Timothy R. Shope, MD, MPH, is an Associate Professor of Pediatrics at the University of Pittsburgh School of Medicine, Pittsburgh, PA. Andrew N. Hashikawa, MD, MS, is a Clinical Lecturer in the Department of Emergency Medicine at University of Michigan School of Medicine, Ann Arbor, MI.
Drs. Shope and Hashikawa have disclosed no relevant financial relationships.
Address correspondence to: Timothy R. Shope, MD, MPH, via fax: 412-692-8516; or email: email@example.com.
Your schedulers fit in Suzy, a 24-month-old girl who has eye discharge, for a same-day appointment at 2 p.m. Mother states Suzy has had a runny nose and mild cough for the past 2 days but is acting fine. She was “kicked out” of the childcare center at 10 a.m. that day because the caregivers noted some yellowish discharge from the eyes. Mom was instructed to take Suzy to the doctor to get her diagnosed and treated, and to get a signed note from you before she could return to care.
The exam shows scant yellow eye discharge without injected conjunctivae, and mild nasal congestion. You decide to write a return-to-care note and not to prescribe any topical antibiotics. Mom is very thankful that you worked her into your busy schedule, but frustrated that she had to miss work for this problem. You think to yourself, “There are several things wrong with this interaction! What are we doing here?”
This scenario unfolds in outpatient practices and emergency departments every day. In this article, we describe the extent of childcare illness and unnecessary exclusion practices, raise awareness of current guidelines, and discuss strategies for pediatric health providers to address this important issue.
Two-thirds of all children in the United States younger than the age of 6 years now require nonparental childcare services as a result of an increased number of working parents, single parents, and socioeconomic necessity.1,2 Welfare reform has increased work requirements for parents with young children and contributed to the increasing number of poor and minority families requiring childcare.3 A large proportion of these children receive care in larger childcare center (CCC) arrangements,4,5 which results in more and longer illnesses, compared with children who stay at home exclusively.6–9 Children in childcare have more upper respiratory tract infections, otitis media, gastrointestinal disease, and myringotomy tube placement.6–11
In 2010, 57% of parents reported that childcare was an economic necessity; this was an increase from 49% in 2006.12 When children become ill, however, they may need to be excluded, placing a significant burden on families, businesses, and health care resources.6,13–15 Child illness accounts for 40% of parents’ absence from work.16 Mothers with children younger than 6 years of age may lose 6 to 29 days of work per year caring for them.17 Parents who must leave work to care for their ill children at home face significant financial pressure to return to work as soon as possible or risk pay or job loss. Many working parents do not receive sick leave benefits to care for children and poor and minority families are disproportionately affected.3,18
Some CCC exclusions are necessary, especially if the child cannot participate adequately in activities or if he or she requires more care than staff can provide while still maintaining adequate staffing ratios. An ill child who cannot safely or appropriately attend childcare should be with a parent. Many studies, however, show a large proportion (33% to 100%) of exclusions is unnecessary, ie, they do not meet accepted exclusion guidelines.19–22 In a state without childcare exclusion guidelines, for every one child appropriately excluded, six children were inappropriately excluded.23 Clearly, substantial work needs to be done to improve unnecessary childcare…