Safer Practices Part 4: Managing contagious diseases and childhood infections

Underlying presentations of serious infectious diseases can mimic common childhood infections in the early stages, so it is vital that providers have policies in place and follow Government guidelines as their first line of defence in infection control.

Measles, which hit headlines this summer, starts off with cold-like symptoms and a high temperature. Several days later, a rash appears. One infected child can pass it on to nine out of ten children who have not been protected by the MMR vaccination. In worst-case scenarios, measles develops into meningitis and sepsis and causes a risk to life.

Measles, alongside whooping cough, meningitis and scarlet fever, is one of 34 ‘notifiable illnesses’ that are required by law to be reported to government authorities when diagnosed.

Melanie Pilcher, quality and standards manager at the Early Years Alliance, says although it is not the responsibility of the early years provider to notify the government authority, if they become aware that a child in their care has been diagnosed with a notifiable disease, they should contact their local health protection teams.

Spread of infection

Most infectious diseases are relatively minor. Children recover quickly from mild childhood illnesses such as chicken pox, colds and tummy bugs, and over time build up immunity to fight further infections.

For chicken pox, the exclusion period is ‘at least five days’ from the onset of the rash and until all blisters have crusted over; for measles it is ‘four days after the onset of the rash’, as set out in the Department for Education’s quick-check ‘exclusion table’.

But Pilcher warns that a ‘seemingly minor illness’ can cause problems in some children, so it should ‘never be taken for granted’ that an infection will follow a predictable course.

‘Some illnesses have similar symptoms, but one may be far more serious,’ she says. ‘Early years practitioners are not medical practitioners and should never diagnose an illness. Sending a child home and informing parents that they have symptoms that may indicate hand, foot and mouth disease, for example, is reasonable. But the practitioner must always follow this up by suggesting that if the parent is concerned, or symptoms worsen, they should seek medical advice immediately. It is always a matter of recognising symptoms and taking appropriate action based on the evidence they have.’

Rose Dias, owner of Cygnets Childcare in Surrey, says the majority of infectious diseases she has encountered in her 15 years working as an early years educator had one of three underlying presentations: a temperature, diarrhoea or a rash.

‘We cannot determine if the symptom the child is presenting with is a result of a common childhood infection or if it could progress into something more sinister. That’s why it’s vital to follow Government guidelines, NHS advice and have policies and procedures in place,’ she says.

‘A rash could be an eczema flare-up, a food allergy or deadly meningitis. If a child has an unexplained rash that appears at nursery, we contact parents to collect them. We only administer Calpol for teething or if a child falls ill at the setting and is in discomfort while waiting to be collected, but a signed agreement from a parent must be given.’

Specific infections

One of the biggest challenges for providers is excluding children who are ill when parents have to be at work, especially when a child has repeated infectious illnesses.

Diarrhoea is often a contentious issue. Official guidance states that three or more instances of stools at 6 or 7 on the Bristol Stool Chart within 24 hours is considered to be diarrhoea and requires exclusion for at least 48 hours after symptoms have stopped.

‘We recommend that our members remind parents of the 48-hour exclusion policy if they try to bring their children in early,’ explains Tina Maltman, executive director at Childminding UK. ‘If it’s an infectious disease and the childminder gets sick, they will not be able to work and this will disrupt other families,’ she says.

Childminders also face the added difficulty of weighting up the potential risk of subjecting their families to potential contagious diseases and meeting the needs of parents. ‘Guidance states that there’s no exclusion period for hand, foot and mouth, impetigo or head lice, but we get calls from members asking if they can exclude infected children, particularly if there are vulnerable people in their households,’ Maltman says.

‘We explain that Government guidance is there for a reason, but as self-employed business owners, their terms and conditions are down to them. Obviously, different rules apply when it comes to notifiable diseases.’

The Managing outbreaks and incidentsguidance states that if a parent insists their child attends a setting when they have symptoms of a confirmed or suspected case of an infectious illness, a provider can ‘refuse the child’ in order to protect other children and staff from possible infection.

Administering medication

There is no ‘specific guidance’ for settings on the use of Calpol and other paracetamol or Ibuprofen-based products that are given to relieve pain and reduce a fever in young children, Pilcher says. She advises settings to take a ‘common sense approach. If a parent tells you that their child has been vaccinated the day before and they have been advised to give Calpol, practitioners should monitor the child throughout the day, and if Calpol is working, and the child is not distressed or otherwise poorly, then it would be reasonable for them to stay.’

‘Nurseries are not equipped to care for poorly children and there is always the risk that they are suffering from an infectious illness,’ she adds.

Maltman says the main rule of thumb for childminders, whether it is an infectious disease or not, is that if a child feels ‘so poorly that they only want mummy or daddy’, the best place for them is at home.

‘In our suggested policy we state that if a child is unwell with a high temperature of over 38 and an infectious illness, including Covid-19, they should stay at home until the infection passes,’ she says.

The Early Years Alliance says good practice in infection control is ‘absolutely essential’ and recommends these steps:

• Following recommended exclusion times.
• Good hand hygiene.
• Schedules for cleaning equipment.
• Suspending certain activities during an outbreak of illness (e.g., sand and water play).

CASE STUDY: Little Pals Nursery, Clacton-on-Sea, Essex

When two children came down with scarlet fever and 20 had hand, foot and mouth disease last December, it was a challenging time for Little Pals Nursery.

‘It was around the time of the national outbreak of Strep A, which is linked to scarlet fever, and parents were fearful because of reports in the media of infant mortalities,’ explains operations manager Amy Doherty.

‘A week after the first case of scarlet fever, another child came down with it. When we saw the distinctive rash and the strawberry tongue, we isolated the children and informed the parents to collect them and take them to get swabbed. After being on antibiotics for 24 hours, the children could return.

‘We deal with scarlet fever every year, but this year parents were scared. About 5 per cent of parents wanted to keep their children away from the setting, especially as it was just before Christmas.

‘We were also dealing with an outbreak of hand, foot and mouth. Children are not required to isolate for this. It was challenging to keep up with wiping down everything with anti-bacterial solution every time the children touched something. We tried to deep clean in the evenings, but felt like we were chasing our tails.

‘We were open and transparent with our parents, and we wanted them to know what to look out for. We provided daily updates through our online learning platform and immediately notified Public Health England about the scarlet fever. We took out the sand, water, playdough and washed bedding and blankets for each child, every day. We reintroduced the resources on a gradual basis. Our key concern was the safety of children and making sure parents felt supported throughout.’

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