fine.
• Tell parent or guardian when a child has new signs of illness. Contact the parent or guardian immediately for emergencies or urgent issues.
• Tell parents or guardians of children immediately if their child has symptoms that need temporary exclusion, so that they pick up their child as soon as possible.
• Only ask for a healthcare provider’s note to return to the program if their advice is needed to decide:
• If the child is a possible health risk to others
• Or if the program needs more information about special care the child needs

Conditions That Do Not Require Exclusion1–2
Conditions	Notes
Common cold, runny nose, and cough	No exclusion regardless of color or consistency of nasal discharge. For allergies that have similar symptoms to a common cold (e.g., runny nose, sneezing, cough), programs can encourage parents or guardians to get documentation from a healthcare provider to avoid unnecessary exclusions. During outbreaks such as COVID-19, follow recommendations from the Centers for Disease Control and Prevention (CDC) or the local health department.
Cytomegalovirus infection (CMV)	No exclusion required.
Diarrhea	No exclusion if stool is contained in the diaper, there are no toileting accidents, and there are no more than 2 stools per day above the normal for that child.
Eye drainage	No exclusion for watery, yellow or white discharge without fever, eye pain, or significant eyelid redness and swelling.
Fever	Temperature above 100.4° F (38° C) (axillary, temporal, or oral) is a fever. Children over 4 months old without signs of illness do not need to be excluded. Only take a child’s temperature if the child seems ill. (During outbreaks such as COVID-19, follow CDC or local health department recommendations.)
Fifth’s Disease (Parvovirus B19 or slapped cheek disease)	No exclusion for children who have normal immune systems and who don’t have an underlying blood disorder like sickle cell disease.
Hand, foot, and mouth (Coxsackie virus)	No exclusion unless the child has a fever with symptoms, mouth sores, and constant drooling, or if recommended by public health authorities to control an outbreak.3
Hepatitis B virus, chronic	No exclusion required.
HIV infection	No exclusion required.
Impetigo	Cover skin lesions until the end of the day if there is no fever or changes in behavior. If medical treatment starts before returning the next day, no exclusion is needed.
Lice or nits	Treatment may start at the end of the day. If treatment starts before returning the next day, no exclusion needed. “No-nit” policies are not effective in controlling spread of lice and are not recommended.2
Methicillin-resistant (MRSA) and methicillin-sensitive (MSSA) colonization	Colonization is the presence of bacteria on the body without illness. Active lesions or illness may require exclusion.
Molluscum contagiosum	No exclusion or covering of lesions is needed.
Pinkeye	No exclusion needed if pink or red on the white of the eye with or without drainage, without fever or behavioral change.2
Rash without fever or behavior changes	No exclusion necessary. Exception: Call EMS (911) for children who have a new rash with rapidly spreading bruising or small blood spots under the skin.
Ringworm	Cover skin lesions until the end of the day. If medical treatment starts before returning the next day, no exclusion is needed.
Roseola	No exclusion needed unless there is a fever and behavior changes.
Scabies	Treatment may be delayed until the end of the day. As long as treatment starts before returning the next day, no exclusion is needed.
Thrush	No exclusion needed. (The signs of thrush are white spots or patches in the mouth, cheeks, or gums.)

Conditions That Require Temporary Exclusion

Specific Conditions Requiring Temporary Exclusion1-2
Conditions	Notes
Abdominal pain	Exclude with persistent or intermittent pain with fever, dehydration, or other signs or symptoms.
Chickenpox	Exclude until all lesions have dried or crusted (usually 6 days after the start of the rash) and no new lesions have appeared for 24 hours.
COVID-19	Exclude according to current CDC guidelines.
Diarrhea	Exclusion is needed for: Diapered children whose stool is not contained in the diaper Toilet-trained children when diarrhea causes “accidents” or when increased number of bowel movements are a risk for accidents and soiling of toileting areas Children who have more than 2 stools per day above normal for that child while the child is in the program Children whose stool contains blood or mucus Children may return when the stool is contained in the diaper, or when toilet-trained children no longer have accidents or when they have no more than 2 stools above what is usual for the child. For some infectious diarrheal illnesses, exclusion is needed until additional guidelines have been met and programs communicate  with healthcare providers and health departments. Children who have germs in their stool but no symptoms do not need to be excluded, except when infected with Shiga toxin-producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi.
Fever	Exclude with behavior change or other symptoms. A temperature of 100.4° F (38° C) or above (from any site) in infants and children with behavior change. For infants younger than 2 months, a temperature of 100.4° F from any site) or above with or without a behavior change or other symptoms (e.g., sore throat, rash, vomiting, diarrhea) needs exclusion and immediate medical attention. (See Standard 3.6.1.3.)
Head lice	Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not had a medically approved treatment by the time they return.
Hepatitis A	Exclude for 1 week after onset of illness or as directed by the health department.
Impetigo	Exclusion is not needed before the end of the program day if impetigo lesions are covered, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Measles	Exclude until 4 days after onset of rash.
Mouth sores	Exclude children who have sores with drooling that a child is unable to control. Or exclude children who are unable to participate due to symptoms related to the mouth sores.
Mumps	Exclude until 5 days after onset of parotid (salivary) gland swelling.
Pertussis (whooping cough)	Exclude until treated with an appropriate antibiotic for 5 days, or 21 days from start of cough if untreated.
Rash with fever or behavior change	Exclude until a healthcare provider decides the illness is not a harmful contagious disease.
Ringworm	Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Rubella	Exclude until 7 days after onset of rash.
Scabies	Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Skin sores	Exclude if the child has sores on an exposed body surface that are leaking fluid and cannot be covered with a waterproof dressing.
Streptococcal pharyngitis (Strep throat, skin infections)	Exclude until treated with an appropriate antibiotic for 12 hours.
Tuberculosis (active)	Exclude until the healthcare provider or local health department decides the child is no longer infectious.
Vomiting	Exclude if the child vomits two or more times within 24 hours, unless vomiting is due to a noncontagious/noninfectious cause and the child can stay hydrated and take part in activities. If a child with a recent head injury vomits, get emergency medical care.

When children need temporary exclusion, staff should¹:

• Ask parents or guardians to pick the child up as soon as possible following the program’s illness exclusion policies.
• Let the child stay in the usual care setting/classroom (if symptoms allow) while waiting for pickup.
• Move the child to a familiar and comfortable place, supervised by someone who knows the child well and who will continue to watch the child for new or worsening symptoms. If the child is coughing or sneezing, separate the child from other children and staff by at least 3 feet to help decrease exposure to others who were not in close contact with the child before. 
• Make decisions on a case-by-case basis about giving care that is comfortable for the child while waiting for pickup. Consider the child’s age, surroundings, potential risk to others, and type and severity of symptoms. Staff should still appropriately tend to the child’s physical and emotional needs while waiting for pickup.
• If the child-to-staff ratio cannot be met while caring for the ill child, extra staff may be needed to care for the other children until the child is picked up. Putting the ill child in the care of an unfamiliar caregiver or in a different space may make it difficult to care for the child and can expose other people to infectious illnesses.
• Wash their hands, and continue to practice good hand hygiene if they (and other children) had contact with the ill child. Wash and sanitize toys, equipment, and surfaces used by the ill child after the child leaves.
• Discuss illness signs and symptoms with the parent or guardian who is picking up the child. Review illness guidelines for return to child care. If needed, give the family written information that may be shared with a healthcare provider. The information should include when symptoms started, observations about the child, if a temperature was taken (e.g., temperature of 101.5° F at 10:30 am), any actions taken, and the time actions were taken (e.g., ½ tsp children’s acetaminophen given orally at 11:00 am).
• Ask the parent or guardian to share written information from the child’s healthcare provider with staff. If more information is needed, ask for the parent’s or guardian’s written permission to contact the child’s doctor. Sharing health information with staff needs written consent from the parent or guardian.
• Follow the medical advice (if the child saw a healthcare provider) for return to child care. When needed, let staff and families know about a possible exposure to an infectious disease.
• Contact the local health department if a child or staff member might have a reportable or harmful infectious disease. If healthcare providers have different opinions about the care of a child with a reportable infectious disease, the health department has the legal authority to make a final decision.
• Document any care for an ill child in the child’s file with date, time, symptoms, and actions taken (and by whom); sign and date the document.

For programs that routinely offer care for ill children in a space designed for such care: Follow special procedures for giving this service, as defined in CFOC Standard 3.6.2.2 (http://nrckids.org/CFOC).

If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for more information from the healthcare provider when the child returns to care. Children who have been sent home due to illness do not always need to see a healthcare provider.

Reportable/Notifiable Conditions¹

The CDC has a list of infectious diseases that must be reported to public health authorities in the United States at the national level (see https://ndc.services.cdc.gov/search-results-year/). Other conditions may need to be reported to local, state, tribal, or territorial public health authorities. Although laboratories and healthcare providers are expected to report these notifiable diseases, their reporting may not alert health authorities that the child attends an early care and education program or is enrolled in school and may have exposed others. Delayed notification may delay quick responses to prevent illness among those exposed to the child in the group setting. If in doubt about whether to report, contact the local, state, tribal, or territorial health department.

Staff should contact the local health department:

• When a child or staff member who is in contact with others has a reportable disease
• If staff, children, or families in the program have a reportable illness
• For help managing a suspected outbreak. An outbreak is 2 or more unrelated children (i.e., not siblings) with the same diagnosis or symptoms in the same group within 1 week. Clusters of mild respiratory illness, ear infections, and certain skin conditions are common and usually do not need to be reported.

Program staff should work with their child care health consultants to develop policies and procedures for alerting staff and families about their responsibility to report illnesses to the program, and for the program to report diseases to the local health authorities.

COVID-19 modification as of March 26, 2024:   Children who are experiencing any of the symptoms listed below should stay home and get tested: COVID-19 symptoms most likely seen in children: Fever (100.4o F/38o C or higher) or chills Cough Shortness of breath or difficulty breathing Fatigue Muscles and body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea Refer to the complete list Symptoms of COVID-19 | CDC Children who arrive in the program with symptoms or develop symptoms while in care should wear a well-fitting mask while in the building, be sent home and get tested. If a child in care is confirmed to have COVID-19: Follow the Cleaning and Disinfecting Your Facility Guidelines Ensure families understand their child cannot return to in-person care until they have met CDC’s guidance, Maintain the sick child’s confidentiality, as required by the Americans with Disabilities Act (ADA), Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA). Additional Resources: Centers for Disease Control and Prevention Operational Guidance for K-12 Schools and Early Care and Education Programs to Support Safe In-Person Learning Respiratory Virus Guidance Masks

RATIONALE

Although young children often become ill, excluding children from early care and education programs can be stressful for families, and many exclusion decisions made by staff are not correct. Most infections in young children are mild and are spread by children who do not have symptoms. Excluding children with mild illnesses is unlikely to reduce the spread of most infections in early care and education settings. The most important reason for exclusion is if the child can’t take part in activities and the staff can’t care for the child. But exclusion is needed for some infectious diseases to control contamination and spread, and these diseases need criteria for a child’s return.²

COMMENTS

ADDITIONAL RESOURCES

For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 6th Edition, has educational handouts that programs can copy and distribute to parents and guardians, healthcare providers, and staff. This publication is available from the American Academy of Pediatrics at https://shop.aap.org/managing-infectious-diseases-in-child-care-and-schools-6th-edition-paperback/

 

State-specific guidelines for licensing and regulations on exclusion and return to care are at https://licensingregulations.acf.hhs.gov/

 

For a more detailed rationale on inclusion and exclusion, return to care, when a health visit is needed, and health department reporting for children with specific symptoms, please see Appendix A: Signs and Symptoms Chart.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
3.1.1.1 Conduct of Daily Health Check
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Guidelines for Taking Children’s Temperatures
3.6.1.4 Infectious Disease Outbreak Control
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix A: Signs and Symptoms Chart

REFERENCES

1. Shope, T.R., Hashikawa, A.N. (2023). Managing Infectious Disease in Child Care and Schools: A Quick Reference Guide, 6^th Edition. American Academy of Pediatrics.

2. American Academy of Pediatrics, Section 2 recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:116-126

3. Centers for Disease Control and Prevention. Hand, foot, and mouth disease (HFMD) Causes & Transmission. CDC.gov Web site. Last reviewed February 2, 2021. Accessed August 8, 2022. https://www.cdc.gov/hand-foot-mouth/about/transmission.html

NOTES

Content in the STANDARD was modified 04/16/2015, 8/2015, 4/4/2017, 5/21/2019 and 10/25/2022.

COVID-19 modification as of March 26, 2024.