Dr. Claire McCarthy,

My name is Tori Fees.  I’m a Registered Nurse and veteran child care provider.  I have cared for kids in the capacity of private nanny, elementary school nurse, and home child care provider for thirty years.

I came upon your article “Why Sick Kids Should Be Allowed at Daycare” published by Huffpost.  As a veteran and expert child care provider, in my opinion it is important to address your article as it speaks to many of the common misconceptions Physicians have regarding admittance into child care after the child has been excluded by a school, child care center, or home child care.  My hope is that you will reconsider some of your viewpoints when you hear some of the concerns from the ladies on the ground who are caring for multi-level aged group children in these settings.

Each licensed and registered child care providers have illness policies.  Every state in the U.S. requires that guidelines are set to differentiate an excludable illness and a “mild” or “minor” illness.   Independently owned child care providers have the blessing and burden of developing their own policies that must at least meet the minimum standards set forth by their respective state.  I’m certain you have come across variations in the policies of the privately owned child care services.

When a parent brings a child into your office, you may not be aware of what the child care policies are.  Fortunately for you, you don’t have to know the specifics as your job is to simply diagnose the child and provide treatment should it be deemed necessary.  The parent may ask you to provide a “return to daycare” note but you are not required to do so.

Your article laments on the frustration you feel when parents access expensive treatment such as emergency rooms and urgent care clinics for minor illnesses solely for the purpose of obtaining a return to daycare note.  I agree wholeheartedly that these very expensive medical services should not be utilized for this purpose if the child is experiencing a mild illness.  Remember the parent is the one choosing to access this level of care.  You would be hard pressed to find a child care provider who would encourage a parent to go to this extreme.  It is likely the cost of the services in these expensive care centers far exceeds the salary loss the parent will endure while missing a few days of work.  If the parent is given free or near free access to these services and chooses to utilize them for minor illness, there should be a swift and immediate financial recourse to recoup the unnecessary expense.  As long as it is free or near free this practice will continue.  I encourage you to use your position to campaign for financial accountability when these services are being misused.

When a parent accesses medical care for the purpose of obtaining a “return to child care” note the first question you need to ask is if the child care asked for one.  It used to be standard practice to ask your opinion but that is no longer the case.  Providers across the country have had SO many bad experiences with these notes that they have changed their requests to ONLY a diagnosis, determination of whether or not the child is communicable, and documentation of any treatment you may prescribe.  There is also a high likelihood that the parent wasn’t asked to take the child to the doctor.  The child may have been excluded based on symptoms observed by the provider and was simply excluded until the symptoms are no longer present within a certain time frame.  There’s a good chance a recommendation to seek medical care for the symptoms didn’t occur.

Often, a parent who has received an exclusion comes to you because they want you in the middle of the “no” they have just received.   The “no” being their child’s exclusion from care.  They misunderstand our relationship because they believe your determination would somehow trump ours.  It doesn’t.

Child care providers don’t work with or under your license.  We can’t rely upon your determination for return to daycare because you don’t know our population.  You can’t possibly know what children are in attendance in our care.  You don’t know if we have newborns, children with compromised immune systems, special needs children, new children to the child care, or children who have been out on vacation.  You don’t know whether or not the children in attendance have even met your patient. You don’t know if the children have been exposed before diagnosis and whether or not the illness could have devastating affects on one when the effect on your patient is minor.  You don’t know if repeated exposure will increase the likelihood of infection.

We can’t rely upon your determination for return to daycare because we aren’t a part of the history you take on the child before the exam.  We don’t know if the parent has been truthful to you when giving an oral account of the child’s condition.  We don’t know if the child’s fever has been masked with antipyretics before coming into your office.  We don’t know if the parent has minimized the account of the excludable symptoms by words such as “spit up” instead of “vomit”, “loose poop” instead of blowout diarrhea.  We don’t know if the parent is attributing the symptoms to something he ate,  undiagnosed allergies, or the infamous “teething” used in nearly every parental diagnosis.

The other parents of the children attending child care with a sick kid aren’t going to be bummed out when they find out your patient is attending with a fever.  They are going to find another daycare.  Parents are very concerned about the health of the other children BEFORE their child becomes ill.  Once their child becomes ill the concern for the health of the other children wanes dramatically.  That lack of concern often drives them to your office to ask you to intercede and remediate the decision of the provider.  There are some exceptional parents who have consistent concern regardless of what child is ill but they are becoming extremely difficult to find.

You are correct that children in child care have more viral illnesses than children who don’t attend child care.  Have you ever considered that the statistical reason for this is that the parents of the children attending day care are bringing their kid in for your return notes when parents of kids who are not in child care don’t access medical care for the same symptoms?  If you stop offering return notes you may find the statistics change dramatically.

If you truly believe the illnesses are minor and the child should not be excluded maybe you should consider offering the child to hang out in your office the next day.  Put him squarely in the middle of the waiting room lounge where the “well child visit” kids are.  When the well child’s visit is over let their mothers know the kids sharing their space were excluded from daycare because of “minor” illnesses like one vomit, a little fever, a diarrhea bout that’s on the tail end, and a slight case of pink eye.  The mothers will be bummed and they will find a new doctor.  When you have your money playing alongside the kid who had diarrhea blow out from center to circumference you may be a bit more conservative in your risk analysis.

If you really want to make a difference and are willing to become involved in this vicious cycle of exclusion the best thing you could do would be to counsel parents on the average number of illnesses young children get per year.  Explain to them that they are going to have to miss work because their kid is most likely going to get sick often.  Encourage them to use their precious paid time off wisely.  Tell them to not be tempted to squander their paid time off with “me” days.  Tell them to suck it up and go to work when they are mildly ill so they have the time available to care for their baby when he is mildly ill.  Tell them it is better for them to go to work amongst other adults with their mild illness than to send their mildly ill kid to daycare with other babies.

If you want to make a difference, put in writing you will assume all liability if another child in the child care contracts the illness.  Put in writing  you will cover the cost of the missed days of work the provider will have if she contracts the illness.  Put in writing the child care providers children can be cared for by you free of charge while you are at it.  If you are going to jump on the accountability train we want you to take actual responsibility for your opinion.  We don’t want a directive to use good hand washing.  We want you to say you will be fully responsible and relieve us of our part in readmitting against our policies and better judgment.  If you can’t offer that then you aren’t a bit of help to us.

Fever is the number one indicator of health and it is masked with a nickel worth of medicine.  If you want to make a difference, test for the presence of antipyretics in the child’s system.  Do not take the parents word for it.  Let your client know that you will ask and you will check.  Google “dope and drop” and get a real education of how providers are deceived by parents to buy time through nap time or a day of daycare.  Realize that, not only are we the unwilling victim of deception, but you are too.  It happens a lot.  If you start testing for it you will write far fewer return notes in your future.

The things that would really make a difference you won’t do.  It’s easy to write a return note.  It’s easy to please your customer.  It makes you money.   It’s hard to tell a parent you can’t recommend return either way because you don’t have the information you need to make a decision and you don’t want the liability.  Encourage them to find a provider with illness policies they agree with rather than use you to intercede when the illness exclusions they agreed to before enrollment are enforced.

Better yet, stay out of the “return to daycare notes” business.  It’s not your job to make sure a parent keeps their job.  Just offer a diagnosis, whether you deem the illness as contagious, and the treatment you are giving the child.  That’s all we need.

If a child care provider or school asks you to give a determination then by all means, accommodate them.  Make sure you are actually being asked before you offer it.  Most child care providers can determine the return time on their own.  Their policies are in place for a reason.  With your diagnosis and declaration of contagiousness, we can make our own decisions on a case by case basis.  If you have any questions feel free to call the provider.  Maybe a few conversations with the ladies on the front lines will change your prospective a bit.  I hope mine has.

Sincerely,

Tori Fees R.N., B.S.N.

(Editor’s Note: Further commentary from Daycare.com Forum Providers is available here: Daycare.com/forum)