In the United States, more than two-thirds of children younger than 6 years, and almost all children older than
6 years, spend significant time in child care and school settings outside of the home. Exposure to groups of children
increases the risk of infectious diseases. This fact has important personal, public health, economic, and social conse-
quences. The intent of this book is to provide an easy-to-use reference for those who are responsible for the preven-
tion and management of infectious diseases in child care and school settings—teachers/caregivers, pediatric clinicians,
public health professionals, and parents. This is the fourth edition of this book. New topics were added at the request
of enthusiastic users. Review of scientific evidence since the previous editions led to a few changes as well.
In this book, educators in group care settings and schools include directors, teachers/caregivers, and other education
professionals. Educators will find that this book offers easy-to-read explanations for how infectious diseases spread,
how to prepare for inevitable illness, and how to incorporate measures that limit any excess burden of illness associ-
ated with group activities. The Signs and Symptoms Chart (Chapter 5) will help nonmedical professionals become
aware of what might cause various signs and symptoms. The set of fact sheets (Chapter 6, Quick Reference Sheets)
describes specific types of infectious diseases in common terms, with guidance about how they spread and what needs
to be done by educators, children, and families when someone in the group has a disease. By using this book as a
handy reference, educators can feel more confident in making decisions about inclusion and exclusion of ill children
and in seeking advice from medical and public health professionals when necessary to reduce the burden of infectious
diseases on other children and staff members.
Pediatricians and other health professionals will find this book helpful as a reference that facilitates communication
with educators. Pediatric health professionals are the primary source of information for educators about the manage-
ment of infectious diseases for individual children and the implications of these infections for groups of children and
the adults who care for them. Pediatric health professionals can use the content of the book to identify exclusion and
inclusion recommendations, supplement their communications with educators about infectious diseases of patients,
and augment their instructions for the care of the child for parents and educators involved in the child’s care. They
also can use the content of the book to identify the need for linking teachers/caregivers with public health authorities
when necessary.
Parents will benefit from the content of this book because it will provide a common means for communication
among family members, pediatric health professionals, and educators that is based on the best available evidence
and expert opinion about best practices. Additionally, parents and educators will benefit from the Quick Reference
Sheets. These may be copied. For example, a health professional can give a copy to parents to share with educators,
or educators can send copies home to parents. Use these sheets to describe a condition or infection affecting their
child or the group of children to which their child is exposed.
This book also addresses the controversial subject of exclusion and return-to-care criteria. Controversy exists because
often, educators, pediatric clincians, public health professionals, and parents disagree about which conditions require
exclusion. For example, children with runny noses may be excluded unnecessarily, but others with diarrhea that is
associated with loss of bowel control that causes a child to have an accident may be allowed to stay, when their loss of
bowel control may pose a greater infection risk. Adding to the confusion, each state health department and licensing
agency has unique rules or exclusion criteria for determining which symptoms, diseases, and conditions require exclu-
sion from child care or school.
The recommendations in this book are based on the best available medical information as determined by the
American Academy of Pediatrics. Some of the exclusion criteria in this book are more detailed than existing guide-
lines and can be followed without conflict with existing rules or regulations. Others will conflict because they
are evidence-based and the evidence does not support practices that have become embedded in existing rules or
regulations developed without the benefit of current evidence. It is our hope that policy makers incorporate the
exclusion and return-to-care recommendations in this book as they move toward revising their state requirements
and regulations.
Susan S. Aronson, MD, FAAP
Timothy R. Shope, MD, MPH, FAAP
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