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