Too Sick for School? Here’s your guide.

In a perfect world, kids would never get sick, and they’d never miss a day of school. (Except maybe to do something really awesome.) But it’s not a perfect world. Kids get sick all the time, and they love to share their nasty little germs with everyone around them.

It’s not uncommon for children to get viral illnesses 10-12 times per year, and these symptoms can last a week or more.  (So if you feel like your child is always sick, you’re probably right. But you’re not alone.) And when kids are sick, parents are faced with a difficult decision: should they send their child to school, or keep them home? I’m going to discuss some general considerations, as well as some requirements for specific symptoms or diseases. Obviously I can’t address every situation (unless your child happens to be my patient), so be sure to talk to your pediatrician about any concerns.

[Note: I mention “school” a lot. What I really mean is “school, daycare, or another similar setting.” Excuse the brevity.]

PRIORITIES

The reason this can be such a tough decision is because there are a lot of conflicting priorities to consider. We all want our children to feel better and recover quickly, and we don’t want them to get other kids sick. But we also want them in school so that their education doesn’t suffer. It’s just not feasible to keep them out for every little sniffle—not to mention the financial impact of parents missing work, or the hassle of trying to find last-minute childcare for a sick kid. It’s not always an easy call.

THINGS TO CONSIDER

  • How sick is your child? Some kids are sick enough that they need medical attention. Depending on the severity, that may mean a trip to your pediatrician’s office, an ER visit, or even a hospital stay. In these cases, the decision tends to be pretty easy. School takes a back seat until things improve. It’s the milder cases that are trickier—when parents don’t necessarily need medical help, but still aren’t sure if they should send their child to school.
  • Can your child participate in the activities at school? The reason kids go to school is to learn. If your child is so uncomfortable, sleepy, or otherwise distracted that he wouldn’t be able to get anything out of school, it may be better to keep him home. In some cases, children are fine to sit in class, but may have trouble with gym or other more demanding activities. In those cases, a note from your doctor asking for temporary accommodations may be helpful.
  • Will those in charge of your child’s daycare or school be able to care for her? Sometimes a sick child just requires more care than the teachers or staff can reasonably provide. Sending her to school probably wouldn’t be in her best interest, and wouldn’t be fair to the other children. That’s a good reason to keep her at home.
  • Will your kid get my kid other kids sick? (And if so, how big of a deal would that be?) The answer to the first questions is probably “yes,” but it’s important to think about the second. While a lot of childhood illnesses are contagious, they’re not all equally dangerous. Sharing pinkeye or lice is a lot different from sharing measles or bacterial meningitis. Many of the more serious illnesses have strict rules based on when the disease is likely to be spread; in other cases, use your judgment or ask your pediatrician.

PREVENTION

Even though children swap germs (a lot), there are a few things we can do to minimize the damage:

  • Immunize. There’s a reason why vaccines are required for school attendance. It’s because they’re an effective way to prevent some serious (potentially life-threatening) diseases.
  • Wash your hands. Good hand washing is probably the best way to limit the spread of disease. Hand sanitizer is ok for most germs, but soap and water are better—it doesn’t have to be antibacterial soap, and it doesn’t have to be hot water. Teach your children how to wash properly: scrub both sides of their hands and between their fingers for at least 20 seconds. Dry with a paper towel and use the towel to turn off the sink and open the door.
  • Cover your mouth. A lot of respiratory illnesses are spread by coughing or sneezing. Teach children to cover their mouths with a tissue, elbow, or shoulder—not their hand. (Because of the doorknob thing.)
  • Keep it clean. School and daycare employees should make efforts to keep the facility as sanitary as possible, with special attention to toilets, diaper changing areas, and food handling areas.
  • Vaccinate. This is just another word for “immunize.” I know, I said that already. It’s really important.

SPECIFIC CONDITIONS

While it’s always important to look at your child’s individual situation, there are certain medical conditions for which there are very specific recommendations or requirements regarding whether kids should stay out of school and when they should return. Below is a list of some of these conditions, with guidance from pediatric infectious disease specialists. Please be aware that requirements vary among states or school districts.

  • Colds/sore throats/etc.: These illnesses are common and usually on the milder side. They’ll probably get passed around, but we just can’t keep kids out of school every time they have a stuffy nose. Kids should go to school as long as symptoms aren’t severe enough to keep them from participating.
  • Influenza or flu-like-illnesses: Influenza (or flu) can be pretty serious and spreads easily. Children should stay home from school and return after being fever-free for 24 hours. Flu shots can prevent a lot (but certainly not all) of these illnesses.
  • Strep throat: Kids who have a sore throat and a positive strep test should stay out of school until they’ve been on antibiotics for 24 hours (although recent research indicates that 12 hours may be enough). Treating with antibiotics limits the spread and reduces the risk of a really rare (like insanely rare) complication called rheumatic heart disease.
  • Ear infections: Ear infections are contained within the middle ear and aren’t typically contagious. They may or may not need antibiotic treatment, but kids should go to school unless they are so miserable they wouldn’t be able to participate.
  • RSV: Respiratory syncytial virus, or RSV, can cause typical cold symptoms, or more severe breathing problems in children under 2 (usually worse in little babies). Just like other cold viruses, your child’s classmates will probably get sick. Fortunately, most of these illnesses will be relatively mild. Unless children are too sick to participate, it’s ok for them to go to school.
  • Conjunctivitis/pinkeye: Conjunctivitis is just inflammation of the eye, and it can be caused by a lot of different things: viruses, allergies, and (more rarely) bacteria. And while the eyes can look similar, the treatment depends on the cause. Many of these cases are viral and don’t require treatment—yes, it can still be spread, but we can’t do anything about it. (Think of it like a cold in your eye.) Red eyes caused by allergies aren’t contagious, but can be treated with antihistamine drops or other allergy medicines. Sorry to make things complicated, but it’s an important point: not all pink eyes need antibiotics. However, cases thought to be caused by bacteria can return after antibiotic drops are started.
  • Vomiting: If kids are vomiting 2 or more times in 24 hours, they should stay home from school until their symptoms resolve. If they are evaluated and determined not to be contagious, they may return to school. (As a side note, the list of possible causes for vomiting without diarrhea is more concerning than for vomiting with diarrhea—although the majority of cases are due to viral illnesses.)
  • Diarrhea: According to the American Academy of Pediatrics and infectious disease experts, kids with diarrhea can go to school as long as they aren’t having 2 more bowel movements per day than whatever their usual number is. For kids who aren’t potty trained, it needs to stay contained in the diaper (no blowouts). And potty trained kids should not be having accidents. If stools contain blood or mucus, keep your child out of school until symptoms resolve (and see your pediatrician—these cases can sometimes require more workup or treatment).
  • Hand, foot, and mouth disease: This is a common outbreak in daycare facilities that can cause some painful mouth ulcers and a rash. Kids should be kept at home for fever or if they are unable to control their drooling. (Although if drooling is controlled, it’s not drooling, right?)
  • Rash: Rashes can be caused by all kinds of things. Some are contagious, and some aren’t. In general, if they don’t fall into another category here, and there’s no fever or change in behavior, they’re ok to go to school.
  • Cold sores: Kids with cold sores can go to school. It’s not that they aren’t contagious; it’s that they are always Even without a current outbreak, kids can still spread the virus, so it doesn’t do any good to banish them for a week. If you want to reduce the risk, teach your children to avoid sharing drinks and utensils. And nobody should kiss anybody, ever.
  • Wounds/skin infections: These are usually fine to go to school, as long as the wound can be covered. Impetigo (a bacterial infection that looks like yellow crusty spots, usually on a toddler’s face) is school-ready 24 hours after starting treatment. Being a carrier of MRSA or having a history of skin abscesses won’t get you out of school. (Sorry.)
  • Ringworm (on the skin or scalp): Just in case your mother lied to you, this infection is caused by a fungus. There is no worm. There never was. It shouldn’t preclude kids from going to school. The treatment usually an antifungal cream for the body or oral antifungal medication for the scalp. Repeat: there is no worm.
  • Athlete’s foot: This is another fungal infection that occurs on the feet (usually between the toes), and causes a red, scaly, itchy/burning rash. It’s frequently spread in locker rooms (hence the name), and is easily treated with antifungal sprays or creams. Kids can go to school with athlete’s foot, but they should avoid pools and wear shoes in the locker room or shower until the symptoms are gone. Really, everybody should wear shoes in the locker room.
  • Lice: My head is itching just writing this, but having lice is not an emergency. Kids shouldn’t be sent home from school early if they’re found to have lice. And they should be allowed to return after their first treatment (which you can purchase over-the-counter and apply the same evening). Nits (eggs) will still be present on the hairs unless combed out, but shouldn’t keep kids from attending school.
  • Scabies: This is an itchy rash caused by tiny mites that crawl around under your skin. (Now I’m itchy everywhere.) Children may be sent home from school if thought to have scabies, and can return after starting treatment (which is often a cream that is applied to the body overnight). Even after successful treatment, it can take a few days for the itching to stop.
  • Erythema infectiosum (Fifth disease): This is a viral infection common in preschoolers that can cause fever, rash (classically a “slapped-cheek” appearance), and sometimes joint pain or other symptoms. In most healthy children, it resolves without major problems. The rash tends to show up late, after kids are no longer contagious. So if they’ve had it long enough to figure out that they have it, anybody else that was going to get it already got it. Send them to school.
  • Hepatitis A: This is a virus that causes inflammation of the liver; in some cases, it can be pretty serious. It’s spread by the “fecal-oral” route—I’ll let you look that one up. Fortunately, there’s a vaccine that can prevent it. If your child is unfortunate enough to get it, he should avoid school for one week after the start of symptoms.
  • Measles: This is a viral illness that causes a fever and rash, and can make kids feel pretty miserable. And while some people don’t see it as being very serious (because it was essentially a rite of passage just a few decades ago), about 1 in 1,000 people that get this disease will die, and others can have permanent neurological damage. That’s why there’s a vaccine to prevent it. You should take advantage of that. Hopefully it never comes up, but children with measles can return to school four days after the beginning of the rash.
  • Mumps: You know, the one that makes your cheeks swell up. But it can also cause meningitis or infertility in males. We vaccinate for this one, too—it’s like a bonus track with the measles vaccine. There have been a few recent outbreaks, mostly in adolescents or adults after the immunity from the vaccine wears off. But any child with mumps should stay out of school for five days after beginning of the facial swelling.
  • Varicella/chickenpox: This is yet another disease that we can prevent with a vaccine. Like measles, some people downplay chickenpox as an itchy rash. And in reality, most children who got it had a really itchy rash. But it can cause some serious complications as well (including death). The handful of kids that are unlucky enough to get it can return to school when all the lesions are crusted over.
  • Pertussis: Also known as “whooping cough,” pertussis causes a cough that lasts weeks. For older children, this is really annoying. For babies it can be deadly. We have a vaccine for this one, too—we need a better one, but it’s still really important. Pertussis is treated with antibiotics (for the whole family), and kids can return after five days of treatment.
  • Asthma: Children with asthma have a lot of different triggers—from allergen exposures to viral infections, exercise, and a lot more. There’s no concern about spreading this to other children (except maybe the cold that kicked it off), so it really depends on the child’s symptoms. If they are having difficulty breathing, or if they need treatments so frequently that the school or daycare can’t provide them, keep them at home. But remember, missing school frequently due to asthma is a sign that it’s not well-controlled.
  • Concussions: This is another obviously non-contagious condition. But in children with concussion, returning to activity (even mental activity) too quickly can worsen or prolong symptoms. Any child suspected of having a concussion should be evaluated by a physician and should return to activity gradually and under close supervision, with the goal of not worsening symptoms.
  • Anxiety: This one is really important. Anxiety is really common in children. But unless you are taking them to see a doctor or therapist, it’s not a reason for children to miss school. Keeping a child home so that she can avoid an imagined or exaggerated fear helps to solidify that fear. It also sets the expectation that difficult situations can be avoided, when what we should be teaching is coping skills to deal with fears (whether real or imagined). I’ll discuss this more fully in my next post, but I just had to mention it here.

 


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-Chad

As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

One thought on “Too Sick for School? Here’s your guide.

  1. I honestly agree with most of these, however, having a child who was immune suppressed in the public school system ( doctor’s told me to) makes some of these decisions a little more complicated. Rash causing illnesses can be easily misdiagnosed by local GPs and this is part (only part) of the reason that our schools have had outbreaks of more serious illnesses. Some of those illnesses could have killed my son or more likely his friends still at the children’s hospital we visit frequently. My thoughts are, unless a Doctor had told you that your child’s rash is not contagious, keep him or her home please. There are medically fragile individuals in every community, whether it be a child, or that adult down the street with cancer, or crohn’s disease or ALS.

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