Hashikawa, Andrew N.

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.

OBJECTIVE:No study has evaluated the association between state endorsement of American Academy of Pediatrics (AAP) and American Public Health Association (APHA) national guidelines and unnecessary exclusion decisions. We sought to determine the rate of unnecessary exclusion decisions by child care directors in a state that endorses AAP/APHA guidelines and to identify factors that are associated with higher unnecessary exclusion decisions.METHODS:A telephone survey was administered to directors in metropolitan Milwaukee, Wisconsin. Directors were randomly sampled from a list of 971 registered centers. Director, center, and neighborhood characteristics were obtained. Directors reported whether immediate exclusion was indicated for 5 vignettes that featured children with mild illness that do not require exclusion by AAP/APHA guidelines. Weighted data were summarized by using descriptive statistics. Regression analysis was used to identify factors that were associated with directors' exclusion decisions.RESULTS:A total of 305 directors completed the survey. Overall, directors would unnecessarily exclude 57% of children. More than 62% had never heard of the AAP/APHA guidelines. Regression analysis showed fewer exclusions among more experienced compared with less experienced directors, among larger centers compared with smaller centers, and among centers that were located in areas with a higher percentage of female heads of household. Centers with ≤10% children on state-assisted tuition excluded more.CONCLUSIONS:High rates of inappropriate exclusion persist despite state endorsement of AAP/APHA guidelines. Focused initial and ongoing training of directors regarding AAP/APHA guidelines may help to reduce high rates of unnecessary exclusions.

This cross-sectional study examines the relationship between parenting stress and concerns identified by developmental screening and their effects on parents' decisions to seek medical care for their children. A total of 182 parents completed both the Parenting Stress Index (PSI) and the Parents' Evaluation of Developmental Status (PEDS) when their children were admitted to a sick child care program that provides parents the option of requesting medical evaluations for their children with mild acute illnesses. Although 31.6% of parents (N = 62) requested medical evaluations, neither PSI nor PEDS scores were associated with these requests. However, PEDS scores indicating significant parental concerns about their child's development or behavior predicted clinically significant levels of parenting stress on the PSI (odds ratio 4.9; 95% confidence interval, 1.5-15.9; P = .007). Primary pediatric health care providers who routinely perform developmental screening need to consider this relationship when interpreting developmental screening results and offer supportive and referral services to families as needed.

The reasons underlying parents' decisions to seek medical evaluations for their mildly ill children are not well understood. This cross-sectional study tracked parents' requests for on-site medical evaluations at a sick child care program. A logistic regression model identified factors associated with parents' decisions to seek medical evaluations for their children based on the data from parent-completed questionnaires. A convenience sample of 196 parents completed all questionnaires; 62 (31.6%) parents sought medical evaluations. Parents were more likely to seek medical evaluations if they were concerned about missing work (odds ratio = 8.6; 95% confidence interval, 3.3-22.0; P = .0001), if they smoked (odds ratio = 3.7; 95% confidence interval, 1.1-12.4; P = .037), or if their spouse's highest educational attainment was some high school (odds ratio = 0.4; 95% confidence interval, 0.1-1.0; P = .044). The data highlight the problems working parents have in accessing health care during usual working hours and the potential value of convenient health care programs.