Nursery School Absences

A fair number of patient encounters for any pediatrician involves toddlers excluded from nursery school/day care for medical problems these places determine are a potential hazard to the other classmates and/or require some treatment for safe return.  Truthfully, it is a fair source of business for us.  Now, while it is impossible to totally ignore the economic realities of maintaining one’s business, it has always been my practice (and, in my experience, for all of my colleague pediatricians that I personally know) to look to the medicine side of things and, as for the other, if not “run itself”, merely let good business flow from good care.

So many of those daycare mandated encounters are simply less than necessary from a treatment or safety standpoint for anyone in that particular center.  As most of these establishments have their exclusion protocols, in reality they are usually drawn up by teachers, administrators, or the business proprietors themselves–in other words, people without formal medical expertise.  They mostly are not based on research or scientific data.

For example, most require antibiotic drops for conjunctivitis with drainage and allow return after 24 hours of treatment.  However, virtually all medical studies indicate that drops have little effect on infection course and do not end contagiousness within 24 hours. >50% of centers require antibiotics to treat diarrhea; as these drugs frequently CAUSE diarrhea that is too often exactly the WRONG approach.

It turns out that the American Academy of Pediatrics, in conjunction with several other medical professional societies, has published a detailed manual for policies and procedures for these childcare facilities.  At almost 600 pages, it covers virtually every non-business/financial issue of those establishments’ daily working routine.  Summarizing , our guidelines do not recommend exclusion for (you intrepid readers can reference page 132 in the link):

  • Common colds irrespective of any nasal discharge
  • cough without fever
  • Pink eye regardless of discharge, unless 2 unrelated students have it at the same time
  • Fever<102 if unaccompanied by any other symptoms of illness
  • Rash without fever or behavior change, including molluscum contagiosum,                ringworm thrush, “Fifth disease” or even MRSA.
  • Lice or nits–only excluded at the end of the day

Recommendations for exclusion include cases where the child is too ill to participate in daily routines; requires care that would be beyond the ability of staff to administer without potentially compromising other children; diarrhea 2x/d greater frequency than the child’s normal stooling pattern or that is not contained in the diaper with blood or mucous, or a demonstrated bacterial cause of that infection; vomiting > 2/24 hours, abdominal pain with fever or > 2 hours; rash with behavior change or fever, mouth sores in drooling child.  Certain diagnosed infections (impetigo, varicella, TB, measles) have recommendations specific to that illness.

I believe it’s a fair question how any childcare center can exceed our scientifically determined recommendations, exclude a child based on their arbitrary decision, AND be justified to keep all of the money for that day’s care.

For what it’s worth, any parent making that point to their daycare facility has my support, even though it likely means fewer office visits for me.  That seems only fair in my mind.  Send along questions and comments, and thanks for following

Immunization update

Let’s review some recent data reported on the unfortunate and ongoing attempts to create controversy regarding immunizations.

Firstly, Danish researchers have summarized 2 large studies. One followed > 530,000 children from 1991-98. Approximately 440,000 were immunized with measles, the rest were not. 738 were diagnosed with either autism or autism spectrum disorder(ASD).  No difference in the incidence of those conditions were discovered between immunized vs  non immunized children either short or long term. Subsequently a second study did the same thing 1999-2010 with > 650,000 children; again, no difference in autism or ASD in children immunized vs those not, despite sorting the data by age, sex, birth cohort, family history of autism, or other immunizations.  Let us note that these 2 studies take place over almost 2 decades and observed over a million people without identifying any association of measles to autism .  I hope all concerned parents will consider that enormous amount of data very carefully.

Another report reviewed injury claims filed and paid by the National Vaccine Compensation Program. The NVCP was developed as a “no fault” system to compensate people for vaccine related injury claims in an effort to help people AND protect the source of life saving vaccine production from destructive litigation.  It is “user friendly”–its default position is that the vaccine is “guilty unless proven innocent” to enable people to receive needed compensation for serious problems (whether there is proof of association or not) and it goes so far as to pay claimants costs for legal representation and witness time irrespective of whether a claim is ultimately paid or not. About 70% of claims received compensation from 2006-17. 3.4 billion vaccine doses were given in that time, and the claim rate was 2/million doses.  A large portion of the claims were localized shoulder injuries when the vaccine was inadvertently injected into joint space causing arthritic changes as opposed to any systemic medical reaction.  For all the heat generated by claims of vaccine risk in the lay press and social media, one must wonder, where are all the actual injury claims?

As of this past Tuesday, New York City has declared the local measles outbreak is over.  Keeping the above in mind, let’s assess the damage: 654 people were diagnosed; 52 hospitalized and 16 required ICU care.  The City spent an additional $6 million to send 500 health workers out to identify and vaccinate recalcitrant citizens.

Unfortunately, here in New Jersey, the infection marches on.  In fact, the Asbury Park Press reports a 53% increase in “religious exemption” claims in schools for measles since 2013-14 (1641 to 2516).  In Ocean County, the absolute number of exemptions has jumped from 145 to 363 students–an increase of 1.8-4.2% of students enrolled. This may sound like small potatoes, but public health studies indicate that we need 95% immunization coverage to achieve “herd immunity.” Less than that and vulnerable people–the old, young, and chronically ill–are at much greater risk of exposure to measles, a disease that historically hospitalizes 25% of its sufferers and kills 2 of every 1,000 who become infected. How is that right, smart, or fair?

Send along questions or comments, and thanks for following.