Day care dilemma: When 'sick' children are unnecessarily sent home

Apr 19, 2010

In a new study, researchers at the Medical College of Wisconsin and Children's Hospital of Wisconsin, working with Community Coordinated Child Care (4C's), have found that many metropolitan Milwaukee child care directors would unnecessarily send children with mild illnesses home.

Andrew N. Hashikawa, M.D., and colleagues surveyed 305 child care centers in metropolitan Milwaukee to see how closely directors followed national guidelines from the American Academy of Pediatrics (AAP) and the American Public Health Association (APHA) and to identify characteristics associated with unnecessary exclusion decisions. Their findings "Unnecessary Child Care Exclusions in a State That Endorses National Exclusion Guidelines," will be published in the May issue of Pediatrics (published online April 19).

Dr. Hashikawa is an instructor in pediatrics and a third year fellow in pediatric emergency medicine at the Medical College and practices at Children's Hospital.

In 2005, more than two-thirds of children in the United States who were under five required nonparental child care, a vast majority of whom received care in a child care setting. "Children who are excluded from child care place a significant on parents, businesses, and health care resources." Dr. Hashikawa points out.

Mild acute illness accounts for the majority of child care exclusions, many of which have been described as not medically indicated. Previous studies in states without guidelines showed rates varying from 33 percent to 100 percent. The national AAP and APHA guidelines were developed to address this high rate of inappropriate exclusions.

To examine adherence to these guidelines, the researchers used five scenarios for children with mild illness consisting of a cold, conjunctivitis, gastroenteritis, fever and tinea capitis (a scalp infection). Child care directors were surveyed by telephone and were asked which of these children would be required to go home immediately. None of these scenarios should warrant exclusion, according to national guidelines.

The researchers found that overall, directors would unnecessarily exclude 57 percent of with mild illnesses. Responses ranged from eight percent of directors unnecessarily excluding a child with a cold, to 84 percent of directors unnecessarily excluding a child with tinea capitis. Directors with greater child care experience and directors of larger centers made fewer unnecessary exclusion decisions.

"This high rate of inappropriate exclusions persists despite state endorsement of the national AAP and APHA guidelines," says Dr. Hashikawa.

Currently there are no formalized ongoing state training programs available for child care directors to learn about appropriate exclusion guidelines.

"The next step," Dr. Hashikawa suggests, "Is to develop formalized state training programs that directors could use to learn about appropriate exclusion guidelines for mild illness. Our meetings and focus groups with local day care directors indicate that they would overwhelmingly welcome the opportunity to take continuing education classes if they were made available by the state."

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