Daily Health Checks and Sick Children
Check children at arrival, spot signs of illness, and follow your program policy on when a child goes home.
Table of contents
Young children in group care get sick often. Most of the time it is a mild cold, and most children can stay in care. Your job is to notice what is different about a child, decide with your program's policy whether they can stay, and keep them and the others comfortable and safe.
This guide uses guidance from the American Academy of Pediatrics (AAP) on when children should stay home from child care. Your state rule and your program's written health policy may be stricter. Those rules decide what you do. You observe and you follow policy, but you do not diagnose or give medical advice to families.
What You Will Be Able to Do
- Do a quick daily health check at arrival
- Tell the difference between signs that call for exclusion and signs that do not
- Respond to fever at different ages
- Care for a child who becomes sick during the day
- Explain return rules clearly to a family
The Daily Health Check
A daily health check takes about a minute per child, and it happens while the parent or guardian is still there. That way, you can ask questions and the family can take a sick child home right away. It also gives you a record of how the child looked at arrival.
Follow these steps as you greet each child:
- Look. Notice skin color, rashes, sores, swelling, bruises, eyes and nose. Notice how the child stands and moves.
- Listen. Listen for a cough, hoarse voice or trouble breathing. Listen to how the child talks and sounds.
- Ask. Ask the adult how the child slept, ate and behaved, and whether there has been fever, vomiting, diarrhea or any medicine since yesterday.
- Compare. Think about how this child usually looks and acts. A quiet child may always be quiet. A lively child who clings and won't play is telling you something.
- Record. Write down anything unusual, following your program's method.
You do not need to take every child's temperature at the door unless your program requires it. Feel for warmth only as a hint. A thermometer gives you the actual number.
If you see an injury or a pattern that worries you, write down what you saw, and speak with your director. Your duties as a mandated reporter may apply.
When a Child Should Go Home
Three questions come first. If you answer yes to any of them, the child usually should not stay, whatever the illness is:
- Is the child too sick to take part in normal activities?
- Does the child need more care than staff can give without taking away from the other children?
- Does the child have a condition on the exclusion list in your policy?
AAP guidance lists these reasons for keeping a child out of care:
| Sign | When it calls for exclusion |
|---|---|
| Severe illness | Unusually sleepy or hard to wake, very irritable, crying more than usual, trouble breathing, or a rash that spreads fast |
| Diarrhea | Stool not contained in the diaper, accidents in a toilet-trained child, more than 2 stools above normal in 24 hours, or blood or mucus in the stool |
| Vomiting | 2 or more times in 24 hours, unless it has a known non-infectious cause and there is no risk of dehydration |
| Abdominal pain | Lasts more than 2 hours, or comes and goes with fever or other worrying symptoms |
| Mouth sores with drooling | The child cannot control the drooling, unless a health professional says it is not infectious |
| Rash | With fever or a change in behavior, until a health care provider says it is not contagious |
| Skin sores | Weeping sores on an exposed area that a waterproof bandage cannot cover |
Warning: A rash that spreads quickly and looks like bruises or tiny red or purple dots needs emergency care. Call 911.
Some named conditions have their own return rules. AAP guidance gives these as examples:
| Condition | Stay out until |
|---|---|
| Strep throat | At least 12 hours after antibiotics start |
| Head lice, scabies, ringworm | After the first treatment. A child found with lice during the day can usually stay until pickup |
| Chickenpox | All sores have crusted and no new ones have appeared for 24 hours |
| Hepatitis A | One week after illness starts, or as the health department directs |
| Certain stool germs (Shiga toxin-producing E. coli, Shigella, Salmonella Typhi) | The health department says so |
Your health department decides what counts as a reportable disease. Your director reports those, and tells families when an illness in the program needs a notice.
When a Child Can Stay
Many common problems do not call for exclusion if the child feels well enough to join in. Sending these children home does not usually stop germs, because they have often already spread before symptoms show up.
- A cold or cough with no fever or other sign of illness
- A runny nose, whatever color the discharge is
- Pinkeye or eye discharge with no fever, if the child can take part
- An ear infection, unless the child cannot take part
- A rash with no fever or behavior change, unless it spreads quickly
- Thrush and fifth disease
- Hand, foot and mouth disease, unless there is constant drooling, fever or other symptoms
Your program may be stricter on some of these, and some states are too. For example, many programs still ask for treatment before a child with pinkeye returns. Follow your written policy, and do not change it for one family.
Understanding Fever
Fever is a sign that the body is fighting something. It is not an illness by itself. A body temperature of 100.4 degrees F (38.0 degrees C) or higher is considered elevated in infants and children. What you do next depends on the child's age and how the child is acting.
| Age | What to do |
|---|---|
| Under 2 months | Any fever is urgent. A temperature above 100.4 degrees F needs urgent medical advice, with or without other symptoms. Call the family right away |
| 2 months and older | Look at the whole child. AAP guidance excludes a child with a temperature above 101 degrees F with a change in behavior or other symptoms |
| Any age with cough, runny nose or sore throat | A child with these symptoms and a fever should not attend. They can return after 24 hours without fever and without fever-reducing medicine |
Many programs and some states use a simpler rule: a child with a temperature of 100.4 degrees F or higher goes home and stays out until they have been fever-free for 24 hours without fever-reducing medicine. If that is your policy, you follow it. Learn the exact number in your own policy on your first day.
Use the thermometer your program provides, and follow its instructions. Record the number, the time and the method. Do not add or subtract a degree based on where you took the temperature. Rectal temperatures are for health professionals or trained staff, and many programs do not allow them.
Warning: A young baby with a fever may have a serious infection, even if the baby looks fine. Treat a fever in a baby under 2 months as urgent. Your program may apply the same urgency to babies up to 3 months.
When a Child Gets Sick During the Day
- Make the child comfortable. Move the child to a quiet spot, within sight of an adult. Keep other children a short distance away. Never leave a sick child alone.
- Check and record. Note the time, what you saw, the temperature if you took one, and any food or drink.
- Tell your lead teacher or director. They decide if the child needs to go home.
- Call the family. Say what you saw, and ask them to pick up the child within the time your policy sets. If you cannot reach them, use the emergency contact list.
- Clean up. Wear gloves for vomit, stool or blood, and follow your program's cleanup procedure. Clean, then sanitize or disinfect toys and surfaces the child used.
- Wash hands. Wash your hands and the child's hands. Good hand hygiene is your best tool against the spread of illness.
- Complete the record. Note who picked the child up and when, and any return instructions you gave.
Call 911 first and then the family if a child has trouble breathing, turns blue, cannot be woken, has a seizure, or looks seriously ill. Do not wait for a parent in those cases.
Do not give fever-reducing medicine to a child unless your program has written permission for it. Medicine can hide a fever and give a false picture of how the child is doing.
Stopping Germs Before They Spread
Handwashing is the most effective step you can take against illness in a group of young children. Wash with soap and water, and scrub for at least 20 seconds, about as long as singing "Happy Birthday" twice. In childcare, wash your hands:
- When you arrive at work, and when you come back from a break
- Before and after handling or serving food
- Before and after giving medication
- After diapering or helping a child use the toilet
- After wiping noses, or touching blood, vomit or other body fluids
- After outdoor play and after touching animals
Children need to wash at the same times. Young children usually need help to use soap and to wash long enough, so stay with children under 5 while they do it. Hand sanitizer can help when no sink is available, but keep it out of children's reach and watch closely if your program lets children use it. It does not work well on visibly dirty hands, and it is not a replacement for soap and water after diapering or before eating.
Talking With Families
Families often depend on childcare to keep their jobs. A call to pick up a sick child can cost them a shift, so be calm and factual.
- State what you saw: "Mia vomited twice this morning and has a temperature of 101.6."
- Refer to the policy, not your opinion: "Our health policy asks that she go home and return after..."
- Do not guess what is wrong. Avoid "I think it's strep."
- Give the return rule in writing if you can.
- Share what you know about illness in the room while protecting privacy. Do not name which child is sick.
If a parent gives a child fever medicine in the morning and drops them off, the policy still applies. Ask your director to speak with the family.
Keeping Records and Staff Health
Your program must keep certain health records. Immunization records are required for enrollment in most states, with exemptions that differ by state. A child's health file is confidential, so share it only with people who need it for that child's care.
Adults count too. If you have vomiting, diarrhea, fever or a contagious illness, tell your director before you come in. Your program should have exclusion rules for staff as well. Working while sick can spread illness to a whole room.
Common Mistakes
| Mistake | What it costs |
|---|---|
| Doing the check after the parent has left | You lose your chance to ask and to send the child home |
| Sending every runny nose home | Families lose work, with no real benefit |
| Waiting on a young baby's fever | A serious infection can get worse quickly |
| Telling a parent what you think the illness is | You are not qualified to diagnose, and you may be wrong |
| Naming a sick child to other families | It breaks confidentiality |
Check Your Understanding
1. A 3-year-old has green discharge from his nose but is running around and playing as usual. Does he need to go home?
Under AAP guidance, no. The color of nasal discharge is not a reason for exclusion. Check that your program's policy agrees, wash hands often, and help him wipe his nose.
2. A 6-week-old feels warm at nap time. Her temperature is 100.8 degrees F. She is calm and sleeping. What do you do?
Treat this as urgent. Tell your lead teacher and call the family right away so that the baby gets medical advice. A baby this young with a fever needs prompt attention even if she looks well.
3. A 4-year-old vomits once after lunch, then says he feels better and goes back to playing. What do you do?
Record it and watch him closely. Clean up safely and let the family know. AAP guidance excludes a child who vomits 2 or more times in 24 hours, so a second episode, or any other sign of illness, would mean he goes home. Your program's policy may be stricter.
4. A father tells you at drop-off that his daughter had a fever last night, but he gave her medicine this morning and she seems fine. What do you do?
Check her and speak with your director. A child with a fever usually needs to be fever-free for 24 hours without medicine before coming back, so the policy probably applies.
Key Takeaways
- Do the daily health check while the family is still there
- Use three questions first: can the child take part, can staff care for them, and is it on the exclusion list
- Fever in a baby under 2 months is urgent, whatever the baby looks like
- Many programs use 100.4 degrees F and 24 hours fever-free without medicine, so learn your policy
- Many common symptoms do not call for exclusion
- Report what you see and follow your policy, and do not diagnose