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Sticher et al. BMC Health Services Research (2018) 18:25
DOI 10.1186/s12913-018-2831-5
RESEARCH ARTICLE
Open Access
Temporary exclusion of ill children from
childcare centres in Switzerland: practice,
problems and potential solutions
Benjamin Sticher, Julia Bielicki and Christoph Berger*
Abstract
Background: In childcare centres, temporary exclusion of ill children, if their illness poses a risk of spread of harmful
diseases to others, is a central approach to fight disease transmission. However, not all ill children need to be excluded.
Previous studies suggested that childcare centre staff have difficulties in deciding whether or not to exclude an ill child,
even when official ill-child guidelines are used. We aimed to describe, quantify and analyse these ambiguities and
discuss potential solutions.
Methods: For this cross-sectional study, we sent postal surveys to 488 childcare centre directors in the Swiss Canton of
Zurich, where no official ill-child guideline is in place. We asked for exclusion criteria for ill children and ambiguities
faced when dealing with ill children. We checked whether existing guidelines provided solutions to the ambiguities
identified.
Results: 249/488 (51%) directors responded to the survey. The most common exclusion criteria were fever (87.4%) and
contagiousness (52.2%). Ambiguities were mostly caused by conjunctivitis (23.7%) and use of antipyretic drugs (22.9%).
Roughly one third of the ambiguities identified could have been resolved with existing guidelines, another third if
existing guidelines contained additional information. For the last third, clear written directives are difficult to formulate.
Conclusions: Written recommendations may help to clarify when an ill child should temporarily be excluded.
However, such a guideline should cover the topics antipyretic drugs and teething and have room for modification to
local circumstances. Collaboration with a paediatrician may be of additional benefit.
Keywords: Paediatrics, Infection control, Childcare centres, Standard operating procedures, Temporary exclusion
Background
In Switzerland, Western Europe and the United States
overall at least 30%, in several countries up to more than
80% of preschool children enjoy some type of formal
care provided in out-of-home childcare centres (CCC)
[1–3]. It is well documented that children attending
CCCs suffer more infections [4–9] and that CCCs can
be the source of and sustain outbreaks of serious infectious diseases [10–12]. As studies have shown decreased
transmission rates of infectious diseases in schools during holidays or school closures, temporary exclusion off
ill children can – besides review of attendee vaccination
* Correspondence: christoph.berger@kispi.uzh.ch
Division of Infectious Diseases and Hospital Epidemiology and Children’s
Research Center, University Children’s Hospital Zurich, Steinwiesstrasse 75,
8032 Zürich, Switzerland
status and hygiene precautions – be an important tool in
preventing infectious disease transmission in CCCs, too
[13, 14]. When deciding whether to temporarily exclude
an ill child or not, CCC staff and directors face the challenging task of needing to ensure unaffected children and
staff are adequately protected while limiting disruption to
the daily routines of the families they serve.
The American Academy of Pediatrics (AAP) in its
Guideline for Early Care and Education Programs defines
exclusion criteria for ill children in CCC [15, 16]. The
presence of highly contagious, potentially harmful infection is one of three key criteria for temporary exclusion.
The other two exclusion criteria in the AAP guideline are
1) “illnesses that prevent the child from participating comfortably in activities” and 2) “illnesses that result in a need
for care that is greater than the staff can provide without
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sticher et al. BMC Health Services Research (2018) 18:25
compromising the health and safety of other children”
[15]. Being mainly symptom-based and designed for
the use by non-medical professionals, endorsed by a
nationwide association of medical professionals and
being frequently scientifically re-evaluated [17–19] the
AAP guideline can be considered as a standard reference
for exclusion criteria for ill children in CCC. Due to these
properties and its easy access this guideline could be applied more than any other also in Switzerland.
The AAP guideline aims to enable CCC staff to identify ill children that require temporary exclusion. Yet
even when applying the guideline, CCC directors are
reported to experience difficulties in dealing with ill children. CCC directors tend to exclude children more often
than necessary, such as children with mild and harmless
illnesses, and frequently do not follow return-to-care
recommendations stated in the AAP guideline [17–19].
All of these can negatively impact affected families and
may have economic consequences, for example in terms
of parental days off work.
Improved support for decision-making in relation to
temporary exclusions is desirable. To achieve this, policy
makers and practitioners need to better understand
CCC directors’ knowledge, attitudes and practices in
handling acutely ill children. We asked CCC directors in
the Canton of Zurich in Switzerland, a setting without
formal guidance, to report their exclusion practice and
name ambiguities they experienced. We sought to relate
our data to the AAP guideline, to assess the guideline’s
applicability and to discuss potential modifications that
could better inform CCCs in dealing with decisions
about temporary exclusion of ill children.
Methods
For this cross-sectional study, we designed a paperbased questionnaire for distribution to CCC directors.
The questionnaire focused on their handling of ill children, including their self-perception of managing this
issue, and eliciting what ambiguities they experience.
Data on centre characteristics were also collected. To
ensure content validity, questionnaires were piloted and
revised by five paediatricians who are in regular contact
with CCCs.
Questionnaires were posted to all 488 CCC in the
Canton of Zurich (Switzerland). The overall population
of Zurich is 1,421,895, of which 5.3% are children less
than 5 years of age [20]. Addresses were compiled from
a list provided by the local administration office and
from entries in a local, Internet based directory [21].
CCC directors who had not responded one month after
distribution received up to two telephone reminders.
The completion time for the questionnaire was about
30–40 min. In a letter accompanying the questionnaire,
CCC directors were informed of the study’s background
Page 2 of 8
and goals. They were asked for voluntary participation.
In accordance with the institutional review board, the
authors did not seek ethics review, as this study did not
collect any data on human subjects.
CCC directors were asked in an open-end question to
name exclusion criteria for ill children. Additionally,
they were asked about the number of children cared for,
the number of children less than 2 years of age, the
number of staff, whether they had any form of in-house
ill-child standard operating procedure (SOP), whether
they have an advising paediatrician and if yes, how they
collaborate. CCC directors without SOP and/or without
an advising paediatrician were asked whether they think
that they would benefit from having one. We also asked
CCC directors to rate their handling of ill children on a
scale from 1 (worst) to 10 (best) and how often they are
unsure if an ill child should be excluded (six categories
of frequency).
Ambiguities with the handling of ill children
In order to describe ambiguities with the handling of ill
children, CCC directors were asked the following openended questions:
1) If you are ever unsure, whether an ill child should
be temporarily excluded or not, how do you handle
the situation? Please describe.
2) Can you describe situations in which parents did not
accept temporary exclusion, although you would
have preferred to do so?
Answers to these questions are summarized as ambiguities with the handling of ill children as reported by
Swiss CCC directors (Table 3). If a statement could be
attributed to several categories, it was exclusively attributed to the category the respondent assumedly wanted
to stress. To be listed as a discrete category, an ambiguity had to be mentioned by more than one respondent.
For every ambiguity in Table 3, we then checked
whether the APP guideline was applicable. If no specific
recommendation was provided, we checked whether information was simply lacking in the guideline, or
whether it was genuinely difficult to address the issue
through written guidance. We referred to the 2011 version of the AAP guideline, which is still consistent with
the updated 2015 version concerning the topics discussed in this study.
Data analysis
Descriptive analyses were undertaken using IBM SPSS
Statistics version 21 (SPSS Inc., Chicago, IL). Differences
between means were assessed using the independent
two-tailed t-test. P-values smaller than 0.05 were considered significant.
Sticher et al. BMC Health Services Research (2018) 18:25
Results
Characteristics
In total, 249/488 CCCs responded to the survey (51,0%
response rate). The response rate was lower in its urban
centre (Zurich city; 43.1%) than in the rest of the Canton
(58.2%). On average, participating CCCs had 10.1 full
time equivalent staff caring for 26 children (range 4–78)
with a total number of 6424 children being served by
the surveyed CCCs. 88.0% of the CCCs accepted children less than 2 years of age. Only 7.6% of the responding centres were part of a multi-centre childcare
organization. Both private and public CCCs participated.
Page 3 of 8
Table 1 Exclusion criteria for ill children as reported by Swiss
CCC directors: Medical and social circumstances
Category
%a
Contagiousness
52.2 Not specified
If contagiousness is suspected; until a
physician confirms that there is no threat
Except for common colds
Extent of Illness
45.3 Discomfort, pain or altered general
condition
Any sign of illness
Exclusion criteria for ill children
Tables 1 and 2 summarize the circumstances and symptoms that reportedly lead to temporary exclusion of ill
children. In addition, specific diseases mentioned as reasons for temporary exclusion from CCCs included
gastroenteritis (20.9%), head lice (9.6%), chickenpox
(8.8%), flu-like disease (6.4%), measles (6.0%).
Ambiguities in decision-making about temporary
exclusion
Table 3 shows situations in which CCC directors experienced ambiguity about temporary exclusion of affected
children. The AAP guideline covers 39% of these, most
often when CCC directors are unsure about the handling
of conjunctivitis, rashes and fever. The remaining 61% of
described situations can be divided into two groups: (i)
those for which an SOP could provide a standardized solution, but for which information is lacking in the AAP
guideline (listed as IL in Table 3); (ii) those, which are
difficult to address in a written directive.
(i) Ambiguous situations that could be addressed
through an SOP.
There are two commonly named situations that could
be managed according to an SOP such as the AAP
%
47.4
1.6
1.6
29.7
7.2
If the child cannot participate comfortably 6.4
in daily activities
Any sign of illness in the last twenty-four
hours
In-house guidelines and policy
The majority of centres (85%) reported having in-house
ill-child standard operating procedures (SOP). 53% of
those without SOPs said they would benefit from such
documentation. 73% of all respondents reported having a
named advising paediatrician. The level of this collaboration differed widely, from simply designating a responsible paediatrician in order to fulfil local administrative
requirements to intensive and on-going cooperation including joint drafting of in-house ill-child SOPs, on-site
visits and provision of telephone advice. 41% of the CCCs
without a named paediatrician stated they would benefit
from such collaboration.
Exclusion criterion
Institutional
limits
8.4 If the child needs medication
2.8
If we cannot provide optimal care
2.4
If the child needs the care of its parents
2.0
If the child needs to see a physician
Interference with
other children’s
need
2.0
3.2 If the child needs more attention than
we can offer
If not being excluded would be possibly
dangerous for the child or the other
children
1.2
2.4
0.8
a
This number includes once-only mentions, which are not further described in
this table
guideline, but for which information is lacking in the
current AAP guideline:
Antipyretic drugs
A majority of the 23% of respondents who named antipyretic drugs as a source of ambiguities indicated that a
particularly problematic situation was when they suspected parents of giving their children antipyretic drugs in
the morning to avoid exclusion for fever or illness. More
than half of these respondents added that parents would
often fail to inform staff about antipyretic use and/or elevated temperature observed at home. Staff stressed that
this lack of information was particularly problematic when
the drug effect was fading, and they were confronted with
deterioration in the child’s general state.
Teething
Some respondents reported that they were not able to determine whether certain symptoms, such as fever, were
related to teething (5.2%). Further, 3.2% reported that parents would insist on inclusion of their ill child if they believed that symptoms could be explained by teething.
(ii)Ambiguous situations not easily addressed through
an SOP.
This second group can be subdivided into four
basic issues: Parental communication, medical knowledge,
Sticher et al. BMC Health Services Research (2018) 18:25
Page 4 of 8
Table 2 Exclusion criteria for ill children as reported by Swiss
CCC directors: Symptoms and signs
Category
%a
Fever
87.4
Conjunctivitis
Vomiting
Diarrhoea
Various symptoms
29.3
19.7
18.0
9.6
Organization of alternative care
Not specified
36.1
Above a defined body temperature
(≥ 38, 38.1 or 38.5 °C)
35.3
5.2% of the respondents reported problems when excluding an ill child, if no alternative care is available.
This is most common when parents are not able to leave
their workplace to look after their ill child themselves.
High fever
8.0
Collaboration with paediatricians
With other signs of illness
3.6
Exclusion criterion
%
Eye irritations, e.g. tearing or red eyes
4.4
Until a physician confirms that there
is no threat
1.6
4.4% of the respondents specifically expressed that some
situations were challenging because of a lack of structured paediatric support. The most common complaint
was that different doctors contacted ad hoc when the
need arose gave different recommendations, for example
with regard to the management of conjunctivitis.
Until a defined time after beginning
of treatment
1.2
Directors’ self-assessment
Not specified
16.9
More than once
1.6
Repeated vomiting
0.8
Not specified
10.4
Above a defined number of unformed
stools
3.6
Heavy diarrhoea
2.8
Abnormal breathing
2.8
Rash of unclear origin
2.8
If it is not due to teething
1.2
Not specified
20.1
a
This number includes once-only mentions, which are not further described in
this table
organization of alternative care and collaboration with
paediatricians.
Parental communication
13.6% of the respondents mentioned difficulties in
decision-making on temporary exclusion related to insufficient or difficult communication with parents. Most
frequently, parents were reported to insist on the inclusion of a child with a potentially contagious disease.
CCC directors also reported having disagreements with
parents regarding the significance of their child’s symptoms for the child or for other children: “Parents start
discussing about the definition of diarrhoea without understanding that this is contagious for other children”
(Quote from survey).
Medical knowledge
Their lack of medical knowledge was a major challenge
for many directors (12.6%). Those naming conjunctivitis
as a potential reason for temporary exclusion, for example, reported uncertainty in differentiating between
infectious and non-infectious conjunctivitis, and regarding the contagiousness of the disease. Some 6% reported
not to be able to gauge the cause of a rash, and therefore
being unsure of how to handle the situation.
Asked to rate their handling of ill children on a scale
from 1 (worst) to 10 (best), 87% chose a grade from 7 to
9, the overall average being 7.97. The directors’ rating of
their handling of ill children was higher, but not significantly, in institutions with a named paediatrician compared to institutions without a named paediatrician (8.01
vs. 7.83, p = 0.373). This also applies to institutions with
in-house ill-child SOPs compared to institution without
in-house ill-child SOPs (8.03 vs. 7.61, p = 0.103). The frequency of being unsure whether or not to exclude an ill
child did not differ significantly either between institutions
with and without a named paediatrician, or between institutions with and without in-house ill-child SOPs (Fig. 1).
Discussion
Our analysis of the handling of ill children in 249 Zurich-based childcare centres (CCCs) and of ambiguous situations reported by CCC staff in relation to temporary
exclusion of ill children identified fever and contagiousness as the two most common exclusion criteria, and conjunctivitis and antipyretic use as the most commonly
reported ambiguous situations.
Participating CCC directors had a positive self-perception
of their handling of ill children. Nevertheless, providing
continuous care, respecting the needs and health of all children at the centre, avoiding the spread of dangerous infectious diseases and ensuring economic profitability were
reported to potentially compete with each other and could
pose challenges in decision-making about temporary exclusion of ill children. Conjunctivitis, antipyretic drugs, rashes,
teething, fever, vomiting and diarrhoea were, in this order,
most frequently mentioned as being potentially challenging
(Table 3). We hypothesize that some of these situations
were already addressed by available guidance, that others
could be addressed by written SOPs, and that further still a
named CCC paediatrician could help in evaluating situations that cannot easily be addressed by a written directive.
In Switzerland, where this study was conducted, there
is no official guideline for CCCs similar to the American
Sticher et al. BMC Health Services Research (2018) 18:25
Page 5 of 8
Table 3 Ambiguities with the handling of ill children as reported by Swiss CCC directors
Description of the ambiguous situation
%a
Conjunctivitis
23.7
AAP?b
Not specified
8.4
Yes
Unclear when or for how long conjunctivitis is contagious
5.6
No; MK
Differentiation between infectious and non-infectious conjunctivitis
4.4
Yes
Parents want to bring the child without seeing a doctor first
1.6
Yes
Parents insist on conjunctivitis not being contagious
1.6
No; PC
1.2
No; CWP
Different doctors give different recommendations
Antipyretic drugs
22.9
If a feverish child has received antipyretic drugs and is increasingly ill, as the effect is fading
13.3
No; IL
Pa …
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