Supportive Health Care

Erin Vasishtah; Isabella Sebastiani

4 Supportive Health Care

Learning Objectives

By the end of this chapter, you should be able to:

Identify symptoms of infectious diseases that are common during early childhood.
Outline criteria for exclusion from care for ill children and staff.
Describe considerations programs must make regarding caring for children that are mildly ill.
Recall licensing requirements for handling medication in early care and education programs.
Explain the communication about illness that should happen between families and early care and education programs.

Licensing Regulations

WAC regulations that relate to this chapter include:

110-300-0205 – CHILD, STAFF, AND HOUSEHOLD MEMBER ILLNESS^{^[1]}

(1) An early learning provider must observe all children for signs of illness when they arrive at the early learning program and throughout the day. Parents or guardians of a child should be notified, as soon as possible, if the child develops signs or symptoms of illness.
(2) If an early learning provider becomes ill, a licensee, center director, assistant director, or program supervisor must determine whether that person should be required to leave the licensed early learning space.
(3) When a child becomes ill, an early learning provider (or school nurse, if applicable) must determine whether the child should be sent home or separated from others. A provider must supervise the child to reasonably prevent contact between the ill child and healthy children.
(4) An ill child must be sent home or reasonably separated from other children if:
- (a) The illness or condition prevents the child from participating in normal activities;
- (b) The illness or condition requires more care and attention than the early learning provider can give;
- (c) The required amount of care for the ill child compromises or places at risk the health and safety of other children in care; or
- (d) There is a risk that the child’s illness or condition will spread to other children or individuals.
(5) Unless covered by an individual care plan or protected by the ADA, an ill child, staff member, or other individual must be sent home or isolated from children in care if the ill individual has:
- (a) A fever 101 degrees Fahrenheit for children over two months (or 100.4 degrees Fahrenheit for an infant younger than two months) by any method, and behavior change or other signs and symptoms of illness (including sore throat, earache, headache, rash, vomiting, diarrhea);
- (b) Vomiting two or more times in the previous twenty-four hours;
- (c) Diarrhea where stool frequency exceeds two stools above normal per twenty-four hours for that child or whose stool contains more than a drop of blood or mucus;
- (d) A rash not associated with heat, diapering, or an allergic reaction;
- (e) Open sores or wounds discharging bodily fluids that cannot be adequately covered with a waterproof dressing or mouth sores with drooling;
- (f) Lice, ringworm, or scabies. Individuals with head lice, ringworm, or scabies must be excluded from the child care premises beginning from the end of the day the head lice, ringworm, or scabies was discovered. The provider may allow an individual with head lice, ringworm, or scabies to return to the premises after receiving the first treatment; or
- (g) A child who appears severely ill, which may include lethargy, persistent crying, difficulty breathing, or a significant change in behavior or activity level indicative of illness.
(6) At the first opportunity, but in no case longer than twenty-four hours of learning that an enrolled child, staff member, volunteer, or household member has been diagnosed by a health care professional with a contagious disease pursuant to WAC 246-110-010(3), as now and hereafter amended, an early learning provider must provide written notice to the department, the local health jurisdiction, and the parents or guardians of the enrolled children.
(7) An early learning provider must not take ear or rectal temperatures to determine a child’s body temperature.
- (a) Providers must use developmentally appropriate methods when taking infant or toddler temperatures (for example, digital forehead scan thermometers or underarm methods);
- (b) Oral temperatures may be taken for preschool through school-age children if single-use covers are used to prevent cross contamination; and
- (c) Glass thermometers containing mercury must not be used.
(8) An early learning provider may readmit a child, staff member, volunteer or household member into the early learning program area with written permission of a health care provider or health jurisdiction stating the individual may safely return after being diagnosed with a contagious disease pursuant to WAC 246-110-010(3), as now and hereafter amended.

246-110 – ILLNESS REPORTING REQUIREMENTS^{^[2]}

WAC 246-110-001

The rules in this chapter identify certain contagious diseases that may affect children, or others who are susceptible, in schools, and childcare centers. When an outbreak or potential outbreak of a contagious disease is identified in a school or childcare center, the rules in this chapter identify what schools, childcare centers and local health officers may do to control or prevent a potential outbreak of the contagious disease. These rules are in addition to other requirements imposed by chapter 246-100 WAC, Communicable and certain other diseases and chapter 246-101 WAC, Notifiable conditions.

These rules do not require school or childcare center personnel to diagnose or treat children.

WAC 246-110-010

The definitions in this section apply throughout this chapter unless the context clearly requires otherwise:

(1) “Childcare center” means any facility or center licensed by the department of early learning as described in chapter 43.215 RCW that regularly provides care for a group of children for periods of less than twenty-four hours per day.
(2) “Contact” means a person exposed to a contagious person or animal, or a contaminated source which might provide an opportunity to acquire the infection.
(3) “Contagious disease” means an illness caused by an infectious agent of public health concern which can be transmitted from one person, animal, or object to another person by direct or indirect means including transmission through an intermediate host or vector, food, water, or air. Contagious diseases include, but are not limited to:
- (a) Bacterial Meningitis
  - (i) Haemophilus influenzae invasive disease (excluding Otitis media)
  - (ii) Meningococcal
- (b) Diarrheal diseases due to or suspected to be caused by an infectious agent
  - (i) Cryptosporidiosis
  - (ii) Giardiasis
  - (iii) Hepatitis A
  - (iv) Salmonellosis
  - (v) Shigellosis
  - (vi) Shiga toxin-producing Escherichia coli (STEC)
- (c) Diseases spread through the air – Tuberculosis
- (d) Vaccine preventable diseases
  - (i) Chickenpox (Varicella)
  - (ii) Diphtheria
  - (iii) German measles (Rubella)
  - (iv) Measles (Rubeola)
  - (v) Mumps
  - (vi) Whooping cough (Pertussis)
(4) “Contaminated” means containing or having contact with infectious agents that pose an immediate threat to present or future public health.
(5) “Exposed” means such association with a person or animal in the infectious stage of a disease, or with a contaminated source, which provides the opportunity to acquire the infection.
(6) “Infectious agent” means an organism that is capable of producing infection or infectious disease.
(7) “Outbreak” means the occurrence of cases of a disease or condition in any area over a given period of time in excess of the expected number of cases as determined by the local health officer.
(8) “School” means each building, facility, and location at or within which any or all portions of a preschool, kindergarten, and grades one through twelve program of education and related activities are conducted for two or more students or children by or on behalf of any public school district and by or on behalf of any private school or private institution subject to approval by the state board of education.
(9) “Susceptible” means a person who has no immunity to an infectious agent.

WAC 246-100-020

(1) When a school or childcare center becomes aware of the presence of a contagious disease at the facility, as defined in WAC 246-110-010, the officials at the school or childcare center shall notify the appropriate local health officer for guidance.
(2) When there is an outbreak of a contagious disease, as defined in WAC 246-110-010, and there is the potential for a case or cases within a school or childcare center, the local health officer, after consultation with the secretary of health or designee if appropriate, shall take all appropriate actions deemed to be necessary to control or eliminate the spread of the disease within their local health jurisdiction including, but not limited to:
- (a) Closing part or all of the affected school(s) or childcare center(s);
- (b) Closing other schools or childcare centers;
- (c) Canceling activities or functions at schools or childcare centers;
- (d) Excluding from schools or childcare centers any students, staff, and volunteers who are infectious, or exposed and susceptible to the disease.
(3) Prior to taking action the health officer shall:
- (a) Consult with and discuss the ramifications of action with the superintendent of the school district, or the chief administrator of the childcare center or their designees on the proposed action; and
- (b) Provide the superintendent of the school district or the chief administrator of the childcare center or their designees a written decision, in the form and substance of an order, directing them to take action. The order must set the terms and conditions permitting;
  - (i) Schools or childcare centers to reopen;
  - (ii) Activities and functions to resume; and
  - (iii) Excluded students, staff and volunteers to be readmitted.
- (c) Pursue, in consultation with the secretary of health or designee if appropriate, and school or childcare officials, the investigation of the source of disease, or those actions necessary to ultimately control the disease.

110-300-0215 – MEDICATION

(1) Managing medication. A medication management policy must include, but is not limited to, safe medication storage, reasonable accommodations for giving medication, mandatory medication documentation, and forms pursuant to WAC 110-300-0500.
(2) Medication training. An early learning provider must not give medication to a child if the provider has not successfully completed:
- (a) An orientation about the early learning program’s medication policies and procedures;
- (b) The department standardized training course in medication administration that includes a competency assessment pursuant to WAC 110-300-0106(10) or equivalent training; and
- (c) If applicable, a training from a child’s parents or guardian (or an appointed designee) for special medical procedures that are part of a child’s individual care plan. This training must be documented and signed by the provider and the child’s parent or guardian (or designee).
(3) Medication administration. An early learning provider must not give medication to any child without written and signed consent from that child’s parent or guardian, must administer medication pursuant to directions on the medication label, and using appropriate cleaned and sanitized medication measuring devices.
- (a) An early learning provider must administer medication to children in care as follows:
  - (i) Prescription medication. Prescription medication must only be given to the child named on the prescription. Prescription medication must be prescribed by a health care professional with prescriptive authority for a specific child. Prescription medication must be accompanied with medication authorization form that has the medical need and the possible side effects of the medication. Prescription medication must be labeled with:
    - (A) A child’s first and last name;
    - (B) The date the prescription was filled;
    - (C) The name and contact information of the prescribing health professional;
    - (D) The expiration date, dosage amount, and length of time to give the medication; and
    - (E) Instructions for administration and storage.
  - (ii) Nonprescription oral medication. Nonprescription (over-the-counter) oral medication brought to the early learning program by a parent or guardian must be in the original packaging.
    - (A) Nonprescription (over-the-counter) medication needs to be labeled with child’s first and last name and accompanied with medication authorization form that has the expiration date, medical need, dosage amount, age, and length of time to give the medication. Early learning providers must follow the instructions on the label or the parent must provide a medical professional’s note; and
    - (B) Nonprescription medication must only be given to the child named on the label provided by the parent or guardian.
  - (iii) Other nonprescription medication: An early learning provider must receive written authorization from a child’s parent or guardian and health care provider with prescriptive authority prior to administering if the item does not include age, expiration date, dosage amount, and length of time to give the medication:
    - (A) Vitamins;
    - (B) Herbal supplements;
    - (C) Fluoride supplements;
    - (D) Homeopathic or naturopathic medication; and
    - (E) Teething gel or tablets (amber bead necklaces are prohibited).
  - (iv) Nonmedical items. A parent or guardian must annually authorize an early learning provider to administer the following nonmedical items:
    - (A) Diaper ointments (used as needed and according to manufacturer’s instructions);
    - (B) Sunscreen;
    - (C) Lip balm or lotion;
    - (D) Hand sanitizers or hand wipes with alcohol, which may be used only for children over twenty-four months old; and
    - (E) Fluoride toothpaste for children two years old or older.
  - (v) An early learning provider may allow children to take his or her own medication with parent or guardian authorization. The early learning staff member must observe and document that the child took the medication.
  - (vi) An early learning provider must not give or permit another to give any medication to a child for the purpose of sedating the child unless the medication has been prescribed for a specific child for that particular purpose by a qualified health care professional.
- (b) Medication documentation (excluding nonmedical items). An early learning provider must keep a current written medication log that includes:
  - (i) A child’s first and last name;
  - (ii) The name of the medication that was given to the child;
  - (iii) The dose amount that was given to the child;
  - (iv) Notes about any side effects exhibited by the child;
  - (v) The date and time of each medication given or reasons that a particular medication was not given; and
  - (vi) The name and signature of the person that gave the medication.
- (c) Medication must be stored and maintained as directed on the packaging or prescription label, including applicable refrigeration requirements. An early learning provider must comply with the following additional medication storage requirements:
  - (i) Medication must be inaccessible to children;
  - (ii) Controlled substances must be locked in a container or cabinet which is inaccessible to children;
  - (iii) Medication must be kept away from food in a separate, sealed container; and
  - (iv) External medication (designed to be applied to the outside of the body) must be stored to provide separation from internal medication (designed to be swallowed or injected) to prevent cross contamination.
- (d) An early learning provider must return a child’s unused medication to that child’s parent or guardian. If this is not possible, a provider must follow the Food and Drug Administration (FDA) recommendations for medication disposal.
- (e) An early learning provider must not accept or give to a child homemade medication, such as diaper cream or sunscreen.

Illness in Early Care and Education Programs

The most frequent infectious disease symptoms that are reported by early care and education settings are sore throat, runny nose, shortness of breath or cough, fever, vomiting and diarrhea (gastroenteritis), earaches, and rashes.

Comparison of illness symptoms — Figure 4.1 Respiratory symptoms are by far the most common for children in care.

However, these are not the symptoms that necessarily lead to children staying home. In fact, although respiratory symptoms are most common, it’s rashes and gastrointestinal disease that more often keep children from attending their early education programs. This is more a reflection of exclusion policies than real risk of serious illness.^{^[3]}

Causes of most absences from child care — Figure 4.2 Rashes, vomiting, and diarrhea results in the most absences from care.

It’s important for early childhood programs to identify illness accurately and respond in ways that protect all children and staff health (whether it be to allow them to stay in care or to exclude them from care).

Infectious Illness

Most children with mild illnesses can safely attend an early learning program “Many health policies concerning the care of ill children [including exclusion policies] have been based upon common misunderstandings about contagion, risks to ill children, and risks to other children and staff. Current research clearly shows that certain ill children do not pose a health threat. Also, the research shows that keeping certain other mildly ill children at home or isolated at the child care setting will not prevent other children from becoming ill.”^{^[4]}

It is extremely important for early childhood educators to know what symptoms to look for and when to separate and/or have a child stay home with an illness. In the Resources section, you will find Infectious Disease Information that describes the symptoms and effects of illnesses that children and adults experience.

Exclusion Policies

When you are familiar with different infectious diseases, it’s easier to identify them in children and adults and determine if those affected should be excluded from the early care and education program. The Resources for Washington State Infections Disease contains information on the signs and symptoms of many illnesses that you may come across when working with young children.

There are times when exclusion is the right answer. Licensing states that a child may need to be reasonably separated from other children or sent home if:

The illness or condition prevents the child from participating in normal activities;
The illness or condition requires more care and attention than the early learning provider can give;
The required amount of care for the ill child compromises or places at risk the health and safety of other children in care; or
There is a risk that the child’s illness or condition will spread to other children or individuals.

Licensing also states that an ill child, staff member, or other individual must be sent home or isolated from children in care (unless they are covered by an individual care plan or protected by the ADA) if the ill individual has:

A fever 101 degrees Fahrenheit for children over two months (or 100.4 degrees Fahrenheit for an infant younger than two months) by any method, and behavior change or other signs and symptoms of illness (including sore throat, earache, headache, rash, vomiting, diarrhea);
Vomiting two or more times in the previous twenty-four hours;
Diarrhea where stool frequency exceeds two stools above normal per twenty-four hours for that child or whose stool contains more than a drop of blood or mucus;
A rash not associated with heat, diapering, or an allergic reaction;
Open sores or wounds discharging bodily fluids that cannot be adequately covered with a waterproof dressing or mouth sores with drooling;
Lice, ringworm, or scabies. Individuals with head lice, ringworm, or scabies must be excluded from the child care premises beginning from the end of the day the head lice, ringworm, or scabies was discovered. The provider may allow an individual with head lice, ringworm, or scabies to return to the premises after receiving the first treatment; or
A child who appears severely ill, which may include lethargy, persistent crying, difficulty breathing, or a significant change in behavior or activity level indicative of illness.

When a child or staff member has been identified as having a contagious illness, they may not return to the early learning program until they have been assessed by a medical professional and received written remission to return to care. Here is the list of infectious diseases that require immediate removal from the early learning program and a medical provider’s written permission to return to care:

Bacterial Meningitis
Haemophilus influenzae invasive disease (excluding Otitis media)
Meningococcal
Diarrheal diseases due to or suspected to be caused by an infectious agent
Cryptosporidiosis
Giardiasis
Hepatitis A
Salmonellosis
Shigellosis
Shiga toxin-producing Escherichia coli (STEC)
Tuberculosis
Chickenpox (Varicella)
Diphtheria
German measles (Rubella)
Measles (Rubeola)
Mumps
Whooping cough (Pertussis)

Danger of Infectious Disease for Adults

Because early care and education program employees are around children who are at higher risk of infectious diseases and have limited understanding of hygiene practices, those employees are also at greater risk for getting sick.

While most illnesses that are spread in early care and education programs are not serious, some can be very dangerous. Knowledge about illness and how to prevent its spread helps. Being fully immunized (from childhood illness and or vaccines) protects adult health as well.

Employees that are or could become pregnant want to be especially careful because first time exposure to chickenpox, cytomegalovirus (CMV), Fifths disease, and Rubella can cause major damage to fetal health, birth defects, and even fetal death.^{^[5]}

Reportable Diseases

Some diseases are enough of a threat to the community that diagnosed cases must be reported to the local health department. If there is an outbreak of any reportable illness (See Table 4.1), a child or staff member who meets the following criteria as determined by the local health department or a health care provider to be:

contributing to transmission of the illness
not adequately immunized when the disease is vaccine-preventable
at increased risk due to the pathogens being circulated.

They can be readmitted when the health department official or that health care provider decides that the risk of transmission is no longer present.^{^[6]}

Table 4.1 – Diseases Reportable to Local Health Department (required by Licensing in Washington)^{^[7]}

Table HC-1 (Conditions Notifiable by Health Care Providers and Health Care Facilities)

Notifiable Condition (Agent)	Laboratory Confirmation Required Before Submitting Case Report	Time Frame for Notification from Identification of a Case	Who Must Be Notified	Who Must Report: Health Care Providers (Providers) or Health Care Facilities (Facilities)
Acquired immunodeficiency syndrome (AIDS)		Within 3 business days	DOH (for facilities) and LHJ (for providers)	Both
Amebic meningitis		Immediately	LHJ	Both
Anaplasmosis		Within 3 business days	LHJ	Both
Anthrax (Bacillus anthracis and confirmed Bacillus cereus biovar anthracis only – Do not report all Bacillus cereus)	Yes	Immediately	LHJ	Both
Arboviral disease (acute disease only) including, but not limited to: Chikungunya Dengue Eastern and western equine encephalitis Japanese encephalitis La Crosse encephalitis Powassan virus infection St. Louis encephalitis West Nile virus infection Zika virus infection See also “Yellow fever”		Within 3 business days	LHJ	Both
Asthma, occupational		Within 30 days	Washington state department of labor and industries (L&I)	Both
Babesiosis		Within 3 business days	LHJ	Both
Baylisascariasis		Within 24 hours	LHJ	Both
Birth defects – Abdominal wall defects (inclusive of gastroschisis and omphalocele)		Within 30 days	DOH	Facilities
Birth defects – Autism spectrum disorders		Within 30 days	DOH	Both
Birth defects – Cerebral palsy		Within 30 days	DOH	Both
Birth defects – Down syndrome		Within 30 days	DOH	Facilities
Birth defects – Alcohol related birth defects		Within 30 days	DOH	Both
Birth defects – Hypospadias		Within 30 days	DOH	Facilities
Birth defects – Limb reductions		Within 30 days	DOH	Facilities
Birth defects – Neural tube defects (inclusive of anencephaly and spina bifida)		Within 30 days	DOH	Facilities
Birth defects – Oral clefts (inclusive of cleft lip with/without cleft palate)		Within 30 days	DOH	Facilities
Blood lead level RST results (See WAC *246-101-200*)		Providers and facilities performing blood lead level RST shall report as a laboratory and comply with the requirements of WAC 246-101-201 through 246-101-230.
Botulism, foodborne, infant, and wound		Immediately	LHJ	Both
Brucellosis		Within 24 hours	LHJ	Both
Campylobacteriosis		Within 3 business days	LHJ	Both
Cancer (See chapter *246-102* WAC)
Candida auris infection or colonization		Within 24 hours	LHJ	Both
Carbapenem-resistant Enterobacteriaceae infections limited to: Klebsiella species E. coli Enterobacter species	Yes	Within 3 business days	LHJ	Both
Chagas disease		Within 3 business days	LHJ	Both
Chancroid		Within 3 business days	LHJ	Both
Chlamydia trachomatis infection	Yes	Within 3 business days	LHJ	Both
Cholera (Vibrio cholerae O1 or O139)	Yes	Immediately	LHJ	Both
Coccidioidomycosis		Within 3 business days	LHJ	Both
Coronavirus infection (severe communicable) SARS-associated coronavirus MERS-associated coronavirus Novel coronavirus (COVID-19)	Yes	Immediately	LHJ	Both
Coronavirus infection (severe communicable) Novel coronavirus (COVID-19) RST results (See WAC *246-101-200*)		Providers and facilities performing Novel coronavirus (COVID-19) RST shall report as a laboratory and comply with the requirements of WAC 246-101-201 through 246-101-230.
Cryptococcus gattii or undifferentiated Cryptococcus species (i.e., Cryptococcus not identified as C. neoformans)	Yes	Within 3 business days	LHJ	Both
Cryptosporidiosis		Within 3 business days	LHJ	Both
Cyclosporiasis		Within 3 business days	LHJ	Both
Cysticercosis		Within 3 business days	LHJ	Both
Diphtheria		Immediately	LHJ	Both
Domoic acid poisoning		Immediately	LHJ	Both
E. coli (See “Shiga toxin-producing E. coli”)
Echinococcosis		Within 3 business days	LHJ	Both
Ehrlichiosis		Within 3 business days	LHJ	Both
Giardiasis		Within 3 business days	LHJ	Both
Glanders (Burkholderia mallei)	Yes	Immediately	LHJ	Both
Gonorrhea		Within 3 business days	LHJ	Both
Granuloma inguinale		Within 3 business days	LHJ	Both
Gunshot wounds (nonfatal)		Within 30 days	DOH	Facilities
Haemophilus influenzae (invasive disease, children under 5 years of age)	Yes	Immediately	LHJ	Both
Hantaviral infection		Within 24 hours	LHJ	Both
Hepatitis A (acute infection)	Yes	Within 24 hours	LHJ	Both
Hepatitis B (acute infection)	Yes	Within 24 hours	LHJ	Both
Hepatitis B, report pregnancy in hepatitis B virus infected patients (including carriers)	Yes	Within 3 business days	LHJ	Both
Hepatitis B (chronic infection) – Initial diagnosis, and previously unreported prevalent cases	Yes	Within 3 business days	LHJ	Both
Hepatitis B (perinatal) – Initial diagnosis, and previously unreported cases	Yes	Within 3 business days	LHJ	Both
Hepatitis C (acute infection)	Yes	Within 24 hours	LHJ	Both
Hepatitis C (acute infection) RST results (See WAC *246-101-200*)		Providers and facilities performing hepatitis C (acute infection) RST shall report as a laboratory and comply with the requirements of WAC 246-101-201 through 246-101-230.
Hepatitis C (chronic infection)	Yes	Within 3 business days	LHJ	Both
Hepatitis C (perinatal) – Initial diagnosis, and previously unreported cases	Yes	Within 24 hours	LHJ	Both
Hepatitis C (chronic infection) RST results (See WAC *246-101-200*)		Providers and facilities performing hepatitis C (chronic infection) RST shall report as a laboratory and comply with the requirements of WAC 246-101-201 through 246-101-230.
Hepatitis D (acute and chronic infection)	Yes	Within 24 hours	LHJ	Both
Hepatitis E (acute infection)	Yes	Within 24 hours	LHJ	Both
Herpes simplex, neonatal and genital (initial infection only)		Within 3 business days	LHJ	Providers
Histoplasmosis		Within 3 business days	LHJ	Both
Human immunodeficiency virus (HIV) infection		Within 3 business days	LHJ	Both
Human immunodeficiency virus (HIV) infection RST results (See WAC *246-101-200*)		Providers and facilities performing HIV infection RST shall report as a laboratory and comply with the requirements of WAC 246-101-201 through 246-101-230.
Human prion disease		Within 3 business days	LHJ	Both
Hypersensitivity pneumonitis, occupational		Within 30 days	L&I	Both
Influenza, novel or unsubtypable strain		Immediately	LHJ	Both
Influenza-associated death (laboratory confirmed)	Yes	Within 3 business days	LHJ	Both
Legionellosis		Within 24 hours	LHJ	Both
Leptospirosis		Within 24 hours	LHJ	Both
Listeriosis		Within 24 hours	LHJ	Both
Lyme disease		Within 3 business days	LHJ	Both
Lymphogranuloma venereum		Within 3 business days	LHJ	Both
Malaria		Within 3 business days	LHJ	Both
Measles (rubeola) – Acute disease only		Immediately	LHJ	Both
Melioidosis (Burkholderia pseudomallei)	Yes	Immediately	LHJ	Both
Meningococcal disease, invasive		Immediately	LHJ	Both
Monkeypox		Immediately	LHJ	Both
Mumps, acute disease only		Within 24 hours	LHJ	Both
Outbreaks and suspected outbreaks		Immediately	LHJ	Both
Paralytic shellfish poisoning		Immediately	LHJ	Both
Pertussis		Within 24 hours	LHJ	Both
Pesticide poisoning (hospitalized, fatal, or cluster)		Immediately	DOH	Both
Pesticide poisoning (all other)		Within 3 business days	DOH	Both
Plague		Immediately	LHJ	Both
Poliomyelitis		Immediately	LHJ	Both
Pregnancy in patient with hepatitis B virus		See “Hepatitis B, report pregnancy in hepatitis B virus infected patients (including carriers)”
Psittacosis		Within 24 hours	LHJ	Both
Q fever		Within 24 hours	LHJ	Both
Rabies (suspect or laboratory confirmed human cases and laboratory confirmed animal cases)	Yes for animal cases	Immediately	LHJ	Both
Rabies, suspected human exposure (suspected human rabies exposures due to a bite from or other exposure to an animal that is suspected of being infected with rabies)		Immediately	LHJ	Both
Relapsing fever (borreliosis)		Within 3 business days	LHJ	Both
Rickettsia infection		Within 3 business days	LHJ	Both
Rubella, acute disease only (including congenital rubella syndrome)		Immediately	LHJ	Both
Salmonellosis		Within 24 hours	LHJ	Both
Serious adverse reactions to immunizations		Within 3 business days	LHJ	Both
Shiga toxin-producing E. coli (STEC) infections/enterohemorrhagic E. coli infections	Yes	Immediately	LHJ	Both
Shigellosis		Within 24 hours	LHJ	Both
Silicosis		Within 30 days	L&I	Both
Smallpox		Immediately	LHJ	Both
Syphilis		Within 3 business days	LHJ	Both
Taeniasis		Within 3 business days	LHJ	Both
Tetanus		Within 3 business days	LHJ	Both
Tick paralysis		Within 3 business days	LHJ	Both
Trichinosis		Within 3 business days	LHJ	Both
Tuberculosis disease (confirmed or highly suspicious, i.e., initiation of empiric treatment)		Within 24 hours	LHJ	Both
Tularemia		Immediately	LHJ	Both
Typhus		Within 3 business days	LHJ	Both
Vaccinia transmission		Immediately	LHJ	Both
Vancomycin-resistant Staphylococcus aureus (not to include vancomycin-intermediate)	Yes	Within 24 hours	LHJ	Both
Varicella-associated death		Within 3 business days	LHJ	Both
Vibriosis (Vibrio species not including Vibrio cholerae O1 or O139) See Cholera (Vibrio cholerae O1 or O139)	Yes	Within 24 hours	LHJ	Both
Viral hemorrhagic fever		Immediately	LHJ	Both
Yellow fever		Immediately	LHJ	Both
Yersiniosis		Within 24 hours	LHJ	Both
Unexplained critical illness or death		Within 24 hours	LHJ	Both

Reflective Practice

Consider the following situations. Should each child be excluded from care or not? If so, why and when should the child return? If not, what should the teacher/caregiver do?

Mario’s dad drops him off and let’s Ms. Michelle know that he is a little under the weather. He is not running a fever, but has a mild cough and a runny nose. But he ate a good breakfast and has a pretty typical level of energy.

About an hour into the day, Li vomits. Mr. Abraham checks and she has a fever of 101.3°. She looks a little pale and just wants to lay down. As he goes to call Li’s family, she vomits again.

When Latanya goes to change Daniel’s diaper she notices a rash on his stomach. She checks his temperature and he is not running a fever. He is not scratching at it or seemingly in any discomfort. She remembers that he has a history of eczema and contact dermatitis.

Apurva wakes up from naptime with discharge coming from a slightly swollen and bloodshot right eye. She tells Ms. Maria that her eye hurts and is “kind of itchy.”

Now, come up with your own examples of a child that should be excluded from care and that should not automatically be excluded.

Caring for Mildly Ill Children

Because young children in early care and education programs have a high incidence of illness and may have ongoing medical conditions (such as eczema and asthma), providers should be prepared to care for mildly ill children, at least temporarily. And since we know that excluding most mildly ill children doesn’t prevent the spread of illness and can have negative effects on families, programs should consider whether they can care for children with mild symptoms (not meeting the exclusion policy). The California Childcare Health Program poses the following questions to consider:

Are there sufficient staff (including volunteers) to provide minor modifications that a child might need (such as quiet activities or extra fluids)?
Are staff willing and able to care for the child’s symptoms (such as wiping a runny nose and checking a fever) without neglecting the care of other children in the group?
Is there a space where the mildly ill child can rest if needed?
Are families able or willing to pay extra for sick care if other resources are not available, so that you can hire extra staff as needed?
Have families made alternative arrangements for someone to pick up and care for their ill children if they cannot?

It’s important that programs recognize the families have to weigh many things when trying to decide whether or not to send a child to child care. They must consider how the child feels (physically and emotionally) whether or not the program can provide care for the specific needs of the child, what alternative care arrangements are available, as well as the income they may lose if they have to stay home.^{^[8]}

Responding to Illness that Requires Medical Care

Some conditions require immediate medical help. If the parents can be reached, tell them to come right away and to notify their medical provider.

Call Emergency Medical services (9-1-1) immediately and also notify parents if any of the following things happen:

You believe a child needs immediate medical assessment and treatment that cannot wait for parents to take the child for care.

A child has a stiff neck (that limits his ability to put his chin to his chest) or severe headache and fever.

A child has a seizure for the first time.

A child who has a fever as well as difficulty breathing.

A child looks or acts very ill, or seems to be getting worse quickly.

[A child has s]kin or lips that look blue, purple or gray.

A child is having difficulty breathing or breathes so fast or hard that he or she cannot play, talk, cry or drink.

A child who is vomiting blood.

A child complains of a headache or feeling nauseous, or is less alert or more confused, after a hard blow to the head.

Multiple children have injuries or serious illness at the same time.

A child has a large volume of blood in the stools.

A child has a suddenly spreading blood-red or purple rash.

A child acts unusually confused.

A child is unresponsive or [has] decreasing responsiveness.

Tell the parent to come right away, and get medical help immediately, when any of the following things happen. If the parent or the child’s medical provider is not immediately available, call 9-1-1 (EMS) for immediate help:

A fever in any child who appears more than mildly ill.

An infant under 2 months of age has an axillary (“armpit”) temperature above 100.4º F.

An infant under four months of age has two or more forceful vomiting episodes (not the simple return of swallowed milk or spit-up) after eating.

A child has neck pain when the head is moved or touched.

A child has a severe stomachache that causes the child to double up and scream.

A child has a stomachache without vomiting or diarrhea after a recent injury, blow to the abdomen or hard fall.

A child has stools that are black or have blood mixed through them.

A child has not urinated in more than eight hours, and the mouth and tongue look dry.

A child has continuous, clear drainage from the nose after a hard blow to the head.

A child has a medical condition outlined in his special care plan as requiring medical attention.

A child has an injury that may require medical treatment such as a cut that does not hold together after it is cleaned.”^[9]

Administering Medications

Some children in your early care and education setting may need to take medications during the hours you provide care for them. It’s important that early care and education programs have a written policy for the use of prescription and nonprescription medication.^{^[10]}

According to licensing, programs that choose to handle medications must abide by the following:

Medicine being poured into a spoon — Figure 4.3 Medication must be given according to the label.

All prescription and nonprescription medications shall be centrally stored in a safe place inaccessible to children, with an unaltered label, and labeled with the child’s name and date
A refrigerator shall be used to store any medication that requires refrigeration.
Prescription medications may be administered with written permission by the child’s authorized representatives in accordance with the label instructions by the physician
Nonprescription medications may be administered without approval or instructions from the child’s physician with written approval and instructions from the child’s authorized representative and when administered in accordance with the product label directions.

Valid reasons for an early care and education program to consider administering medication:

Some medication dosing cannot be adjusted to be taken before and after care (and keeping them out of care when otherwise well enough to attend, would be a hardship for families.
Some children may have chronic conditions that may require urgent administration of medication (such as asthma and diabetes).^{^[11]}

Communication with Families

When children are excluded from care, it’s important to provide documentation for families of how the child meets the guidelines in your exclusion policy and what needs to happen before the child can return to care. Programs are also required to inform families when children are exposed to a communicable disease.

Reflective Practice

Why is it important for early care and education programs to communicate clearly with families regarding communicable illness?

Summary

Becoming familiar with infectious diseases that are common in early childhood enables early care and education program staff to identify illness and respond appropriately. This included knowing when children (and staff) should be excluded from care and what needs to happen before they should come back.

Programs must create policies on how they will handle children that are mildly ill (those that need care before they can be picked up from care and those that do not require exclusion) and children who have illness that requires medical care. Programs who choose to administer medication, must be familiar with the licensing regulations they must follow.

Open communication with families is important when a child becomes ill or is potentially exposed to an illness. Helping families understand and follow policies regarding exclusion is vital to keeping everyone in the program as healthy as possible.

Resources for Further Exploration

Health and Safety in the Child Care Setting: Prevention of Infectious Disease A Curriculum for the Training of Child Care Providers

Georgia School Resource Health Manual

Diseases & Conditions A-Z Index

Childhood Infectious Illnesses

Appropriate Antibiotic Use

When to Keep Your Child Home from Child Care

WAC 110-300-0205.pdf (SECURED) ↵
https://app.leg.wa.gov/WAC/default.aspx?cite=246-110 ↵
Infectious Diseases: Prevention and Management by Head Start Early Childhood Learning & Knowledge Center is in the public domainhttps://eclkc.ohs.acf.hhs.gov/physical-health/article/infectious-diseases-prevention-management ↵
California Childcare Health Program. (2018). Preventive Health and Safety in the Child Care Setting: A Curriculum for the Training of Child Care Providers (3rd ed.). University of California, San Francisco. Retrieved from https://cchp.ucsf.edu/sites/g/files/tkssra181/f/PHT-Handbook-Student-2018-FINAL.pdf ↵
California Child Care Health Program. (2011). Health and Safety in the Child Care Setting: Prevention of Infectious Disease. University of California San Francisco. Retrieved from https://cchp.ucsf.edu/sites/g/files/tkssra181/f/idc2book.pdf ↵
Infectious Disease Outbreak Control by Head Start Early Childhood Learning & Knowledge Center is in the public domain ↵
https://app.leg.wa.gov/WAC/default.aspx?cite=246-101-101 ↵
California Childcare Health Program. (2018). Preventive Health and Safety in the Child Care Setting: A Curriculum for the Training of Child Care Providers (3rd ed.). University of California, San Francisco. Retrieved from https://cchp.ucsf.edu/sites/g/files/tkssra181/f/PHT-Handbook-Student-2018-FINAL.pdf ↵
California Childcare Health Program. (2018). Preventive Health and Safety in the Child Care Setting: A Curriculum for the Training of Child Care Providers (3rd ed.). University of California, San Francisco. Retrieved from https://cchp.ucsf.edu/sites/g/files/tkssra181/f/PHT-Handbook-Student-2018-FINAL.pdf ↵
California Childcare Health Program. (2018). Preventive Health and Safety in the Child Care Setting: A Curriculum for the Training of Child Care Providers (3rd ed.). University of California, San Francisco. Retrieved from https://cchp.ucsf.edu/sites/g/files/tkssra181/f/PHT-Handbook-Student-2018-FINAL.pdf ↵
California Childcare Health Program. (2018). Preventive Health and Safety in the Child Care Setting: A Curriculum for the Training of Child Care Providers (3rd ed.). University of California, San Francisco. Retrieved from https://cchp.ucsf.edu/sites/g/files/tkssra181/f/PHT-Handbook-Student-2018-FINAL.pdf ↵

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Health, Safety, and Nutrition in Early Childhood Education Copyright © 2024 by Lake Washington Institute of Technology is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.