December 03, 2018
3 min read

Exclusion from child care for diarrheal disease often unnecessary

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NEW YORK — According to a presentation at the annual Infectious Diseases in Children Symposium, 61% of all children in the United States attend some type of out-of-home child care. Exclusions from school or child care are often unnecessary — especially for diarrheal illness — and they add to the burden of lost work time, the presenter said.

“As pediatric health care providers, we look at children and sometimes wonder why a child is in the office,” Timothy R. Shope, MD, MPH, professor of pediatrics at UPMC Children’s Hospital of Pittsburgh, said in his presentation. “You cannot tell the parent when their child is going to be better, so you cannot tell them when they can go back to school or child care. Parents often are in the office with their child because they have been kicked out of care and, in some cases, they are losing income and might lose their job. They are also in the office because they are required by the care program or school.”

These visits, according to a study conducted by Shope and colleagues, make up 20% of all emergent visits in pediatric practices. More than 80% of parents would not have brought their child to the office if it was not required for their child to return to care.

With diarrheal disease, the language used to define the condition impacts inclusion and exclusion from child care. Factors that physicians need to consider when determining whether children can return to school include loose, watery stools with increased frequency, potty training or diaper containment issues, and the likelihood of transmitting infection. According to Shope, children who have blood or mucus in their stool, appear ill, are infected during an outbreak, or have vomiting in addition to diarrhea should be excluded from child care.

Figure 1.Exclusion from child care or school for diarrheal illness often places unnecessary burden on parents. At the annual Infectious Diseases in Children Symposium, Timothy R. Shope, MD, MPH, discussed what pediatricians need to know about school exclusion criteria and when children are ready to go back to child care. 

However, each state has different exclusion criteria for diarrheal disease, and some states are clearer in their language than others.

“In Managing Infectious Diseases in Child Care and Schools” — known as the Purple Book — “we recognize that child care providers see symptoms first,” Shope said. “They do not know what the diagnosis is when a child has diarrhea, so we have a symptoms chart with a list of symptoms, including diarrhea. Each column includes common causes, when a health consultant or parents should be notified, whether they should be excluded or not and when they can return.”


Additionally, there is a quick reference sheet that can be used as a handout from the program or school to the parent. In 2016, the Purple Book was used by 73% of all U.S. child care centers. This guidance is synergistic with the AAP’s Red Book.

According to Shope, most cases of viral gastroenteritis in child care settings are caused by norovirus. For all children with diarrhea, including those with norovirus, children may return to care once they can participate in daily activities, when they do not require more care than staff can provide, when stool can be easily contained with no accidents if potty trained, and the frequency is two or less stools above normal.

Shope also stressed that the consistency of the stool does not need to be resolved, nor does stool need to be tested in most cases of watery diarrhea before children can return to care.

“Our main goal is to keep kids safe, healthy and in care, not in our office when it is not needed,” Shope said. “We also want to keep parents at work when possible, become aware of and use evidence-based guidelines that limit exclusions. When exclusions are needed, we want to get kids back into care as soon as it is safe.” – by Katherine Bortz


Shope TR. What’s new with managing infectious diseases in child care and schools. Presented at: Annual Infectious Diseases in Children Symposium; Nov. 17-18, 2018; New York.

Disclosure: Shope reports receiving grants from the AAP and the CDC.