Too Sick for School?

Updated Guidelines for When to Keep a Child Home from School/Exclusion from School

Adapted from:  Aronson, S.S., T.R. Shope, eds. 2017.  Managing infectious diseases in child care and schools:  A quick reference guide, pp. 43-48.  4^th Edition.  Elk Grove village, IL:  American Academy of Pediatrics. 

It is sometimes difficult to know when to keep a student home from school, when sick. The following updated guidelines are available to assist in this decision. Please contact the school nurse for help in making the decision to keep your child home. When deciding whether to keep your child home, the most important things to think about are:

1.     Does your child’s illness keep him/her from comfortably taking part in activities?

2.     Does the sick child need more care that the staff can give without affecting the health and safety of other children?  

o   If the answer to either of these questions is yes, then your child should not go to school.

o   If a sick child is sent to school, he/she may not be allowed to stay.

3.     Could other students/staff get sick from your child’s condition / is the illness contagious? If the answer to this question is yes, your child should not be in school.

If any of the above criteria are met, the child should be excluded, regardless of the type of illness. Decisions about caring for the child while awaiting parent/guardian pick-up shall be made on a case-by- case basis providing care that is comfortable for the child considering factors such as the child's age, the surroundings, potential risk to others, and the type and severity of symptoms the child is exhibiting.

Temporary exclusion is recommended when the child has any of the following conditions:

1.     The illness prevents the child from participating comfortably in activities.

2.     The illness results in a need for care that is greater than the staff can provide without compromising the health and safety of other children.

3.     A severely ill appearance - this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash.

Condition	When to keep a child home / When to send a child home from school
Fever	Fever is defined as temperature above 101°F [38.3°C] by any method) with a behavior change.
Vomiting	Vomiting more than two times in the previous twenty-four hours, unless the vomiting is determined to be caused by a non-infectious condition and the child remains adequately hydrated.
Abdominal Pain	Abdominal pain that continues for more than two hours or intermittent pain associated with fever or other signs or symptoms of illness.
Rash	Rash with fever or behavioral changes, until the primary care provider has determined that the illness is not an infectious disease.
Active TB	Active tuberculosis, until the child’s primary care provider or local health department states child is on appropriate treatment and can return
Impetigo	Impetigo, only if child has not been treated after notifying family at the end of the prior program day. Exclusion is not necessary before the end of the day as long as the lesions can be covered
Strep	Streptococcal pharyngitis (i.e., strep throat or other streptococcal infection), until the child has two doses of antibiotic (one may be taken the day of exclusion and the second just before returning the next day).
Head Lice	Head lice, only if the child has not been treated after notifying the family at the end of the prior program day. (Note: exclusion is not necessary before the end of the program day.)
Scabies	Scabies, only if the child has not been treated after notifying the family at the end of the prior program day. (Note: exclusion is not necessary before the end of the program day.)
Chicken Pox	Chickenpox (varicella), until all lesions have dried or crusted (usually six days after onset of rash and no new lesions have appeared for at least 24 hours).
Rubella	Rubella, until seven days after the rash appears.
Pertussis	Pertussis (Whooping Cough), until five days of appropriate antibiotic treatment.
Mumps	Mumps, until five days after onset of parotid gland swelling.
Measles	Measles, until four days after onset of rash.
Hepatitis A	Hepatitis A virus infection, until one week after onset of illness or jaundice if the child’s symptoms are mild or as directed by the health department. (Note: Protection of the others in the group should be checked to be sure everyone who was exposed has received the vaccine or receives the vaccine immediately.)

Conditions/symptoms that do not require exclusion:

·      Common colds, runny noses (regardless of color or consistency of nasal discharge).

·      A cough not associated with fever, rapid or difficult breathing, wheezing or cyanosis (blueness of skin or mucous membranes).

·      Pinkeye (bacterial conjunctivitis) indicated by pink or red conjunctiva with white or yellow eye mucous drainage and matted eyelids after sleep.

o   This may be thought of as a cold in the eye.

o   Exclusion is no longer required for this condition.

o   Health professionals may vary on whether or not to treat pinkeye with antibiotic drops.

o   The role of antibiotics in treatment and preventing spread of conjunctivitis is unclear.

o   Most children with pinkeye get better after 5 or 6 days without antibiotics.

o   Parents/guardians should discuss care of this condition with their child’s primary care provider, and follow the primary care provider’s advice.

o   If no treatment is provided, the child should be allowed to remain in care. If the child’s eye is painful, a health care [provider should examine the child.

·       Watery, yellow, or white discharge or crusting eye discharge without fever, eye pain, or eyelid redness.

·       Yellow or white eye drainage that is not associated with pink or red conjunctiva (i.e., the whites of the eyes).

·       Fever without any signs or symptoms of illness regardless of whether acetaminophen or ibuprofen was given.

o   For this purpose, fever is defined as temperature above 101 degrees F (38.3 degrees C) by any method.      

o   These temperature readings do not require adjustment for the location where they are made. They are simply reported with the temperature and the location, as in “101 degrees in the armpit/axilla".

o   Notes: Fever is an indication of the body’s response to something, but is neither a disease nor a serious problem by itself. Body temperature can be elevated by overheating caused by overdressing or a hot environment, reactions to medications, and response to infection. If the child is behaving normally but has a fever, the child should be monitored, but does not need to be excluded for fever alone. For example, an infant with a fever after an immunization who is behaving normally does not require exclusion.

·       Rash without fever and behavioral changes.

·       Impetigo lesions should be covered, but treatment may be delayed until the end of the day. If treatment is started before return the next day, no exclusion is needed.

·       Lice or nits treatment may be delayed until the end of the day. If treatment is started before returning the next day, no exclusion is needed.

·       Ringworm treatment may be delayed until the end of the day. If treatment is started before returning the next day, no exclusion is needed.

·       Scabies treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed.

·       Molluscum contagiosum (does not require covering of lesions).

·       Thrush (i.e., white spots or patches in the mouth or on the cheeks or gums).

·       Fifth disease (slapped cheek disease, parvovirus B19) once the rash has appeared.

·       Methicillin-resistant Staphylococcus aureus, or MRSA, without an infection or illness that would otherwise require exclusion. Known MRSA carriers should not be excluded.

·       Cytomegalovirus infection.

·       Chronic hepatitis B infection.

·       Human immunodeficiency virus (HIV) infection.

·       Children with chronic infectious conditions that can be accommodated according to the legal requirement of federal law in the Americans with Disabilities Act. The act requires that child care programs make reasonable accommodations for children with disabilities and/or chronic illnesses, considering each child individually.