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Caring for Our Children: National Health and Safety Performance Standards A Exclusion criteria are resolved. Exclusion criteria are resolved. Exclusion criteria are resolved. If Excluded, Readmit When Oozing sores that leak body fluids outside the diaper. criteria. Child meets routine exclusion Fever accompanied by behavior change. Fever Child looks or acts very ill. Child has difficulty breathing. Child has blood-red or purple rash not associated with injury. criteria. Child meets routine exclusion Severe cough. Rapid or difficult breathing. Wheezing if not already evaluated and treated. blue color of skin or mucous Cyanosis (ie, membranes). is diagnosed and not yet treated.Pertussis with behavior change. Fever criteria. Child meets routine exclusion No, unless • • No, unless • • • • • No, unless • • • • • • • Temporarily Exclude? Yes Yes Yes Notify Parent Not necessary Not necessary unless epi - demics occur (ie, RSV or vaccine-preventable disease like measles or varicella [chickenpox]) Not necessary unless the cough is due to a vaccine-preventable disease, such as pertussis Notify Health Consultant Signs and Symptoms Chart Redness Scaling Red bumps Sores Cracking of skin in diaper region Coughing Runny or stuffy nose Scratchy throat Sneezing Fever Watery eyes Dry or wet cough or yellow-green) white, Runny nose (clear, Sore throat Throat irritation barking cough Hoarse voice, Coughing fits • • • • • • • • • • • • • • • • • Complaints or What Might Be Seen Infection with yeast or bacteria Irritation by rubbing of diaper material against skin wet with urine or stool Adenovirus Coronavirus Enterovirus Influenza virus virus Parainfluenza Respiratory virus (RSV) syncytial Rhinovirus Mycoplasma Pertussis Common cold Lower respiratory infection (eg, bronchiolitis) pneumonia, Croup Asthma Sinus infection Bronchitis Pertussis Noninfectious causes like allergies • • Viruses (early stage of many viruses) • • • • • • • Bacteria • • • • • • • • • • Common Causes Unable to participate. Care would compromise staff’s ability to care for other children. Child meets other exclusion criteria. Cough Diaper Rash Cold Symptoms (Cough is a body response to some - thing that is irritat - ing tissues in the airway anywhere from the nose to the lungs.) Sign or Symptom Routine Exclusion Criteria Applicable to All Signs and Symptoms American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL: Pediatrics; 2017. Used with permission of the American Academy Pediatrics, 2017.

Appendix A Caring for Our Children: National Health and Safety Performance Standards A toilet-trained children do not Cleared to return by health care provider for all cases of bloody diarrhea and diarrhea caused by Shiga toxin-producing Shigella , or Salmonella Escherichia coli, until negative stool culture Typhi serotype requirement has been met. Diapered children have their stool contained by the diaper (even if the stools remain loose) and have toileting accidents. is no more than 2 stools Stool frequency above normal during the time child or what has become is in the program, normal for that child when the seems otherwise well. criteria are resolved. Exclusion Exclusion criteria are resolved. Exclusion criteria are resolved. • • • • If Excluded, Readmit When diaper for diapered Fever with behavior change. Fever Child looks or acts very ill. Child has difficulty breathing. Rapid or difficult breathing. Wheezing if not already evaluated and treated. blue color of skin or mucous Cyanosis (ie, membranes). Cough interferes with activities. Breath sounds can be heard when the child is at rest. Child has blood-red or purple rash not associated with injury. criteria. Child meets routine exclusion Directed by the local health department as part of outbreak management. Stool is not contained in the children. for toilet-trained “accidents” Diarrhea is causing children. exceeds 2 stools above normal Stool frequency during the time child is in program because this may cause too much work for teachers/ caregivers and make it difficult to maintain good sanitation. Blood/mucus in stool. Black stools. No urine output in 8 hours. yellow skin or eyes). Jaundice (ie, with behavior change. Fever Looks or acts very ill. criteria. Child meets routine exclusion ) No, unless child meets routine exclusion criteria. Yes, if • • • • • • • • • • Yes, if • • • • • • • • • • • Temporarily Exclude? Yes Yes Yes Notify Parent continued Not necessary Not necessary except for epiglottitis Yes, if 1 or more cases of bloody diarrhea or 2 or more children in same group with diarrhea within a week Notify Health Consultant Signs and Symptoms Chart ( Fever or irritability Pain Difficulty hearing “Blocked ears” Drainage Swelling around ear Common cold: stuffy/runny nose, sore throat, stuffy/runny nose, Common cold: or mild fever. cough, possible fever, hoarseness, barking cough, Croup: or chest discomfort (symptoms worse at night), especially when breathingvery in. noisy breathing, gasping noisily for breath with mouth Epiglottitis: or bluish high fever, chin pulled down, wide open, unwilling to nails and skin; drooling, (cyanotic) lie down. child is working hard Bronchiolitis and asthma: to breathe; rapid breathing; space between ribs looks like it is sucked in with each breath (retrac - tions); wheezing; whistling sound with breathing; longer to Takes cold/cough; irritable and unwell. breathe out than to breathe in. or rapid breathing, fever, deep cough, Pneumonia: space between ribs looks like it is sucked in with each breath (retractions). croup to symptoms similar Object stuck in airway: (listed previously). Exposed to a known trigger of asthma symptoms: a known trigger and breathing that sounds or looks different from what is normal for that child. Frequent loose or wateryFrequent stools compared with normal pattern (Note that exclusively child’s breastfed infants normally have frequent unformed and somewhat watery stools or may have several days with no stools.) Abdominal cramps Fever Generally not feeling well occasionally present Vomiting • • • • • • • • • • • • • • • • • • Complaints or What Might Be Seen Bacteria Often occurs in context of common cold virus Common cold Croup Epiglottitis Bronchiolitis Asthma Pneumonia Object stuck in airway Exposed to a known trigger of animal asthma symptoms (eg, pollen) dander, Usually viral, less commonly Usually viral, bacterial or parasitic Noninfectious causes such as dietary (drinking too much juice), inflammatorymedications, bowel fibrosis or cystic disease, • • • • • • • • • • • • Common Causes Earache Difficult or Noisy Breathing Diarrhea Sign or Symptom

Appendix A Caring for Our Children: National Health and Safety Performance Standards A For bacterial conjunctivitis, once parent has bacterial conjunctivitis, For Antibi - discussed with health care provider. otics may or not be prescribed. criteria are resolved. Exclusion Exclusion criteria are resolved. Exclusion criteria are resolved. • • If Excluded, Readmit When exclusion criteria. months is above 101°F (38.3°C) Behaviorchange or other signs of illness in addition to fever or child meets other routine exclusion criteria. Unable to participate. ability to care for Care would compromise staff’s other children. ) No, unless child meets routine exclusion criteria. Note: Notify health care provider in case of sudden, severe headache with vomiting or stiff neck that might signal meningitis. It would be concerning if the back of the neck is painful or child can’t look at his or her belly button (putting chin to chest)—differ - ent from soreness in the side of neck. No, unless • • • Note: A temperature considered meaningfully ele - vated above normal, although not necessarily an indi - cation of a significant health problem, for infants and children older than 2 from any site (axillary, oral, or rectal). Get medical attention when infants younger than 4 months have unexplained fever. In any infant younger than 2 months, a temperature above 100.4°F (38.0°C) is considered meaningfully elevated and requires that the child get medical attention immediately, within an hour if possible. The fever is not harmful; however, the illness causing it may be serious in this age group. For bacterial conjunctivitis No. Exclusion is no longer required for this condition. Health care providers may vary on whether to treat this condition with antibiotic medication. The role of antibiotics in treatment and preventing spread is unclear. Most children with pinkeye get better after 5 or 6 days without antibiotics. For other eye problems No, unless child meets other Note: One type of viral conjunctivitis spreads rapidly and requires exclusion. If 2 or more children in the group have watery red eyes without any known chemical irritant exposure, exclusion may be required and health authorities should be notified to determine if the situation involves uncommon epidemic conjunctivitis caused by a specific type of adenovirus. Herpes simplex conjunctivitis (red eyes with blister - ing/vesicles on eyelid) occurs rarely and would also require exclusion if there is eye watering. Temporarily Exclude? Yes Yes Yes Notify Parent continued Not necessary Not necessary Yes, if 2 or more children have red eyes with watery discharge Notify Health Consultant Signs and Symptoms Chart ( Do not give aspirin. It has been linked to Tired and irritable Tired Can occur with or without other symptoms Fever alone is not harmful. When a child has an alone is not harmful. Fever raising the body temperature is part of infection, normal defense against germs. the body’s Rapid elevation of body temperature sometimes triggers a febrile seizure in young children; this The first usually is outgrown by age 6 years. the child requires time a febrile seizure happens, These seizures are frightening medical evaluation. but are usually brief (less than 15 minutes) and do Parents not cause the child any long-term harm. health care provider should inform their child’s even if the child every time the child has a seizure, is known to have febrile seizures. Bacterial infection: pink color of the “whites” of “whites” pink color of the Bacterial infection: Eyelid may eyes and thick yellow/green discharge. or crusted. swollen, be irritated, pinkish/red color of the whites Viral infection: swollen eyelids; waterythe eye; irritated, dis - charge with or without some crusting around the eyelids; may have associated cold symptoms. itchy, tearing, red, Allergic and chemical irritation: sneezing; watery/stringypuffy eyelids; runny nose, discharge with or without some crusting around the eyelids. • • Flushing, tired, irritable, decreased activity Notes • • Warning: an increased risk of Reye syndrome (a rare and seri - ous disease affecting the brain and liver). • • • Complaints or What Might Be Seen Any bacterial/viral infection Other noninfectious causes Any viral, bacterial, or parasitic bacterial, Any viral, infection Vigorous exercise Reaction to medication or vaccine Other noninfectious illnesses (eg, malignancy) rheumatoid arthritis, Bacterial infection of the mem - brane covering 1 or both eyes and eyelids (bacterial conjunctivitis) Viral infection of the membrane covering 1 or both eyes and eyelids (viral conjunctivitis) Allergic irritation of the membrane covering 1 or both eyes and eyelids (allergic conjunctivitis) Chemical irritation of the mem - brane covering the eye and eyelid swim - (irritant conjunctivitis) (eg, ming in heavily chlorinated water, smoke exposure) air pollution, • • • • • • • • • • Common Causes Headache Fever Eye Irritation, Pinkeye Sign or Symptom

Viral: roseola infantum, fifth roseola infantum, Viral: herpesvirus, chickenpox, disease, warts, molluscum contagiosum, shingles (herpes cold sores, and others zoster), Skin infections and infestations: scabies ringworm (fungus), abscesses, impetigo, (parasite), and cellulitis (bacteria) Scarlet fever (strep infection) Severe bacterial infections: pneumo - meningococcus, Staphylococcus coccus, (methicillin-susceptible S aureus ; methicillin-resistant S aureus ), Streptococcu s allergy Noninfectious causes: contact (irritant) eczema, (hives), medication related, dermatitis, poison ivy Oral thrush (yeast infection) Herpes or coxsackievirus infection Canker sores Ringworm Chickenpox Pinworm Head lice Scabies Allergic or irritant reaction (eg, poison ivy) Dry skin or eczema Impetigo Many causes • • • • • • • • • • • • • • • • Common Causes Rash Mouth Sores Itching Sign or Symptom

Appendix A Caring for Our Children: National Health and Safety Performance Standards A condition. For conditions that For condition. On antibiotic medication for required period (if indicated). Infestations (lice and scabies) ringworm can be treated at the end of day with immediate return the following day. criteria are resolved. Exclusion Exclusion criteria are resolved. Exclusion On medication or treated as recommended by a health care provider if treatment is in - dicated for the require application of antibiotics to lesions the period of or taking antibiotics by mouth, treatment to reduce risk of spread others most children with For is usually 24 hours. readmission insect infestations or parasites, as soon the treatment has been given is acceptable. Vomiting ends. ends. Vomiting Able to participate. criteria are resolved. Exclusion Child is on antibiotics (if indicated). criteria are resolved. Exclusion Pain resolves. Pain Able to participate. criteria are resolved. Exclusion Able to swallow. On medication at least 12 hours (if strep). criteria are resolved. Exclusion • • • Exclusion criteria are resolved. • • If Excluded, Readmit When • • • • • • • • • • • If Excluded, Readmit When hours of antibiotics preventable condition, years because these children do not Rash with behavior change or fever. Has oozing/open wound. Has bruising not associated with injury. Has joint pain and rash. Rapidly spreading blood-red rash. especially if it is increasing red area of skin, Tender, in size or tenderness. criteria. Child meets routine exclusion Diagnosed with a vaccine- such as chickenpox. Drooling steadily related to mouth sores. with behavior change. Fever criteria. Child meets routine exclusion Vomited more than 2 times in 24 hours Vomited and fever Vomiting with hives Vomiting that appearsVomit green/bloody No urine output in 8 hours Recent history of head injury Looks or acts very ill criteria. Child meets routine exclusion Difficulty breathing or swallowing. warm glands. tender, Red, with behavior change. Fever criteria. Child meets routine exclusion Severe pain causing child to double over or scream. Abdominal pain after injury. Bloody/black stools. No urine output for 8 hours. Diarrhea (see Diarrhea). Vomiting (see Vomiting). skin/eyes. Yellow with behavior change. Fever Looks or acts very ill. criteria. Child meets routine exclusion Inability to swallow. Excessive drooling with breathing difficulty. with behavior change. Fever criteria. Child meets routine exclusion ) ) No, unless • • • • • • • • No, unless • • • For chickenpox Yes, until lesions are fully crusted For ringworm, impetigo, scabies, and head lice Yes, at the end of day Children should be referred to a health care provider at the end of day for treatment. For pinworm, allergic or irritant reactions like hives, and eczema No, unless appears infected as a weeping or crusty sore Note: Although exclusion for these conditions is not necessary, families should seek advice from the child’s health professional for how to care these health problems. For any other itching No, unless the child meets routine exclusion criteria. Temporarily Exclude? Yes, if • • • • • • • • No, unless • • • • No, unless • • • • • • • • • • No, unless • • • • Note: Most children with red back of throat or tonsils, pus on tonsils, or swollen lymph nodes have viral infections. If strep is present, 12 is required before return to care. However, tests for strep infection are not often necessary for children younger than 3 develop rheumatic heart disease—the primary rea - son for treatment of strep throat. Temporarily Exclude? Yes Yes Yes Notify Parent Yes Yes Yes Yes Notify Parent continued continued For outbreaks, such as mul - tiple children with impetigo within a group Not necessary Yes, for infestations such as lice and scabies; if more than 1 child in group has impetigo or ringworm; for chickenpox Notify Health Consultant For outbreak Not necessary If multiple cases in same group within 1 week Not necessary Notify Health Consultant - Signs and Symptoms Chart ( Signs and Symptoms Chart ( " across. " across. Skin may show similar findings with many differ Determining cause of rash requires ent causes. a competent health care provider evaluation that takes into account information other than just if the child appears well However, how rash looks. a health care provider visit is other than the rash, not necessary. usually signs of general illness such as runny Viral: and fever (except not for warts or cough, nose, Some viral rashes have a distinctive molluscum). appearance. see Itching. Minor skin infections and infestations: fever, pain, redness, More serious skin infections: pus. These children rare. Severe bacterial infections: usually have fever with a rapidly spreading blood- red rash and may be very ill. itchy, Allergy may be associated with a raised, pink rash with bumps that can be as small See a pinpoint or large welts known as hives. also Itching for what might be seen for allergy or contact (irritant) dermatitis or eczema. Oral thrush: white patches on tongue, gums, and gums, white patches on tongue, Oral thrush: along inner cheeks pain on swal - Herpes or coxsackievirus infection: white/red spots in mouth; lowing; fever; painful, cold sore; swollen neck glands; fever blister, painful lips swollen, reddened, painful ulcers inside cheeks or on Canker sores: gums Ringworm: itchy ring-shaped patches on skin or Ringworm: bald patches on scalp. spots surrounded by red blister-like Chickenpox: and body; fever; irritable. face, halos on scalp, anal itching. Pinworm: small insects or white egg sheaths that Head lice: look like grains of sand (nits) in hair. severely itchy red bumps on warm areas Scabies: especially between fingers or toes. of body, mobile circular, raised, Allergic or irritant reaction: rash; reddening of the skin; blisters occur with contact reaction). local reactions (poison ivy, More often dry areas on body. Dry skin or eczema: and behind in front of elbows, worse on cheeks, may be dry areas on face and In infants, knees. If anywhere on body but not usually in diaper area. think about infection. or oozing, red, swollen, oozing sores. areas of crusted yellow, Impetigo: Often around mouth or nasal openings areas of scrapes). broken skin (insect bites, Normal lymph node response: swelling at front, Normal lymph node response: and back of the neck ear; in armpit sides, or groin; anywhere else near an area of these nodes are less than Usually, infection. 1 warm swollen, Bacterial infection of lymph nodes: tender to lymph nodes with overlying pink skin, usually located near an area of the body the touch, Usually these nodes are that has been infected. larger than 1 Viral gastroenteritis or strep throat: Vomiting and Vomiting Viral gastroenteritis or strep throat: diarrhea or cramping are signs of a viral infection Strep throat may of the stomach or intestine. headache, cause stomachache with sore throat, In children older than 3 years, and possible fever. strep is very if cough or runny nose is present, unlikely. Problems with internal organs of the abdomen: persistent severe pain in abdomen. vague complaints with - Nonspecific stomachache: out vomiting/diarrhea or much change in activity. Viral: verbal children will complain of sore throat; Viral: younger children may be irritable with decreased appetite and increased drooling (refusal to swal - Often see symptoms associated with upper low). and cough, such as runnyrespiratory nose, illness, congestion. fight against signs of the body’s Strep throat: red tissue with white patches infection include at back of tongue (tonsil area), on sides of throat, Unlike viral pharyngitis, and at back wall of throat. strep throat infections are not accompanied with cough or runny nose in children older than 3 years. even touching each other. may be large, Tonsils “swollen Swollen lymph nodes (sometimes called glands”) occur as body fights off the infection. • • • • • • • • • • • • • • • • • Complaints or What Might Be Seen Diarrhea, vomiting, or cramping for viral gastroenteritis • • • • • • • • Complaints or What Might Be Seen

in the neck for any Viral: roseola infantum, fifth roseola infantum, Viral: herpesvirus, chickenpox, disease, warts, molluscum contagiosum, shingles (herpes cold sores, and others zoster), Skin infections and infestations: scabies ringworm (fungus), abscesses, impetigo, (parasite), and cellulitis (bacteria) Scarlet fever (strep infection) Severe bacterial infections: pneumo - meningococcus, Staphylococcus coccus, (methicillin-susceptible S aureus ; methicillin-resistant S aureus ), Streptococcu s allergy Noninfectious causes: contact (irritant) eczema, (hives), medication related, dermatitis, poison ivy Oral thrush (yeast infection) Herpes or coxsackievirus infection Canker sores Ringworm Chickenpox Pinworm Head lice Scabies Allergic or irritant reaction (eg, poison ivy) Dry skin or eczema Impetigo Viral infection of the stomach or intestine (gastroenteritis) Coughing strongly Other viral illness with fever food Noninfectious causes: sometimes allergy (—vomiting, dietary and with hives,) trauma, headache medication related, Normal body defense response to viral or bacterial infection in the area where lymph nodes are located (ie, upper respiratory infection) Bacterial infection of lymph nodes that is more than the normal response to infection near where the lymph nodes are located Viral gastroenteritis or strep throat Problems with internal organs of the abdomen such as intestine, bladder liver, colon, and behavioral, Nonspecific, dietary causes may be If combined with hives, associated with a severe allergic reaction Viral—common cold viruses that cause upper respiratory infections Strep throat Many causes • • • • • • • • • • • • • • • • Common Causes • • • • • • • • • • • • Common Causes Rash Mouth Sores Itching Sign or Symptom Vomiting Swollen Glands (properly called swollen lymph nodes) Stomachache Sore Throat (pharyngitis) Sign or Symptom

Appendix A