Caring for Our Children: National Health and Safety Performance Standards A Signs and Symptoms Chart Routine Exclusion Criteria Applicable to All Signs and Symptoms Unable to participate. Care would compromise staff’s ability to care for other children. Child meets other exclusion criteria. Notify Sign or Symptom Common Causes Complaints or What Might Be Seen Notify Health Consultant Parent Temporarily Exclude? If Excluded, Readmit When Cold Symptoms Viruses (early stage of many • Coughing Not necessary unless epi- Yes No, unless Exclusion criteria are resolved. viruses) • Runny or stuffy nose demics occur (ie, RSV or • Fever accompanied by behavior change. • Adenovirus • Scratchy throat vaccine-preventable disease • Child looks or acts very ill. • Coronavirus • Sneezing like measles or varicella • Child has difficulty breathing. • Enterovirus • Fever [chickenpox]) • Child has blood-red or purple rash not associated • Influenza virus • Watery eyes with injury. • Parainfluenza virus • Child meets routine exclusion criteria. • Respiratory syncytial virus (RSV) • Rhinovirus Bacteria • Mycoplasma • Pertussis Cough • Common cold • Dry or wet cough Not necessary unless Yes No, unless Exclusion criteria are resolved. (Cough is a body • Lower respiratory infection (eg, • Runny nose (clear, white, or yellow-green) the cough is due to a • Severe cough. response to some- pneumonia, bronchiolitis) • Sore throat vaccine-preventable disease, • Rapid or difficult breathing. thing that is irritat- • Croup • Throat irritation such as pertussis • Wheezing if not already evaluated and treated. ing tissues in the • Asthma • Hoarse voice, barking cough • Cyanosis (ie, blue color of skin or mucous airway anywhere from the nose to • Sinus infection • Coughing fits membranes). the lungs.) • Bronchitis • Pertussis is diagnosed and not yet treated. • Pertussis • Fever with behavior change. • Noninfectious causes like • Child meets routine exclusion criteria. allergies Diaper Rash • Irritation by rubbing of diaper • Redness Not necessary Yes No, unless Exclusion criteria are resolved. material against skin wet with • Scaling • Oozing sores that leak body fluids outside the urine or stool • Red bumps diaper. • Infection with yeast or bacteria • Sores • Child meets routine exclusion criteria. • Cracking of skin in diaper region 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: American Academy of Pediatrics; 2017. Used with permission of the American Academy of Pediatrics, 2017. Appendix A Caring for Our Children: National Health and Safety Performance Standards A Signs and Symptoms Chart (continued ) Complaints or What Might Notify If Excluded, Sign or Symptom Common Causes Be Seen Notify Health Consultant Parent Temporarily Exclude? Readmit When Diarrhea • Usually viral, less commonly • Frequent loose or watery stools compared with Yes, if 1 or more cases of Yes Yes, if • Cleared to return by health care provider bacterial or parasitic child’s normal pattern (Note that exclusively bloody diarrhea or 2 or more • Directed by the local health department as part of for all cases of bloody diarrhea and • Noninfectious causes such as breastfed infants normally have frequent unformed children in same group with outbreak management. diarrhea caused by Shiga toxin-producing dietary (drinking too much juice), and somewhat watery stools or may have several diarrhea within a week • Stool is not contained in the diaper for diapered Escherichia coli, Shigella, or Salmonella medications, inflammatory bowel days with no stools.) children. serotype Typhi until negative stool culture disease, or cystic fibrosis • Abdominal cramps • Diarrhea is causing “accidents” for toilet-trained requirement has been met. • Fever children. • Diapered children have their stool contained • Generally not feeling well • Stool frequency exceeds 2 stools above normal by the diaper (even if the stools remain • Vomiting occasionally present during the time the child is in the program because loose) and toilet-trained children do not this may cause too much work for teachers/ have toileting accidents. caregivers and make it difficult to maintain good • Stool frequency is no more than 2 stools sanitation. above normal during the time the child • Blood/mucus in stool. is in the program, or what has become • Black stools. normal for that child when the child seems • No urine output in 8 hours. otherwise well. • Jaundice (ie, yellow skin or eyes). • Exclusion criteria are resolved. • Fever with behavior change. • Looks or acts very ill. • Child meets routine exclusion criteria. Difficult or Noisy • Common cold • Common cold: stuffy/runny nose, sore throat, Not necessary except for Yes Yes, if Exclusion criteria are resolved. Breathing • Croup cough, or mild fever. epiglottitis • Fever with behavior change. • Epiglottitis • Croup: barking cough, hoarseness, fever, possible • Child looks or acts very ill. • Bronchiolitis chest discomfort (symptoms worse at night), or • Child has difficulty breathing. • Asthma very noisy breathing, especially when breathing in. • Rapid or difficult breathing. • Pneumonia • Epiglottitis: gasping noisily for breath with mouth • Wheezing if not already evaluated and treated. • Object stuck in airway wide open, chin pulled down, high fever, or bluish • Cyanosis (ie, blue color of skin or mucous • Exposed to a known trigger of (cyanotic) nails and skin; drooling, unwilling to membranes). asthma symptoms (eg, animal lie down. • Cough interferes with activities. dander, pollen) • Bronchiolitis and asthma: child is working hard • Breath sounds can be heard when the child is to breathe; rapid breathing; space between ribs at rest. looks like it is sucked in with each breath (retrac- • Child has blood-red or purple rash not associated tions); wheezing; whistling sound with breathing; with injury. cold/cough; irritable and unwell. Takes longer to • Child meets routine exclusion criteria. breathe out than to breathe in. • Pneumonia: deep cough, fever, rapid breathing, or space between ribs looks like it is sucked in with each breath (retractions). • Object stuck in airway: symptoms similar to croup (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. Earache • Bacteria • Fever Not necessary Yes No, unless child meets routine exclusion criteria. Exclusion criteria are resolved. • Often occurs in context of • Pain or irritability common cold virus • Difficulty hearing • “Blocked ears” • Drainage • Swelling around ear Appendix A Caring for Our Children: National Health and Safety Performance Standards Signs and Symptoms Chart (continued ) Complaints or What Might Notify If Excluded, Sign or Symptom Common Causes Be Seen Notify Health Consultant Parent Temporarily Exclude? Readmit When Eye Irritation, • Bacterial infection of the mem- • Bacterial infection: pink color of the “whites” of Yes, if 2 or more children Yes For bacterial conjunctivitis • For bacterial conjunctivitis, once parent has Pinkeye brane covering 1 or both eyes and eyes and thick yellow/green discharge. Eyelid may have red eyes with watery No. Exclusion is no longer required for this condition. discussed with health care provider. Antibi- eyelids (bacterial conjunctivitis) be irritated, swollen, or crusted. discharge Health care providers may vary on whether to treat otics may or may not be prescribed. • Viral infection of the membrane • Viral infection: pinkish/red color of the whites of this condition with antibiotic medication. The role • Exclusion criteria are resolved. covering 1 or both eyes and the eye; irritated, swollen eyelids; watery dis- of antibiotics in treatment and preventing spread is eyelids (viral conjunctivitis) charge with or without some crusting around the unclear. Most children with pinkeye get better after 5 • Allergic irritation of the membrane eyelids; may have associated cold symptoms. or 6 days without antibiotics. covering 1 or both eyes and • Allergic and chemical irritation: red, tearing, itchy, For other eye problems eyelids (allergic conjunctivitis) puffy eyelids; runny nose, sneezing; watery/stringy No, unless child meets other exclusion criteria. • Chemical irritation of the mem- discharge with or without some crusting around Note: One type of viral conjunctivitis spreads rapidly brane covering the eye and eyelid the eyelids. and requires exclusion. If 2 or more children in the (irritant conjunctivitis) (eg, swim- group have watery red eyes without any known ming in heavily chlorinated water, chemical irritant exposure, exclusion may be required air pollution, smoke exposure) and health authorities should be notified to determine if the situation involves the 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. Fever • Any viral, bacterial, or parasitic Flushing, tired, irritable, decreased activity Not necessary Yes No, unless Exclusion criteria are resolved. infection Notes • Behavior change or other signs of illness in addition • Vigorous exercise • Fever alone is not harmful. When a child has an to fever or child meets other routine exclusion • Reaction to medication or vaccine infection, raising the body temperature is part of criteria. • Other noninfectious illnesses