Prohibiting a child with a dermatological problem from school requires careful consideration

There are three main areas to consider when deciding whether or not exclusion may be appropriate for the child.

Issue: September 2007

ORLANDO, Fla. — When it comes to keeping a child with a rash out of school or childcare, there are certain criteria caregivers should be aware of before making the final decision.

Susan S. Aronson, MD, clinical professor of pediatrics The Children’s Hospital of Philadelphia, and a member of the AAP Board of Directors, spoke at the AAP’s Future of Pediatrics Conference 2007: “Community Pediatrics, the Medical Home and Beyond,” and said there are three areas to consider when deciding whether or not exclusion may be appropriate in school or in childcare.

The three main areas are:

If the child is too ill to participate in the program.
When a need for care compromises the ability of the teachers to care for the other children.
Specific conditions that pose an infectious disease risk.

“If the exclusion rules are used wisely, they will prevent unnecessary visits to the physician’s office and it will help childcare providers to make wise decisions,” Aronson said.

“Parents do not make the decision of whether or not the child is OK to stay in school. It is the childcare providers’ decision, so parents need to understand upfront that this is not something that can be decided by them,” she said.

When a child is identified at school or childcare with head lice, this is considered to be a nuisance, but is not a health hazard, according to the AAP.

“The child does not need to be excluded until the end of the program day. Once the lice is identified the child must be treated before returning and any close contacts should be inspected and treated for lice or nits,” Mary Wu Chang, MD, chief of pediatric dermatology of the Connecticut Children’s Medical Center and associate professor of dermatology and pediatrics of the University of Connecticut School of Medicine, said here.

When treating lice, one should use effective products and avoid unproven remedies and frequent exposure to pediculicides.

“Mechanical removal of nits … is tedious and usually removes empty casings and nonviable material,” Chang said. “If a child fails treatment with 1% permethrin, then move on to 5% permethrin. Apply the ointment over night and wash off the next day, this should work well.”

Suffocation methods are trendy right now, according to Chang, but there is no evidence showing these methods work and they can also be messy.

Exclusion for a rash, such as hand-foot-and-mouth disease, is only necessary if the child has a fever or a behavior change.

“With ringworm (tinea corporis), the child should receive treatment immediately and once treatment is initiated, exclusion is not necessary. It is better if the ringworm is covered by a long shirt or pants,” Chang said.

“Molluscum contagiosum is also a part of our community and is a nuisance, but is not a health hazard,” Chang said. “Diagnosis may be made by appearance, but remember that the very early lesions are difficult to recognize. There is no one perfect treatment for this, but the main point is that it does not require exclusion.”

For children with chronic skin conditions, such as atopic dermatitis and methicillin-resistant Staphylococcus aureus, both require treatment but atopic dermatitis does not require exclusion.

“This is a situation where physicians need to be aware that when there is pus and oozing, a culture needs to be taken because you do not know if the child has MRSA without the culture,” Chang said. “It is tricky because you want to get the child back in school or childcare, but you do not want MRSA to spread. So remember that atopic dermatitis needs to be treated and controlled so they are at less risk for getting MRSA, and if they do get it, MRSA needs to be treated as soon as possible. This is a commitment of both the parent and the physician.”

Aronson and Chang suggested the following references for physicians:

Red Book Report of the AAP Committee on Infectious Diseases (current edition).
Hurwitz Clinical Pediatric Dermatology 3rd Edition: A Textbook of Skin Disorders of Childhood and Adolescence.
Pediatric Dermatology 3rd Edition.
Dermatology.
Caring for Our Children.
Managing Infectious Diseases in Child Care and Schools.
Model Child Care Health Policies.

“The panic about rashes and infectious diseases in childcare programs is real. Parents worry about children with a rash spreading to their healthy child, but if the childcare provider knows that it is not a problem, then this will calm things down,” Aronson said.

For more information on these reference books, visit www.naeyc.org or www.aap.org. – by Jennifer Southall

For more information:

Aronson S, Chang M. “Rash” decisions: what keeps children out of school/child care? Presented at: the American Academy of Pediatrics Future of Pediatrics Conference; June 29-July 1, 2007; Orlando, Fla.