Illness in Early Learning and Child Care Programs

However, these are not the symptoms that necessarily lead to absences. In fact, although respiratory symptoms are most common, it’s rashes and gastrointestinal disease that more often keep children from attending their early learning and child care programs. This is more a reflection of exclusion policies than real risk of serious illness.

It’s important for early learning and child care 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).

Identifying Infectious Disease

When you are familiar with different infectious diseases, it’s easier to identify them in children and know whether children (and educators) who are affected should be excluded from the early learning and child care program.

A child is sneezing and has a stuffy, runny nose. It’s quite likely that they have a common cold. Children get sick many times a year, probably between 4 and 12 times, depending on age and amount of time in child care. Many of these are likely due to the common cold. More than 200 viruses can cause a cold, but rhinoviruses are the most common type.

Symptoms of a cold usually peak within 2 to 3 days and can include:

When viruses that cause colds first infect the nose and air-filled pockets in the face (sinuses), the nose makes clear mucus. This helps wash the viruses from the nose and sinuses. After 2 or 3 days, mucus may change to a white, yellow, or green color. This is normal and does not mean an antibiotic is needed. Some symptoms, particularly runny nose, stuffy nose, and cough can last for up to 10 to 14 days, but those symptoms should be improving during that time.

There is no cure for a cold. It will get better on its own—without antibiotics. Because colds can have similar symptoms to flu, it can be difficult to tell the difference between the two illnesses based on symptoms alone. Flu and the common cold are both respiratory illnesses, but they are caused by different viruses.

Influenza (Flu)

In general, flu is worse than a cold, and symptoms are more intense. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations. Flu can have very serious associated complications.

Flu can cause mild to severe illness, and at times can lead to death. Flu usually comes on suddenly. People who have flu often feel some or all these symptoms:

• Fever (common, but not always) or feeling feverish/chills
• Cough
• Sore throat
• Runny or stuffy nose
• Muscle or body aches
• Headaches
• Fatigue (tiredness)
• Some people may have vomiting and diarrhea, though this is more common in children than adults

Most people who get flu will recover in a few days to less than two weeks, but some people will develop complications (such as pneumonia) because of flu, some of which can be life-threatening and result in death.

Sinus and ear infections are examples of moderate complications from flu, while pneumonia is a serious flu complication that can result from either influenza virus infection alone or from co-infection of flu virus and bacteria. Other possible serious complications triggered by flu can include inflammation of the heart (myocarditis), brain (encephalitis) or muscle (myositis, rhabdomyolysis) tissues, and multi-organ failure (for example, respiratory and kidney failure). Flu virus infection of the respiratory tract can trigger an extreme inflammatory response in the body and can lead to sepsis, the body’s life-threatening response to infection. Flu also can make chronic medical problems worse. For example, people with asthma may experience asthma attacks while they have flu.

A yearly flu vaccine is the first and most important step in protecting against influenza and its potentially serious complications for everyone 6 months and older. While there are many different flu viruses, flu vaccines protect against the 3 or 4 viruses that research suggests will be most common. Flu vaccination can reduce flu illnesses, doctors’ visits, missed school due to flu, prevent flu-related hospitalizations, and reduce the risk of dying from influenza. Also, there are data to suggest that even if someone gets sick after vaccination, their illness may be milder.

Once a person has the flu, their health care provider may recommend antiviral drugs. When used for treatment, antiviral drugs can lessen symptoms and shorten the length of sickness by 1 or 2 days. They also can prevent serious flu complications, like pneumonia. For people at high risk of serious flu complications (including children), treatment with antiviral drugs can mean the difference between milder or more serious illness possibly resulting in a hospital stay.

COVID-19

COVID-19 is an infectious disease caused by SARS-CoV-2, the coronavirus that emerged in December 2019. The virus is spread in small liquid particles when an infected person coughs, sneezes, speaks, sings, or breathes. It can take anywhere from 5-14 days for symptoms to show in someone who is infected with the virus.

The most common symptoms include fever, cough, tiredness and loss of taste or smell. Less common symptoms include sore throat, headache, aches and pains, diarrhea, skin rash, discolouration of fingers and toes, red or irritated eyes. Serious symptoms are difficulty breathing or shortness of breath, loss of speech or mobility, confusion, and chest pain (WHO, 2023).

The Government of Ontario has provided guidelines for early learning and childcare programs for:

• Use of masks
• Cleaning practices
• Self-screening
• Ventilation
• COVID-19 testing

Avoiding Spreading Germs to Others

Early learning and childcare programs should teach children and model good cough and sneeze etiquette. Always sneeze or cough into a tissue that is discarded after use. If a tissue is not available, use your upper sleeve, completely covering the mouth and nose. Always wash hands after coughing, sneezing, and blowing noses.

Sinusitis (Sinus Infection)

Sinus infections happen when fluid builds up in the air-filled pockets in the face (sinuses), which allows germs to grow. Viruses cause most sinus infections, but bacteria can cause some sinus infections.

Common symptoms of sinus infections include:

• Runny nose
• Stuffy nose
• Facial pain or pressure
• Headache
• Mucus dripping down the throat (post-nasal drip)
• Sore throat
• Cough
• Bad breath

Most sinus infections usually get better on their own without antibiotics.

Sore Throat

A sore throat can make it painful to swallow. A sore throat can also feel dry and scratchy. Sore throat can be a symptom of the common cold, allergies, strep throat, or other upper respiratory tract illness. Strep throat is an infection in the throat and tonsils caused by bacteria called group A Streptococcus (also called Streptococcus pyogenes).

Infections from viruses are the most common cause of sore throats. The following symptoms suggest a virus is the cause of the illness instead of the bacteria called group A strep:

• Cough
• Runny nose
• Hoarseness (changes in your voice that makes it sound breathy, raspy, or strained)
• Conjunctivitis (also called pink eye)

The most common symptoms of strep throat include:

• Sore throat that can start very quickly
• Pain when swallowing
• Fever
• Red and swollen tonsils, sometimes with white patches or streaks of pus
• Tiny red spots on the roof of the mouth
• Swollen lymph nodes in the front of the neck

A doctor can determine the likely cause of a sore throat. If a sore throat is caused by a virus, antibiotics will not help. Most sore throats will get better on their own within one week.

Since bacteria cause strep throat, antibiotics are needed to treat the infection and prevent rheumatic fever and other complications. A doctor cannot tell if someone has strep throat just by looking in the throat. If a doctor suspects strep throat, they may test to confirm diagnosis.

Ear Infection

There are different types of ear infections. Middle ear infection (acute otitis media) is an infection in the middle ear.

Another condition that affects the middle ear is called otitis media with effusion. It occurs when fluid builds up in the middle ear without being infected and without causing fever, ear pain, or pus build-up in the middle ear.

When the outer ear canal is infected, the condition is called swimmer’s ear, which is different from a middle ear infection.

Middle Ear Infection

A middle ear infection may be caused by:

• Bacteria, like Streptococcus pneumoniaeand Haemophilus influenza (nontypeable) – the two most common bacterial causes
• Viruses, like those that cause colds or flu

Common symptoms of middle ear infection in children can include:

• Ear pain
• Fever
• Fussiness or irritability
• Rubbing or tugging at an ear
• Difficulty sleeping

A doctor can make the diagnosis of a middle ear infection by looking inside the child’s ear to examine the eardrum and see if there is pus in the middle ear. Antibiotics are often not needed for middle ear infections because the body’s immune system can fight off the infection on its own. However, sometimes antibiotics, such as amoxicillin, are needed to treat severe cases right away or cases that last longer than 2 – 3 days.

Swimmer’s Ear

Ear infections can be caused by leaving contaminated water in the ear after swimming. This infection, known as “swimmer’s ear” or otitis externa, is different from the common childhood middle ear infection. The infection occurs in the outer ear canal and can cause pain and discomfort for swimmers of all ages.

Symptoms of swimmer’s ear usually appear within a few days of swimming and include:

• Itchiness inside the ear.
• Redness and swelling of the ear.
• Pain when the infected ear is tugged or when pressure is placed on the ear.
• Pus draining from the infected ear.

Although all age groups are affected by swimmer’s ear, it is more common in children and can be extremely painful. If swimmer’s ear is suspected, a healthcare provider should be consulted. Swimmer’s ear can be treated with antibiotic ear drops.

Head Lice

Head lice are parasitic insects that live on the head. They survive by feeding on human blood. Lice infestations are spread most by close person-to-person contact. Adult head lice are 2 – 3 mm in length. Head lice infest the head and neck and attach their eggs to the base of the hair shaft. Lice move by crawling; they cannot hop or fly.

Symptoms of a head lice infestation include:

• Tickling feeling of something moving in the hair.
• Itching, caused by an allergic reaction to the bites of the head louse.
• Irritability and difficulty sleeping; head lice are most active in the dark.
• Sores on the head caused by scratching. These sores can sometimes become infected with bacteria found on the person’s skin.

Head-to-head contact with a person who already has an infestation is the most common way to get head lice. Head-to-head contact is common during play at school, at home, and elsewhere (sports activities, playground, slumber parties, camp).

Although uncommon, head lice can be spread by sharing clothing or belongings. This happens when lice crawl, or the nits that are attached to shed hair hatch and get on the shared clothing or belongings. Examples include:

• Sharing clothing (hats, scarves, coats, sports uniforms) or articles (hair ribbons, barrettes, combs, brushes, towels, stuffed animals) recently worn or used by a person with an infestation.
• Lying on a bed, couch, pillow, or carpet that has recently been in contact with a person with an infestation.

Dogs, cats, and other pets do not play a role in the spread of head lice.

The diagnosis of a head lice infestation is best made by finding a live nymph or adult louse on the scalp or hair of a person. Because nymphs and adult lice are very small, move quickly, and avoid light, they can be difficult to find. Use of a magnifying lens and a fine-toothed comb may be helpful to find live lice.

If crawling lice are not seen, finding nits firmly attached within a ¼ inch of base of the hair shafts strongly suggests, but does not confirm, that a person is infested and should be treated. Nits that are attached more than ¼ inch from the base of the hair shaft are almost always dead or already hatched. Nits are often confused with other things found in the hair such as dandruff, hair spray droplets, and dirt particles. If no live nymphs or adult lice are seen, and the only nits found are more than ¼-inch from the scalp, the infestation is probably old and no longer active and does not need to be treated.

Treatment for head lice is recommended for persons diagnosed with an active infestation. All household members and other close contacts should be checked; those persons with evidence of an active infestation should be treated with an over the counter or prescription medication (following the provided instructions).

Hats, scarves, pillow cases, bedding, clothing, and towels worn or used by the person with the infestation in the 2-day period just before treatment is started can be machine washed and dried using the hot water and hot air cycles because lice and eggs are killed by exposure for 5 minutes to temperatures greater than 128.3°F. Items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for two weeks. Items such as hats, grooming aids, and towels that come in contact with the hair of a person with an infestation should not be shared. Vacuuming furniture and floors can remove hairs that might have viable nits attached. Head lice do not survive long if they fall off a person and cannot feed.

After treatment, it’s important to check the hair and comb with a nit comb to remove nits and lice every 2–3 days which will decrease the chance of self–reinfestation. Checking for 2–3 weeks will ensure that all lice and nits are gone.

Personal hygiene or cleanliness in the home or school has nothing to do with getting head lice. According to the Canadian Paediatric Society “Children with head lice should be treated and then attend school or childcare as usual. ‘No-nit’ policies that keep children with head lice or nits after treatment away from school are not necessary because:

• Head lice are common among young children. Many days of school would be missed if children had to stay home.
• People are often wrong when they think a child has head lice. It would be unfortunate to see children missing school when they don’t really have lice.
• Making children stay at home will not get rid of head lice. Often, other children in the class have lice but don’t have any symptoms. Without treatment, they will continue to spread lice.
• Head lice don’t spread disease. They are a nuisance and unpleasant, but they are not dangerous.” (Canadian Paediatric Society, 2022)

Other Illnesses

To learn more about the following illnesses, go to Appendix A at the end of Module 1.2.

• Bronchitis
• Chickenpox
• Conjunctivitis (Pink Eye)
• Fifth Disease (Slapped Cheek)
• Hand, Foot, and Mouth Disease
• Hepatitis A
• Impetigo
• Measles
• Meningitis
• Molluscum Contagiosum
• Mumps
• Norovirus
• Pertussis
• Pinworms
• Respiratory Syncytial Virus
• Ringworm
• Roseola
• Rotavirus
• Rubella (German Measles)
• Shigella
• Tuberculosis

Danger of Infectious Disease for Adults

Because early learning and childcare 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 illness that are spread in early learning and childcare 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.

Reportable Diseases

Some diseases are enough of a threat to the community that it is required that diagnosed cases are reported to Public Health Ontario. For a complete list of reportable diseases, go to Public Health Ontario Reportable Diseases.

Exclusion Policies

Most children with mild illnesses can safely attend childcare. “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 childcare setting will not prevent other children from becoming ill.” (California Childcare Health Program, 2018)

See Appendix B at the end of Module 1.2 for the Region of Waterloo Public Health Infectious Diseases Exclusion Guidelines for Childcare Providers and Schools. Please note that policies may differ between Public Health Units.

What to do When a Child Requires Exclusion

When a child becomes ill enough to be excluded, they should be immediately isolated from other children.

The child’s authorized emergency contact shall be notified immediately when the child becomes ill enough to require isolation and shall be asked to have the child picked up from the center as soon as possible.

Caring for Mildly Ill Children

Because young in early learning and childcare programs have high incidence of illness and may have conditions (such as eczema and asthmas), 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).

It’s important that programs recognize the families must weigh many things when trying to decide whether to send a child to childcare. They must consider how the child feels (physically and emotionally), whether 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.

Responding to Illness that Requires Medical Care

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

Call Emergency Medical services (9-1-1) immediately and notify parents or the designated emergency contact 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 skin or lips that look blue, purple, or gray.
• A child is having difficulty breathing or breathes so fast or hard that they 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 parents or designated emergency contact to come right away, and get medical help immediately, when any of the following things happen. If the parents or the designated emergency contact or the child’s medical provider is not immediately available, call 9-1-1 (EMS, Emergency Medical Services) 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 stomach-ache that causes the child to double up and scream.
• A child has a stomach-ache 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.” (California Childcare Health Program, 2018)

---

References

1. 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. https://cchp.ucsf.edu/sites/g/files/tkssra181/f/PHT-Handbook-Student-2018-FINAL.pdf
2. Canadian Paediatric Society (2022). Head Lice. https://caringforkids.cps.ca/handouts/health-conditions-and-treatments/head_lice
3. O. Reg. 137/15: General. https://www.ontario.ca/laws/regulation/150137
4. World Health Organization (2023). Coronavirus disease (COVID-19). https://www.who.int/health-topics/coronavirus#tab=tab_3

Appendix A: Additional Infectious Disease Information

Bronchitis (Chest Cold)

A chest cold occurs when the airways of the lungs swell and produce mucus in the lungs. That’s what produces the cough. A chest cold, often called acute bronchitis, lasts less than 3 weeks and is the most common type of bronchitis.

Acute bronchitis is usually caused by a virus and often occurs after an upper respiratory infection. Bacteria can sometimes cause acute bronchitis, but even in these cases, antibiotics are NOT recommended and will not help an infected person get better.

Symptoms of acute bronchitis last less than 3 weeks and can include:

• Coughing with or without mucus
• Soreness in the chest
• Feeling tired (fatigue)
• Mild headache
• Mild body aches
• Sore throat

Most chest colds will get better on their own within one week.

Chickenpox

Chickenpox is a highly contagious disease caused by the varicella-zoster virus (VZV). It can cause an itchy, blister-like rash. The rash first appears on the chest, back, and face, and then spreads over the entire body, causing between 250 and 500 itchy blisters. Chickenpox can be serious, especially in babies, adolescents, adults, pregnant women, and people with a weakened immune system. The best way to prevent chickenpox is to get the chickenpox vaccine.

The classic symptom of chickenpox is a rash that turns into itchy, fluid-filled blisters that eventually turn into scabs. The rash may first show up on the chest, back, and face, and then spread over the entire body, including inside the mouth, eyelids, or genital area. It usually takes about one week for all of the blisters to become scabs.

Other typical symptoms that may begin to appear 1-2 days before rash include:

• Fever
• Tiredness
• Loss of appetite
• Headache⁷⁷⁴

The virus spreads mainly through close contact with someone who has chickenpox (or shingles). It takes about 2 weeks (from 10 to 21 days) after exposure to a person with chickenpox or shingles for someone to develop chickenpox. A person with chickenpox is contagious beginning 1 to 2 days before rash onset until all the chickenpox lesions have crusted (scabbed).

Conjunctivitis (Pink Eye)

Pink eye, or conjunctivitis, is one of the most common and treatable eye conditions in the world. It can affect both children and adults. It is an inflammation of the thin, clear tissue that lines the inside of the eyelid (conjunctiva) and the white part of the eyeball. This inflammation makes blood vessels more visible and gives the eye a pink or reddish colour.

The symptoms may vary, but usually include:

• Redness or swelling of the white of the eye or inside the eyelids
• Increased amount of tears
• Eye discharge which may be clear, yellow, white, or green
• Itchy, irritated, and/or burning eyes
• Gritty feeling in the eye
• Crusting of the eyelids or lashes
• Contact lenses that feel uncomfortable and/or do not stay in place on the eye

There are four main causes of pink eye:

• Viruses
• Bacteria
• Allergens (like pet dander or dust mites)
• Irritants (like smog or swimming pool chlorine) that infect or irritate the eye and eyelid lining

It can be difficult to determine the exact cause of pink eye because some signs and symptoms may be the same no matter the cause. When pink eye is caused by a virus or bacteria, it is very contagious. It can spread easily and quickly from person to person (through contact with the discharge from the infected eye). Pink eye caused by allergens or irritants is not contagious.

Fifth Disease (Slapped Cheek)

Fifth disease is a mild rash illness caused by parvovirus B19. It is more common in children than adults. A person usually gets sick with fifth disease within 14 days after getting infected with parvovirus B19.

The symptoms of fifth disease are usually mild and may include

• Fever
• Runny nose
• Headache
• Rash (on face and body)

Parvovirus B19—which causes fifth disease—spreads through respiratory secretions, such as saliva, sputum, or nasal mucus, when an infected person coughs or sneezes. You are most contagious when it seems like you have “just a fever and/or cold” and before you get the rash or joint pain and swelling. After you get the rash, you are not likely to be contagious. Fifth disease is usually mild and will go away on its own. Children and adults who are otherwise healthy usually recover completely.

Hand, Foot and Mouth Disease

Hand-foot-mouth disease is a common viral infection that most often begins in the throat. Hand-foot-mouth disease (HFMD) is most caused by a virus called coxsackievirus A16. Children under age 10 are most often affected.

Symptoms of HFMD include:

• Fever
• Headache
• Loss of appetite
• Rash with very small blisters on the hands, feet, and diaper area that may be tender or painful when pressed
• Sore throat
• Ulcers in the throat (including tonsils), mouth, and tongue