100 Degrees of Separation
Tammie Smith
Richmond Times Dispatch

State and federal guidelines say a child with a fever of 100 degrees should be sent home. The idea is to prevent illness from spreading. U.Va. researchers surveyed day-care centers in the state and found those guidelines aren't always followed. The uncertainty adds to the stress of parents, especially single working parents without backup baby sitters.

"Sometimes the day care will put the child in a secluded place until the end of the day, but the majority of the time they call Mom or Dad right away," said Dr. Richard H. Schwartz, a pediatrician and co-leader of the survey reported in the June issue of Southern Medical Journal.

Schwartz thinks the rules can be too strict.

"What is the difference, if a child does not appear ill, if they stay in school with a temperature of 98.8 or 100.8? . . . What we are trying to do is say unless there is a really good reason for excluding children from day care - things such as early chicken pox, bacterial diarrhea, something communicable and potentially dangerous - there is no problem with them staying."

Dr. Diane Pappas led the research project, which analyzed the responses of 183 day-care centers. Guidelines spell out temperature thresholds if measured from the mouth, ear, skin, armpit or rectum, but they were not necessarily followed.

"Some child-care centers may be more or less stringent in application of the same regulation," said Pappas, an assistant professor of pediatrics at U.Va.

Federal guidelines, for instance, say a fever of 100 degrees or higher from the armpit is a problem. If taken orally, the cutoff is 101 degrees. By rectum, 102 degrees is the threshold unless the child is 4 months old or younger (in that case, 101 degrees is the cutoff). But the survey found many centers use a 100-degree cutoff no matter how the fever is measured.

"Fever is probably the number one reason a child is excluded from day care," said Gail Johnson, a pediatric nurse and former president of the National Association for Sick Children.

Johnson, owner of Rainbow Station preschool and child-care centers in the Richmond area, started the Get Well Place, a day care for sick children, to help parents deal with the incongruity between the rules and reality. Parents, she said, keep their children home if they are really sick, but mild illnesses throw many for a loop.

"Physicians are saying, 'What's the big deal?' Parents are screaming, 'What are you doing? I'm trying to keep my job,'" Johnson said. "There's a lot of conversation out there."

Lorna Parkins, a working mother of four children, ages 3, 5, 6 and 8, has had her share of calls to pick up a sick child.

"I had to deal with that a lot of times when my children were infants and teething," said Parkins, who works as a consultant so she can have flexibility with child care.

"You get them and get home, and you say after a few hours, 'This child was not sick.' The child-care center I have now, they will call you and say he got up from a nap and seemed warm and fuzzy. They don't necessarily send him home but just let you know they are keeping an eye on it. That's a helpful way of dealing with it."

A few times a year, she uses the Get Well Place, usually for something such as strep throat and usually for a half-day.

The U.Va. researchers suggest that strict day-care guidelines can cause parents to pressure doctors to prescribe antibiotics. The overuse of antibiotics may be making many of the drugs ineffective against some common germs.

A national committee updating child-health standards is looking at the medical exclusion rules, said Dr. Larry Pickering, director of the Center for Pediatric Research at Eastern Virginia Medical School in Norfolk. He is on the committee.

"Children who have mild fevers with normal behavior and without a rash potentially could stay in child care," Pickering said. "The difficulty is if child-care providers are overworked. It's difficult for them to diagnose how sick a child really is. Fever is often associated in their minds with illness that can be severe."

The updated guidelines should be out later this year, he said. Even with less strict guidelines, experts say parents should not expect consistency.

"We even get questions sometimes asking what is diarrhea," said Dr. C. Diane Woolard, an epidemiologist with the state Health Department. "They ask, 'Do they need to have two episodes of loose stools for it to be diarrhea?'"

As a day-care operator, Sharon Johnson, chairwoman of the Virginia Child Day Care Council, has mixed feelings about excluding mildly feverish children.

"It's a difficult call," she said. "Parents are having to miss time from work. . . . But some parents want to be called every time their child sneezes. Some parents understand children run a fever with teething, for example. It depends upon the situation. That's what makes it so difficult for child-care operators."