Infection control: “When can my child return to school?”

Two common questions asked of pediatricians by parents are “When can my child return to school?” and “how long will I be staying home with my child?” Understanding when, how long, and under what conditions a pediatric patient with an infection is contagious to others is an important part of disease prevention and treatment. Similarly, the pediatrician needs to educate parents and educators about infection control practices that improve prevention and decrease risk of disease transmission.

These practices are particularly important in regard to school-aged children, because inappropriate exclusion can lead to a significant number of school days missed. At times, the pediatrician may need to contact schools if a child is inappropriately excluded and provide sound reasoning as to why exclusion is not appropriate.

Recommended: Deciphering bacterial meningitis

This article is not a complete review of communicable diseases or prevention control measures. Rather, the article reviews a number of diseases that do not require exclusion; common diseases and problems that may require some aspect of exclusion; and a number of prevention control measures.

Infections spread via respiratory routes

When children cough or sneeze, aerosolized droplets can be inhaled by individuals who are nearby and place them at risk for an infection. A person is more commonly infected, however, when the droplet comes to rest on a surface and then they touch their hand to their face, nose, or mouth. As a result, if a child covers their cough or sneezes with their hands, this may increase risk of transmission by contaminating surfaces with mucus from their nose, eyes, or throat.¹

Children should be taught to sneeze or cough into a tissue or paper towel. If this is not available, they should be instructed to sneeze into the crook of the elbow. Children should then perform good hand hygiene.

Preventing infections via direct contact

Children touch everything and often touch their nose, face, and mouth. Good hand hygiene prevents risk of transmission of diseases that transmit through direct contact.

The Centers For Disease Control and Prevention recommends a 5-step handwashing process to avoid getting sick and spreading germs to others:²

Wet. Wet hands first with clean, running water and apply soap.

Lather. Rub hands together to lather up and focus on the backs of the hands, between the fingers, and under finger nails.

Scrub. Scrub hands for at least 20 seconds. Asking children to sing “Happy Birthday” to themselves twice will be about the right amount of time.

Rinse. Run hands under running water and not standing water. Standing water potentially increases risk of reinfection with the germ or virus. Tell child to think of the germ/virus circling the drain away from them.

Dry. Dry hands with a clean towel or let them air dry.

If access to handwashing is not available, hand sanitizer is an option. 

NEXT: Infections not requiring exclusion

Infections not requiring exclusion

In general, school-aged children with the following conditions presented in the Table¹ do not need to be excluded from school if they feel well enough to participate in their regular activities and do not have fever, rash, or severe illness symptoms requiring temporary exclusion.

Specific conditions that may require exclusion

Boils, abscesses, cellulitus. Signs and symptoms include furuncles and carbuncles (boils) that occur in hairy areas and contain pus. Skin abscesses are collections of pus and may be tender, painful, and fluctuant. With cellulitis, skin is red and tender. Fever may be present with boils, abscesses, or cellulitus.

Incubation period depends on the causative agent. It is spread through person-to-person contact, with a smaller risk of indirect spread via a contaminated surface or object.

More: Staphylococcus aureus infections in atopic dermatitis

Staph and strep are the most common bacteria causing boils, abscesses, or cellulitus. These infections are contagious if the infected area is open and draining. The child does not need to be excluded unless there are other symptoms (eg, fever) or the draining lesion cannot be covered or drainage is significant and going through the bandage, contaminating other surfaces.¹

Good handwashing is an important way to avoid spread of infections from child to child. Infected children should be instructed to not share personal items such as towels. Having a methicillin-resistant Staphylococcus aureus (MRSA) infection or being a MRSA carrier is not a reason for exclusion in and of itself.

Next: Chickenpox

Chickenpox (varicella). Regarding signs and symptoms of chickenpox, after a prodrome that may include fever, malaise, pharyngitis, or loss of appetite, a macular rash appears that progresses to pruritic vesicles and then scabs. Eruptions occur in crops, so that 1 person may have findings in all 3 stages.

The incubation period is usually from 14 to 16 days. As to how it is spread, the disease is communicable from 48 hours before appearance of the rash until vesicles have dried and no new vesicles are forming. It is spread through aerosolized droplets or direct contact with fluid from a skin vesicle.

Although immunization has made these infections much less common in the pediatrician’s office (vaccine is ~70%–90% effective in preventing chickenpox), infections may still be seen in unimmunized patients or atypical presentations in immunized or underimmunized populations. School exclusion is appropriate for active cases, and school systems may also exclude at-risk, unimmunized children. Children with uncomplicated varicella infections may return to school when the rash has crusted or no new lesions are present in 24 hours in an appropriately immunized child without crusts.³ This often occurs about 6 days after the start of the rash.

Conjunctivitis (bacterial and viral [pinkeye]). Signs and symptoms include redness of the eye and discharge. Discharge may be mucopurulent or clear. Eyes are often matted shut in the morning. Patients may also report itching, pain, burning, sandy, or gritty feeling in the eye.

The incubation period for bacterial conjunctivitis is 24 to 72 hours, whereas for adenovirus (the most common cause of viral conjunctivitis) it is 5 days. As to how it is spread, both bacterial and viral pathogens are highly contagious. Spread is via direct contact with discharge from the eye or indirect contact from a contaminated surface or object.

Related: Risk factors for severe allergic rhinoconjunctivitis

Although the safest preventive measure would be to exclude children until the discharge has resolved, this is not feasible. Hand hygiene is important, especially when touching the eyes, nose, or mouth. Infected individuals should not share towels, cosmetics, or other personal items. Many schools require 24 hours of antibiotics for a child with an eye discharge before the child can return to school. This is appropriate to decrease risk of infecting others with bacterial conjunctivitis, but it will not impact risk of spread of viral conjunctivitis. If concerned about school systems requiring antibiotic treatment, explaining that pinkeye is like the common cold and that exclusion is not appropriate for the common cold may get the child back in school without an unneeded treatment.¹

Diarrheal illness. Signs and symptoms of diarrheal illness include 3 or more large, loose (increased water content or decreased form) stools per day. Patients often have other symptoms such as nausea or vomiting.

Incubation period depends on the causative agent. It is spread by person-to-person contact via fecal–oral route.

Good handwashing and personal hygiene are paramount in the prevention and control of diarrheal illnesses. If good handwashing and personal hygiene are not practiced, there is an increased chance of spread of illness between children, particularly if food is contaminated and shared among students.

Most cases of diarrhea are viral, and a pathogen is never identified. An etiology for bloody diarrhea is more commonly sought and may identify a pathogen.  Younger children who are not able to reliably toilet and practice good personal hygiene should stay home until diarrhea has resolved for 24 hours.

Older children who are able to reliably toilet, practice good personal hygiene, and do not have other symptoms requiring exclusion (eg, fever) do not need to stay home unless the diarrhea is uncontrollable.

Children who have experienced 2 or more episodes of vomiting in a 24-hour period related to acute gastroenteritis should remain excluded from school. Children may return to school when the child has no accidents using the toilet and stool frequency is no more than 2 stools per day more than the child’s normal stooling frequency.⁴ The National Institute for Health and Care Excellence  has a more conservative recommendation and advises exclusion until 48 hours after the last episode of diarrhea.⁵

If an enteric pathogen is identified as the cause of diarrhea, the following additional exclusions will apply:¹

·      Shigella: the child should be excluded until diarrhea resolves and 1 or more stool cultures are negative. The requirements will vary by state.

·      Shiga toxin-producing Escherichia coli: the child should be excluded until there are 2 negative cultures 24 hours apart.

Additionally, state and local jurisdictions may have different laws governing exclusion and return to school.

NEXT: Strep throat

Strep throat. Signs and symptoms of strep throat include fever, sore throat, variable throat exam that may or may not reveal visible pus spots, or tender and swollen lymph nodes.

Incubation period is 1 to 3 days. Strep throat is spread by large respiratory droplets of a child with an infection (or a carrier), or direct contact with nasal/throat secretions. Indirect transmission is uncommon.

Strep throat can cause real havoc in the lives of families with dual working parents. One parent needs to leave work early and bring a child to the pediatrician’s office, and then current guidelines and many school systems advise exclusion until the completion of 24 hours of antibiotics and avoidance of close contact with other students.⁴

Next: State of the art office rapid strep tests

A 2015 article published in the Pediatric Infectious Disease Journal, however, found that a single dose (50 mg/kg) of amoxicillin led to 91% of children having undetectable testing the next morning. This led the investigators to conclude that children treated with strep throat by 5 pm may return to school the next day if afebrile and improved.⁶

Infections are a common reason for school exclusion. Pediatricians need to be comfortable discussing appropriate exclusion and willing to intervene if children are being inappropriately excluded from school or daycare.

References

1. Silfverdal S-A. Book review. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. 3rd ed. Aronson SS, Shope TR, eds. Elk Grove Village, IL: American Academy of Pediatrics; 2013. Acta Paediatr. 2015;104(5):535.

2. Centers for Disease Control and Prevention. When & how to wash your hands. http://www.cdc.gov/handwashing/when-how-handwashing.html. Updated September 5, 2015. Accessed June 23, 2016.

3. American Academy of Pediatrics. Summaries of infectious diseases: varicella-zoster virus infections. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30^th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015. http://redbook.solutions.aap.org/.

4. American Academy of Pediatrics. Recommendations for care of children in special circumstances. Children in out-of-home child care: recommendations for inclusion or exclusion. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015. http://redbook.solutions.aap.org/.

5. National Institute for Health and Care Excellence. Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. https://www.nice.org.uk/guidance/cg84. Published: April 22, 2009. Accessed June 1, 2016.

6. Schwartz RH, Kim D, Martin M, Pichichero ME. A reappraisal of the minimum duration of antibiotic treatment before approval of return to school for children with streptococcal pharyngitis. Pediatr Infect Dis J. 2015;34(12):1302-1304.

7. Clark RC. ‘No-nit' policy adopted to battle lice in schools. Star News. February 4, 2014. http://www.starnewsonline.com/article/20140204/articles/140209863?tc=ar. Accessed June 1, 2016.

8. American Academy of Pediatrics. School health: infections spread by direct contact. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015. http://redbook.solutions.aap.org/.

9. American Academy of Pediatrics. Summaries of infectious diseases: pediculosis capitis. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015. http://redbook.solutions.aap.org/.

Dr Bass is chief medical information officer and associate professor of medicine and of pediatrics, Louisiana State University Health Sciences Center–Shreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.