Return-to-Care
WHAT’S KNOWN ON THIS SUBJECT: Previous studies have found variable child care provider compliance with American Academy of Pediatrics child care illness exclusion guidelines and high rates of unnecessary exclusion of mildly ill children from child care.
WHAT THIS STUDY ADDS: Our study is thefirst to compare child care directors’return-to-child care practices before the release of the new American Academy of Pediatrics return-to-child care guidelines and to describe the guidelines’impact if actively adopted by child care providers.
abstract
BACKGROUND:The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors’ practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines.
METHODS: A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations.
RESULTS: A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis—antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms—physician visit (45.6%), antibiotics (10%), and symptom resolution (25%).
CONCLUSIONS:Directors’self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care.Pediatrics2012;130:1046–1052
AUTHORS:Andrew N. Hashikawa, MD, MS,aMartha W.
Stevens, MD, MSCE,bYoung J. Juhn, MD, MPH,cMark
Nimmer, BA,bKristen Copeland, MD,dPippa Simpson, PhD,e
and David C. Brousseau, MD, MSb
aDepartment of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan;bSection of Emergency Medicine, Department of Pediatrics, andeQuantitative Health Sciences, Children’s Research Institute, Medical College of Wisconsin, Milwaukee, Wisconsin;cDepartment of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; and dDivision of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
KEY WORDS
child care, readmission, mild illness
ABBREVIATION
AAP—American Academy of Pediatrics
Dr Hashikawa conceptualized and designed the study, helped with data acquisition, drafted the initial manuscript, and approved thefinal manuscript as submitted; Dr Stevens made substantial contributions to study design and data
interpretation, reviewed and revised the manuscript, and approved thefinal manuscript as submitted; Dr Juhn made substantial contributions to study design, study analysis and data interpretation, critically reviewed the manuscript, and approved thefinal manuscript as submitted; Mr Nimmer coordinated and assisted with data collection, helped develop data collection instruments, critically reviewed the manuscript, and approved thefinal manuscript as submitted; Dr Copeland made substantial contributions to study design and
development of data collection instruments, critically reviewed and revised the manuscript, and approved thefinal manuscript as submitted; Dr Simpson performed data analysis and interpretation, critically reviewed the manuscript, and approved thefinal manuscript as submitted; and Dr Brousseau helped conceptualize and design the study, contributed substantially to data interpretation, critically reviewed and revised the manuscript, and approved thefinal manuscript as submitted.
Dr Stevens’current affiliation is the Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-1184
doi:10.1542/peds.2012-1184
Accepted for publication Jul 31, 2012
Address correspondence to Andrew N. Hashikawa, MD, MS, Department of Emergency Medicine, Children’s Emergency Services, 24 Frank Lloyd Wright, Suite H-3200, Ann Arbor, MI 48105. E-mail: drewhash@umich.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURES:The authors have indicated they have nofinancial relationships relevant to this article to disclose.
Two-thirds of all children in the United States ,6 year of age now require nonparental child care services as a result of the socioeconomic necessity of working parents and welfare re-form.1,2Children in child care are sick
more often in comparison with chil-dren who stay at home exclusively, and they are routinely excluded from child care, placing a significant burden on families, businesses, and health care resources.3–8Although the most
com-monly reported symptoms of illness in child care are respiratory, symptoms of rash, conjunctivitis, and fever are more likely to cause longer absence from child care for each episode be-cause of policies requiring a health care provider visit for these condi-tions.9Return-to-care decisions made
by child care providers may not be based on the best available evidence but on outdated policies, criteria, or beliefs. Child care illness guidelines for exclusion and return-to-care are often lacking, and, when present, receive variable levels of state endorsement.10
The lack of clear return-to-care guide-lines may lead to inappropriate child care readmission policies and practices, prolonged unnecessary exclusion of children, and substantial delays in parents’ return to work. Employed parents who leave work to care for their mildly ill children at home face significant financial pressure to re-turn to work as soon as possible or risk pay or job loss, with many poor and minority working families dispro-portionately affected.11,12
Unnecessary return-to-care require-ments for mild illness have substantial implications for pediatric health care resources. An estimated 10 million pediatric health care visits resulted in unnecessary antibiotic prescriptions, with children in the child care age more likely to receive unnecessary broad-spectrum antibiotics for respiratory symptoms.13One-third to one-half of the
20 million pediatric patient visits to the emergency department are thought to be for nonurgent conditions.14Factors
associated with nonurgent pediatric emergency visits include single-parent status and the need for convenient before and after work hours are typical of employed parents with children in child care.14,15 To aid child care
pro-viders in making safe and appropriate return-to-care decisions, the American Academy of Pediatrics (AAP) in 2009 released updated national return-to-care guidelines for conjunctivitis, fe-ver, and diarrhea, which were later added to the third edition ofCaring for Our Children – National Health and Safety Performance Standards Guide-lines for Early Care and Education Program in 2011 based on the best medical evidence available.16,17 The
state of Wisconsin has endorsed the AAP/American Public Health Associa-tion child care exclusion guidelines for .10 years, but the use of return-to-child care guidelines are not em-phasized and local practices remain unclear. Ongoing educational classes for child care providers surrounding return-to-child care guidelines do not exist. How these revised AAP guidelines compare with child care directors’ self-reported readmission practices are unknown. Our goal was to investigate child care director’s reported return-to-child care practices in comparison with newly revised AAP return-to-child care recommendations.
METHODS
Study Design, Setting, and Population
The study was a cross-sectional tele-phone survey of licensed child care centers in the southeastern Wisconsin, 6-county Milwaukee metropolitan area (Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha). Racial demographics in this 6-county area closely approximate national demographics.18
Center directors were identified by us-ing a list of 971 licensed child care centers in the 6-county Milwaukee met-ropolitan area provided by the Commu-nity Coordinated Child Care of Wisconsin. Child care centers were eligible if they met Wisconsin’s definition as a licensed group child care center ($9 children who are supervised and cared for,24 hours per day).19 Centers were
ex-cluded if they cared for only sick, spe-cial needs, or chronically ill children, if they did not care for children,5 years of age, if they were closed during the study, operated,3 hours per day, were unreachable by telephone (answering machine after 6 separate attempts/ messages, technical difficulties [phone no longer in service, wrong phone number despite yellow pages and In-ternet search, phone disconnected, poor phone connection], or no answer 6 separate times), or if the directors were non–English-speaking, had previously participated in the study, or were not responsible for the daily administrative operation of the child care centers. Study methods are described fully in a pre-viously published study in Pediatrics.20
Our study was approved by the hospital’s institutional review board.
Survey Instrument
We adapted 5 vignettes used by Copeland et al21for telephone use (Table 1). Child
care directors were asked about return-to-care criteria based on the illness de-scribed in each vignette. Questions for return-to-care criteria were open-ended, with multiple responses allowed for each vignette. For the gastroenteritis vignette, return-to-care questions for symptoms of vomiting and diarrhea were asked separately, because the AAP return-to-child care guidelines lists each symptom individually.
Survey Administration
(Milwaukee County versus the sur-rounding 5 counties), and size (small centers with $9 children and #42 children versus large centers with.42 children). Within each stratum, the lists were ordered by using a random num-ber generator. Directors agreeing to participate were either interviewed at that time or scheduled for a later tele-phone interview. The interviews oc-curred over a 4-month period (May to August 2008) and were concluded when a sample size of 300 directors was reached, as described in our previous study.20Two authors (A.H. and M.N.)
ad-ministered the 15-minute telephone questionnaires. A maximum total of 6 phone calls were made to each child care center at different times, with no further attempts made after that point if a director could not be reached. Dis-connected or incorrect numbers were explored for alternatives.
Survey Analysis
Telephone questionnaires were com-pleted with center directors and answers recorded by 2 investigators (A.H. and
M.N.) on a scannable form or recorded verbatim if open-ended. Two study investigators (A.H. and M.N.) indepen-dently verified scanned information against the original surveys. SAS ver-sion 9.1 (SAS Institute Inc, Cary, NC) was used for statistical analysis. Descrip-tive statistics were used to summarize responses. Answers were compared with AAP return-to-care recommenda-tions to determine percentage of com-pliance. AAP return-to-care guidelines included updates to the following ill-nesses: (1) conjunctivitis, antibiotics no longer required for readmission; (2) diarrhea, diapered children have stools contained by the diaper and stool frequency reduced to,2 stools above normal for the child, even if loose; (3) fever, health profes-sional visit not necessarily required (Table 1).
Univariate analyses (x2) were con-ducted to test the relationship be-tween director responses (correct versus incorrect) for individual vignettes and child care center and director demographic characteristics. To
as-sess independent association of center and director variables with director responses to vignettes, each director’s total number of correct responses for all 6 vignettes were summed (score ranging from 0 to 6). The total correct scores were then collapsed into a di-chotomous variable“low correct”(0–1 correct vignette responses) and“high correct”(2+ correct vignette responses) used as the main outcome in a step-wise logistic regression model. Re-gression analysis was performed by using center variables (size, location, presence of health care consultant, percentage children receiving state funding, and child race) and director variables (AAP guideline knowledge, education, experience, previous medi-cal training, and race). All variables achieving a 0.05 level of significance were kept in our final model that showed satisfactoryfit.
RESULTS
Of the 971 child care centers, 367 were ineligible (Fig 1). Of the remaining 604 directors, 482 agreed to participate;
Cold symptoms 3-y-old, clear runny nose for 5 d, dry cough for 3 d, temp (97°F), and active.
Return to child care if . . . Not required
•Exclusion criteria (fever, behavior change) resolved, AND
•Child can participate, AND staff can safely care for child Conjunctivitis 4-y-old with red eyes, clear drainage,
temp (97.5°F)
Return to child care if . . . Not required
•Exclusion criteria (fever, behavior change) resolved, AND
•Child can participate, AND staff can safely care for child
•Antibiotics NOT required Gastroenteritis 2-y-old, toilet-trained, vomited once what
she ate, 2 watery stools contained in toilet, temp (97.8°F)
Return to child care if . . . Only if blood or mucus in stool or dehydration
•Stool (nonbloody) contained by diaper (OK if loose) OR no more toileting accidents, AND fewer than 2 stools above normal frequency, AND/OR
•Vomiting resolved (if$2 episodes in 24 h)
•Child can participate, AND staff can safely care for child Fever 3-y-old, felt warm, fever (101°F axillary),
no symptoms, perky self
Return to child care if . . . Not required unless,4 mo of age
•Exclusion criteria (behavior change or other signs of illness) resolved, AND
•Child can participate, AND staff can safely care for child Ringworm 4-y-old circular rash scalp, playful,
temp (97.6°F)
Return child care if . . . Only to initiate treatment
•Exclusion criteria (behavior change or other signs of illness) resolved, AND
•Child can participate, AND staff can safely care for child
telephone interviews were concluded when we reached our sample size of 305 directors. Overall, a total of 305 directors participated in the telephone survey. Child care center, director, and center neighborhood characteristics are summarized in Table 2. Overall baseline characteristics for directors revealed that 97% were female; 63% were white and 32% black; 73% had.3 years experience; 86% reported some college or college degree; 84% had no previous medical training; and 62% had no knowledge of AAP child care illness guidelines.20Based on director
responses to vignettes, the percentage of correct responses, in comparison with AAP return-to-care recommen-dations, were low (Fig 2): fever (0%), conjunctivitis (0%), diarrhea (1.6%), cold symptoms (12%), ringworm (21%), and vomiting (80%). The top 3 child care director responses to vignettes are shown in Fig 2. Based on director responses, 2 illnesses (con-junctivitis and cold symptoms) would require urgent medical evaluation or treatment before a child could return to child care: conjunctivitis, antibiotics for 24 hours (61.6%), physician visit (48.5%), and any antibiotic treatment (5.9%); and cold symptoms, physician
visit (45.6%), antibiotics (9.5%), and symptom resolution (25.3%) in com-pared with AAP return-to-care recom-mendations.
We found other director-reported readmission policies that would delay a child’s return to child care and also a parent’s return-to-work. Four per-centage of directors reported they would require complete symptom res-olution for conjunctivitis before a child was allowed to return to child care. For symptoms of diarrhea, 80% of direc-tors required symptoms to completely resolve, delaying return to child care. For ringworm, responses of“24 hours of treatment” (28%) and complete symptom resolution (8%), would also delay readmission. For the symptoms of fever, however, substantial variabil-ity existed regarding return-to-child care, including 13% of surveyed pro-viders requiring physician evaluation.
For univariate analysis, responses to only 1 vignette (vomiting) showed a consistent pattern, with 5 variables associated with increased percentage of correct director responses to vi-gnettes: suburban centers (87%) ver-sus urban centers (68%) (P , .01); directors with college education (83%)
versus no college (68%) (P,.03); white directors (93%) versus nonwhite direc-tors (59%) (P , .01); centers with a majority of white children (94%) ver-sus a majority nonwhite children (62%) (P,.01); centers without health care consultants (84%) versus centers with health care consultants (71%) (P,.02); and directors without previous medical training (83%) versus with previous medical training (66%) (P,.01).
Of the 6 vignettes, 3 vignettes (fever, conjunctivitis, and diarrhea) had 98% to 100% incorrect director responses. When the total sum of correct respon-ses were added (score of zero correct to a maximum of 6 correct), the vast majority (222 or 72% of directors) were in the“low correct”category and only 1 director had 4 correct responses of 6. Results of logistic regression analysis revealed only 1 significant variable, director education. Directors with some college education/college degree were more likely to give correct answers to vignettes (high correct group) com-pared with directors with no college education (odds ratio, 2.95; 95% confi -dence interval, 1.51–5.77). The group of directors with some college/college degree, however, performed only mar-ginally better, with 28% of directors
FIGURE 1
Flow diagram of child care center director enrollment.
tors without college education in the high correct group.
DISCUSSION
Revised AAP return-to-care guidelines include conditions that do not require exclusion to control spread of dis-ease, including mild cold symptoms
and conjunctivitis.16,17Antibiotics for
conjunctivitis are no longer a pre-requisite for returning to child care. A health professional visit is not re-quired after exclusion for fever, un-less they are,4 months of age. Most importantly, the AAP guidelines focus on child care illness management and exclusion based upon general guiding principles, including the ability of a child to participate comfortably and the ability to maintain adequate staff resources and care.
Our results showed that directors’ responses differed substantially in comparison with the revised AAP return-to-child care illness recom-mendations. Correct return-to-care responses for fever and conjunctivitis
were completely lacking. Results also reveal that director self-reported practices would necessitate urgent medical evaluation or unnecessary antibiotic treatment.
We found that only 1 vignette (vomiting) was associated with specific center and director demographics; however, 80% of director responses were correct for this vignette. Multivariate analysis revealed that directors with a college education were more likely to answer vignettes correctly; however, they per-formed only marginally better overall when directors self-reported their return-to-care practices. Our findings show that there is a substantial need and opportunity to improve child care provider knowledge regarding revised TABLE 2 Center and Director
Characteristics
Characteristics %
Center (305)a
Size
Small (134) 44
Large (171) 56
Location
Milwaukee County (175) 57
5 other counties (130) 43
Health care consultant
Yes (77) 25
No (225) 74
Missing (3) 1
Child race majority
White (174) 56
Nonwhite (131) 44
Children on state assistance
,10% (90) 29
.10% (213) 70
Missing (2) ,1
Directors Race
White (193) 63
Black (96) 32
Other (14) 4
Missing (2) ,1
Experience
0–2 y (80) 26
3–10 y (128) 42
10+ years (95) 31
Missing (2) ,1
Education
No college (40) 13
Some college (117) 39
College/advanced degree (147) 47
Missing (1) ,1
AAP guidelines
Some knowledge (103) 34
No knowledge (190) 62
Missing (12) 4
Previous medical trainingb
Yes (44) 14
No (256) 84
Missing (5) 2
aActual number of child care center directors in paren-theses.
bNurse, nursing assistant, physical therapist, and medical assistant.
FIGURE 2
AAP return-to-child care guidelines. We were unable to identify a particular group to specifically target, because the overall high number of incorrect re-sponses suggests that all types of directors would benefit from an edu-cational intervention regarding child care AAP return-to-care guidelines. Widespread dissemination of AAP child care guidelines at the state and national level along with active child care pro-vider training has the potential to de-crease parental work absenteeism and health resource utilization, in particu-lar, urgent evaluation for nonurgent conditions. Adoption of AAP guidelines may particularly benefit poor and mi-nority families requiring child care services, because many parents are single, lack adequate sick leave, live in areas with medical provider shortages, or lack access to same-day appoint-ments for acute visits at convenient, nonworking hours.11,12Improved
return-to-care practices could also decrease demand for antibiotic prescriptions from parents seeking to return to work as soon as possible, which would help address the larger issue of unnecessary
antibiotic prescribing practices for re-spiratory conditions for which anti-biotics are unlikely to provide benefit.13
Unfortunately, Wisconsin, like many states, does not require knowledge or use of the AAP guidelines and, most importantly, does not provide child care directors with formal educational courses related to child care exclusion and return-to-care practices. Previous studies have shown that active training of child care providers results in im-proved quality of child care and in-creased knowledge and compliance related to child care health–related measures.22,23We believe that any
for-mal child care provider training must include both illness exclusion and return-to-care criteria. Most impor-tantly, active adoption of guidelines by child care providers promotes appro-priate and safe exclusion of ill children to safely protect other children from harmful illnesses.
Our study has several potential limi-tations. The study included only English-speaking directors and may not be representative of non–English-speaking directors. Our sample population,
although mirroring national demo-graphics, may not be generalizable to other states with different policies and guidelines. Additionally, our re-sults were obtained from vignettes and may not reflect actual return-to-child care practices.
CONCLUSIONS
Child care directors’ return-to-child care practices for several illnesses differ from the newly revised AAP to-care guidelines. The AAP return-to-care recommendations have the po-tential to significantly impact directors’ readmission practices, in particular, for conjunctivitis, cold symptoms, and diarrhea. Active adoption of new AAP recommendations would decrease the need for (1) urgent medical care for nonurgent illnesses, (2) unnecessary antibiotic treatment, and (3) parental time away from work. We advocate for focused child care provider education regarding the AAP return-to-child care guidelines and adoption of these guide-lines at the state and national level to reduce health care utilization and to decrease the burden on working parents.
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THE KEY TO THINKING CLEARLY MIGHT LIE IN YOUR MOUTH:New research might
serve as motivation for those who need a reason to keep up their daily oral hygiene routine. As reported byReuters(Health: August 21, 2012), a recent study examining the connection between dental health and dementia diagnosis high-lights the importance of regular tooth brushing. Researchers monitored the dental health and cognitive function of 5,468 individuals (3,735 women and 1,733 men; median age at entry 81 years) with initially normal cognitive function living in a California retirement community for more than 18 years. Dental health was assessed through surveys with particular attention paid to the number of teeth each participant had, whether or not they wore dentures, regularity of teeth brushing, and how often the study participants saw a dentist within the past year. Patients were assessed for dementia through questionnaires, exploration of hospital records, death certificates, and in-person evaluations as a part of a separate dementia study. After 18 years, approximately 25% of the group had developed dementia. On follow-up, women who reported brushing their teeth less than once a day were 65% more likely to be diagnosed with dementia than those who had reported brushing at least daily. Among men, the risk was much smaller. Men who infrequently brushed their teeth had a 22% increased risk of being diagnosed with dementia compared to those who brushed their teeth at least daily. Dementia risk was also significantly increased in men who had not seen their dentist within the past year when compared to those who had. Researchers propose that inflammation secondary to increased oral bacteria might be re-sponsible for the increased risk of dementia. Although participants did not have formal dental evaluations and the diagnosis of dementia was ascertained only through medical records, other studies have linked oral hygiene with poor health outcomes. While additional research is needed to better define the relationship between dental health and dementia, it appears that regular tooth brushing may have greater benefits than just having a nice smile.
DOI: 10.1542/peds.2012-1184 originally published online November 12, 2012;
2012;130;1046
Pediatrics
Copeland, Pippa Simpson and David C. Brousseau
Andrew N. Hashikawa, Martha W. Stevens, Young J. Juhn, Mark Nimmer, Kristen
Self-Report of Child Care Directors Regarding Return-to-Care
Services
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