By the end of this chapter, you should be able to:
Identify symptoms of infectious disease that is common during early childhood.
Outline criteria for exclusion from care for ill children and staff.
Describe considerations programs must make regarding caring for children that are mildly ill.
Recall licensing requirements for handling medication in early care and education programs.
Explain the communication about illness that should happen between families and early care and education programs.
WI Department of Children and Families Licensing Rules for Group Child Care Centers
DCF 251 Administrative Code regulations that relate to this chapter include:
DCF 251.07 Program
Health
Observation. Each child upon arrival at a center shall be observed by a staff person for symptoms of illness and injury. For an apparently ill child, the procedure under par. (c) shall be followed.
Isolation. A center shall have an isolation area for the care of children who appear to be ill. If the area is not a separate room, it shall be separated from space used by other children by a partition, screen, or other means to keep other children away from the ill child.
Ill child procedure. The following procedures shall apply when a child with an illness or condition that has the potential to affect the health of other persons, such as vomiting, diarrhea, unusual lethargy, or uncontrolled coughing, is observed in the child care center:
The child shall be isolated until the child can be removed from the center
The child in the isolation area shall be within sight and sound supervision of a staff member
The child shall be provided with a bed, crib, playpen, cot, or padded mat and a sheet and blanket or a sleeping bag.
The child’s parent or emergency contact shall be contacted as soon as possible after the illness is discovered and arrangements shall be made for the child to be removed from the center
Illness in Early Care and Education Programs
The most frequent infectious disease symptoms that are reported by early care and education settings are sore throat, runny nose, shortness of breath or cough, fever, vomiting and diarrhea (gastroenteritis), earaches, and rashes.
However, these are not the symptoms that necessarily lead to absences. In fact, although respiratory symptoms are most common, it's rashes and gastrointestinal disease that more often keep children from attending their early education programs. This is more a reflection of exclusion policies than real risk of serious illness.
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It’s important for early childhood programs to identify illness accurately and respond in ways that protect all children and staff health (whether it be to allow them to stay in care or to exclude them from care).
Identifying Infectious Disease
When you are familiar with different infectious diseases, it’s easier to identify them in children and know whether or not children (and staff) who are affected should be excluded from the early care and education program.
Common Cold
A child is sneezing and has a stuffy, runny nose. It’s quite likely that they have a common cold. As presented in Chapter 8, children get sick many times a year, probably between 4 and 12 times, depending on age and amount of time in child care. Many of these are likely due to the common cold. More than 200 viruses can cause a cold, but rhinoviruses are the most common type.
Symptoms of a cold usually peak within 2 to 3 days and can include:
Sneezing
Stuffy nose
Runny nose
Sore throat
Coughing
Mucus dripping down your throat (post-nasal drip)
Watery eyes
Fever (although most people with colds do not have fever)
When viruses that cause colds first infect the nose and air-filled pockets in the face (sinuses), the nose makes clear mucus. This helps wash the viruses from the nose and sinuses. After 2 or 3 days, mucus may change to a white, yellow, or green color. This is normal and does not mean an antibiotic is needed. Some symptoms, particularly runny nose, stuffy nose, and cough, can last for up to 10 to 14 days, but those symptoms should be improving during that time.
There is no cure for a cold. It will get better on its own—without antibiotics. When a child with a cold is feeling well enough to participate and staff are able to provide adequate care for them and all of the other children, the child does not need to be excluded from care.
Because colds can have similar symptoms to flu, it can be difficult to tell the difference between the two illnesses based on symptoms alone. Flu and the common cold are both respiratory illnesses, but they are caused by different viruses.
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Influenza (Flu)
In general, flu is worse than a cold, and symptoms are more intense. People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in serious health problems, such as pneumonia, bacterial infections, or hospitalizations. Flu can have very serious associated complications.
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Flu can cause mild to severe illness, and at times can lead to death. Flu usually comes on suddenly. People who have flu often feel some or all of these symptoms:
Fever (common, but not always) or feeling feverish/chills
cough
sore throat
runny or stuffy nose
muscle or body aches
headaches
fatigue (tiredness)
some people may have vomiting and diarrhea, though this is more common in children than adults.
Most people who get flu will recover in a few days to less than two weeks, but some people will develop complications (such as pneumonia) as a result of flu, some of which can be life-threatening and result in death.
Sinus and ear infections are examples of moderate complications from flu, while pneumonia is a serious flu complication that can result from either influenza virus infection alone or from co-infection of flu virus and bacteria. Other possible serious complications triggered by flu can include inflammation of the heart (myocarditis), brain (encephalitis) or muscle (myositis, rhabdomyolysis) tissues, and multi-organ failure (for example, respiratory and kidney failure). Flu virus infection of the respiratory tract can trigger an extreme inflammatory response in the body and can lead to sepsis, the body’s life-threatening response to infection. Flu also can make chronic medical problems worse. For example, people with asthma may experience asthma attacks while they have flu.
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A yearly flu vaccine is the first and most important step in protecting against influenza and its potentially serious complications for everyone 6 months and older. While there are many different flu viruses, flu vaccines protect against the 3 or 4 viruses that research suggests will be most common. Flu vaccination can reduce flu illnesses, doctors’ visits, missed school due to flu, prevent flu-related hospitalizations, and reduce the risk of dying from influenza. Also, there are data to suggest that even if someone gets sick after vaccination, their illness may be milder.
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Once a person has the flu, their health care provider may recommend antiviral drugs. When used for treatment, antiviral drugs can lessen symptoms and shorten the length of sickness by 1 or 2 days. They also can prevent serious flu complications, like pneumonia. For people at high risk of serious flu complications (including children), treatment with antiviral drugs can mean the difference between milder or more serious illness possibly resulting in a hospital stay. CDC recommends prompt treatment for people who have influenza infection or suspected influenza infection and who are at high risk of serious flu complications.
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As with a cold, a child with the flu does not need to be excluded if staff can care for them and all of the other children and they feel well enough to participate.
Note
Avoiding Spreading Germs to Others
Early care and education programs should teach children and model good cough and sneeze etiquette. Always sneeze or cough into a tissue that is discarded after use. If a tissue is not available, use your upper sleeve, completely covering the mouth and nose. Always wash hands after coughing, sneezing, and blowing noses.
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Sinusitis (Sinus Infection)
Sinus infections happen when fluid builds up in the air-filled pockets in the face (sinuses), which allows germs to grow. Viruses cause most sinus infections, but bacteria can cause some sinus infections.
Common symptoms of sinus infections include:
Runny nose
Stuffy nose
Facial pain or pressure
Headache
Mucus dripping down the throat (post-nasal drip)
Sore throat
Cough
Bad breath
Most sinus infections usually get better on their own without antibiotics.
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As with colds and flu, a child does not need to be automatically excluded from care for a sinus infection.
Pause to Reflect
What was your last experience with an upper respiratory infection (such as cold, flu, or sinus infection? If a child had the same symptoms as you, would they have needed to be excluded from care?
Sore Throat
A sore throat can make it painful to swallow. A sore throat can also feel dry and scratchy. Sore throat can be a symptom of the common cold, allergies, strep throat, or other upper respiratory tract illness. Strep throat is an infection in the throat and tonsils caused by bacteria called group A
Streptococcus
(also called
Streptococcus pyogenes
).
Infections from viruses are the most common cause of sore throats. The following symptoms suggest a virus is the cause of the illness instead of the bacteria called group A strep:
Cough
Runny nose
Hoarseness (changes in your voice that makes it sound breathy, raspy, or strained)
Conjunctivitis (also called pink eye)
The most common symptoms of strep throat include:
Sore throat that can start very quickly
Pain when swallowing
Fever
Red and swollen tonsils, sometimes with white patches or streaks of pus
Tiny red spots on the roof of the mouth
Swollen lymph nodes in the front of the neck
A doctor can determine the likely cause of a sore throat. If a sore throat is caused by a virus, antibiotics will not help. Most sore throats will get better on their own within one week and are not cause for exclusion from child care.
Since bacteria cause strep throat, antibiotics are needed to treat the infection and prevent rheumatic fever and other complications. A doctor cannot tell if someone has strep throat just by looking in the throat. If a doctor suspects strep throat, they may test to confirm diagnosis. A child with strep throat should be excluded from care until they no longer have fever AND have taken antibiotics for at least 24 hours.
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Ear Infection
There are different types of ear infections. Middle ear infection (acute otitis media) is an infection in the middle ear.
Another condition that affects the middle ear is called otitis media with effusion. It occurs when fluid builds up in the middle ear
without
being infected and without causing fever, ear pain, or pus build-up in the middle ear.
When the outer ear canal is infected, the condition is called swimmer’s ear, which is different from a middle ear infection.
middle, and inner ear, showing inflammation and fluid in the ear.
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Middle Ear Infection
A middle ear infection may be caused by:
Bacteria, like
Streptococcus pneumoniae
and
Haemophilus influenza
(nontypeable)
–
the two most common bacterial causes
Viruses, like those that cause colds or flu
Common symptoms of middle ear infection in children can include:
Ear pain
Fever
Fussiness or irritability
Rubbing or tugging at an ear
Difficulty sleeping
A can make the diagnosis of a middle ear infection by looking inside the child’s ear to examine the eardrum and see if there is pus in the middle ear. Antibiotics are often not needed for middle ear infections because the body’s immune system can fight off the infection on its own. However, sometimes antibiotics, such as amoxicillin, are needed to treat severe cases right away or cases that last longer than 2–3 days.
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Swimmer’s Ear
Ear infections can be caused by leaving contaminated water in the ear after swimming. This infection, known as “swimmer’s ear” or otitis externa, is not the same as the common childhood middle ear infection. The infection occurs in the outer ear canal and can cause pain and discomfort for swimmers of all ages.
Symptoms of swimmer’s ear usually appear within a few days of swimming and include:
Itchiness inside the ear.
Redness and swelling of the ear.
Pain when the infected ear is tugged or when pressure is placed on the ear.
Pus draining from the infected ear.
Although all age groups are affected by swimmer’s ear, it is more common in children and can be extremely painful. If swimmer’s ear is suspected, a healthcare provider should be consulted. Swimmer’s ear can be treated with antibiotic ear drops.
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Head Lice
Head lice are parasitic insects that live on the head. They survive by feeding on human blood. Lice infestations are spread most commonly by close person-to-person contact. Lice move by crawling; they cannot hop or fly.
Adult head lice are 2–3 mm in length. Head lice infest the head and neck and attach their eggs to the base of the hair shaft. Lice move by crawling; they cannot hop or fly.
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Symptoms of a head lice infestation include:
Tickling feeling of something moving in the hair.
Itching, caused by an allergic reaction to the bites of the head louse.
Irritability and difficulty sleeping; head lice are most active in the dark.
Sores on the head caused by scratching. These sores can sometimes become infected with bacteria found on the person’s skin.
Head-to-head contact with a person who already has an infestation is the most common way to get head lice. Head-to-head contact is common during play at school, at home, and elsewhere (sports activities, playground, slumber parties, camp).
Although uncommon, head lice can be spread by sharing clothing or belongings. This happens when lice crawl, or the nits that are attached to shed hair hatch, and get on the shared clothing or belongings. Examples include:
Sharing clothing (hats, scarves, coats, sports uniforms) or articles (hair ribbons, barrettes, combs, brushes, towels, stuffed animals) recently worn or used by a person with an infestation;
Or lying on a bed, couch, pillow, or carpet that has recently been in contact with a person with an infestation.
Dogs, cats, and other pets do not play a role in the spread of head lice.
The diagnosis of a head lice infestation is best made by finding a live nymph or adult louse on the scalp or hair of a person. Because nymphs and adult lice are very small, move quickly, and avoid light, they can be difficult to find. Use of a magnifying lens and a fine-toothed comb may be helpful to find live lice.
If crawling lice are not seen, finding nits firmly attached within a ¼ inch of base of the hair shafts strongly suggests, but does not confirm, that a person is infested and should be treated. Nits that are attached more than ¼ inch from the base of the hair shaft are almost always dead or already hatched. Nits are often confused with other things found in the hair such as dandruff, hair spray droplets, and dirt particles. If no live nymphs or adult lice are seen, and the only nits found are more than ¼-inch from the scalp, the infestation is probably old and no longer active and does not need to be treated.
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Treatment for head lice is recommended for persons diagnosed with an active infestation. All household members and other close contacts should be checked; those persons with evidence of an active infestation should be treated with an over-the-counter or prescription medication (following the provided instructions).
Hats, scarves, pillow cases, bedding, clothing, and towels worn or used by the person with the infestation in the 2-day period just before treatment is started can be machine washed and dried using the hot water and hot air cycles because lice and eggs are killed by exposure for 5 minutes to temperatures greater than 128.3°F. Items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for two weeks. Items such as hats, grooming aids, and towels that come in contact with the hair of a person with an infestation should not be shared. Vacuuming furniture and floors can remove hairs that might have viable nits attached. Head lice do not survive long if they fall off a person and cannot feed.
After treatment, it’s important to check the hair and comb with a nit comb to remove nits and lice every 2–3 days which will decrease the chance of self–reinfestation. Checking for 2–3 weeks will ensure that all lice and nits are gone.
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Note
No More “No Nits” Policies
Children diagnosed with live head lice do not need to be sent home early from early care and education programs or school; they can go home at the end of the day, be treated, and return to class after appropriate treatment has begun. Nits may persist after treatment, but successful treatment should kill crawling lice.
Head lice can be a nuisance but they have not been shown to spread disease. Personal hygiene or cleanliness in the home or school has nothing to do with getting head lice.
Both the American Academy of Pediatrics (AAP) and the National Association of School Nurses (NASN) advocate that “no-nit” policies should be discontinued. “No-nit” policies that require a child to be free of nits before they can return to schools should be discontinued for the following reasons:
Many nits are more than ¼ inch from the scalp. Such nits are usually not viable and very unlikely to hatch to become crawling lice, or may in fact be empty shells, also known as ‘casings’.
Nits are cemented to hair shafts and are very unlikely to be transferred successfully to other people.
The burden of unnecessary absenteeism to the students, families and communities far outweighs the risks associated with head lice.
Misdiagnosis of nits is very common during nit checks conducted by nonmedical personnel.
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Pause to Reflect
What experience with or knowledge do you have about policies that specific early education and care program and schools have on head lice? Are (or were) those policies “no nits” or in line with the recommendations above?
Other Illnesses
To learn more about the following illnesses, go to Appendix J.
Bronchitis
Chickenpox
Conjuctivitis (Pink Eye)
Fifth Disease (Slapped Cheek)
Hand, Foot, and Mouth Disease
Hepatitis A
Impetigo
Measles
Meningitis
Molluscum Contagiosum
Mumps
Norovirus
Pertussis
Pinworms
Respiratory Syncytial Virus
Ringworm
Roseola
Rotavirus
Rubella (German Measles)
Shigella
Tuberculosis
Note
Danger of Infectious Disease for Adults
Because early care and education program employees are around children who are at higher risk of infectious diseases and have limited understanding of hygiene practices, those employees are also at greater risk for getting sick.
While most illness that are spread in early care and education programs are not serious, some can be very dangerous. Knowledge about illness and how to prevent its spread helps. Being fully immunized (from childhood illness and or vaccines) protects adult health as well.
Employees that are or could become pregnant want to be especially careful because first time exposure to chickenpox, cytomegalovirus (CMV), Fifths disease, and Rubella can cause major damage to fetal health, birth defects, and even fetal death.
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Reportable Diseases
Some diseases are enough of a threat to the community that it is required that diagnosed cases are reported to the local health department. See Table 9.1 for which diseases must be reported, how, and how quickly. Refer to the Wisconsin Childhood Communicable Diseases chart for reporting requirements specific to Wisconsin child care programs.
Table 9.1 – Diseases Reportable to Local Health Department (required by Licensing in Wisconsin)
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Most children with mild illnesses can safely attend child care. “Many health policies concerning the care of ill children [including exclusion policies] have been based upon common misunderstandings about contagion, risks to ill children, and risks to other children and staff. Current research clearly shows that certain ill children do not pose a health threat. Also, the research shows that keeping certain other mildly ill children at home or isolated at the child care setting will not prevent other children from becoming ill.”
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But there are times when exclusion is the right answer. Licensing states that a child may be too sick to attend if:
The child does not feel well enough to participate comfortably in the program's activities.
The staff cannot adequately care for the sick child without compromising the care of the other children.
The child has any of the following symptoms unless a health provider determines that the child is well enough to attend and that the illness is not contagious:
Fever (above 100° F. axillary or above 101° F. orally) accompanied by behavior change and other signs or symptoms of illness (i.e., the child looks and acts sick)
Signs or symptoms of possibly severe illness (e.g., persistent crying, extreme irritability, uncontrolled coughing, difficulty breathing, wheezing, lethargy)
Diarrhea: Changes from the child's usual stool pattern--increased frequency of stools, looser/watery stools, stool runs out of the diaper, or child can't get to the bathroom in time.
Vomiting more than once in the previous 24 hours
Mouth sores with drooling
Rash with a fever or behavior change
The child has any of the following diagnoses from a health provider (until treated and/or no longer contagious):
Infectious conjunctivitis/pink-eye (with eye discharge)-until 24 hours after treatment started
Scabies, head lice, or other infestation-until 24 hours after treatment and free of nits
Impetigo-until 24 hours after treatment started
Strep throat, scarlet fever, or other strep infection-until 24 hours after treatment started and the child is free of fever
Pertussis-until five days after treatment started
Tuberculosis (TB)-until a health care provider determines that the disease is not contagious
Chicken pox-until six days after start of rash or all sores have crusted over
Mumps-until nine days after start of symptoms (swelling of "cheeks")
Hepatitis A-until seven days after start of symptoms (e.g., jaundice)
Measles-until six days after start of rash
Rubella (German measles)-until six days after start of rash
Oral herpes (if child is drooling or lesions cannot be covered)-until lesions heal
Shingles (if lesions cannot be covered)-until lesions are dry
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If there is an outbreak of any reportable illness (See Table 9.X), a child or staff member who meets the following criteria as determined by the local health department or a health care provider to be:
contributing to transmission of the illness
not adequately immunized when the disease is vaccine-preventable
at increased risk due to the pathogens being circulated.
They can be readmitted when the health department official or that health care provider decides that the risk of transmission is no longer present.
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What to do When a Child Requires Exclusion
When a child becomes ill enough to be excluded, they should be immediately isolated from other children. Early care and education programs are required to be equipped to isolate and care for any child who becomes ill during the day. The isolation area shall be located to afford easy supervision of children by center staff and equipped with a mat, cot, couch or bed for each ill child (or a crib if caring for infants).
The child's authorized representative shall be notified immediately when the child becomes ill enough to require isolation, and shall be asked to have the child picked up from the center as soon as possible.
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See Table 9.2 for a list of illnesses that require exclusion and when children who are diagnosed with those illnesses can return to care. Refer to the Wisconsin Childhood Communicable Diseases chart for State specific exclusion information.
Table 9.2 – Conditions that Require Exclusion
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Condition
Exclusion Criteria
Chickenpox
Until 6 days after the beginning of the rash or once the sores have dried or crusted over.
Shingles
Only sores is cannot be covered with bandages or clothing. If not, until sores are dry and have crusted over.
Rash with fever or joint pain
Until 6 days after the beginning of the rash.
Measles and Rubella
Until diagnosed not be measles or rubella.
Pertussis
If two or more episodes in 24 hours or if accompanied by a fever, until vomiting resolves or is determined not be caused by contagious illness.
Mumps
Until 9 days after the glands begin to swell.
Diarrheal Illness
It three or more episodes in the past 24 hours or if accompanied by a fever, until diarrhea resolves.
Hepatitis A
As directed by health department.
Impetigo
Until 24 hours after treatment begins and lesions are not draining.
Active Tuberculosis
Until local health department approves the return to care.
Strep Throat (and other streptococcal infections)
Until 24 hours after treatment and fever is gone.
Head lice
Until after first treatment
Scabies
Until treatment is completed
Haemophilus Influenza Type b (Hib)
Until antibiotic treatment has begun.
Respiratory Illness
If the child is not well enough to participate and/or caring for the child limits the provider from caring for the other children or if it compromises the health and safety of the other children.
Herpes cold sores
Only if sores are not able to be covered (or kept from being touched).
Other conditions mandated by state public health law
As required by local health department.
Pause to Reflect
Consider the following situations. Should each child be excluded from care or not? If so, why and when should the child return? If not, what should the teacher/caregiver do?
Mario’s dad drops him off and let’s Ms. Michelle know that he is a little under the weather. He is not running a fever, but has a mild cough and a runny nose. But he ate a good breakfast and has a pretty typical level of energy.
About an hour into the day, Li vomits. Mr. Abraham checks and she has a fever of 101.3°. She looks a little pale and just wants to lay down. As he goes to call Li’s family, she vomits again.
When Latanya goes to change Daniel’s diaper she notices a rash on his stomach. She checks his temperature and he is not running a fever. He is not scratching at it or seemingly in any discomfort. She remembers that he has a history of eczema and contact dermatitis.
Apurva wakes up from naptime with discharge coming from a slightly swollen and bloodshot right eye. She tells Ms. Maria that her eye hurts and is “kind of itchy.”
Now, come up with your own examples of a child that should be excluded from care and that should not automatically be excluded.
Caring for Mildly Ill Children
Because young in early care and education programs have high incidence of illness and may have conditions (such as eczema and asthmas), providers should be prepared to care for mildly ill children, at least temporarily. And since we know that excluding most mildly ill children doesn’t prevent the spread of illness and can have negative effects on families, programs should consider whether they can care for children with mild symptoms (not meeting the exclusion policy). The California Childcare Health Program poses the following questions to consider:
Are there sufficient staff (including volunteers) to provide minor modifications that a child might need (such as quiet activities or extra fluids)?
Are staff willing and able to care for the child’s symptoms (such as wiping a runny nose and checking a fever) without neglecting the care of other children in the group?
Is there a space where the mildly ill child can rest if needed?
Are families able or willing to pay extra for sick care if other resources are not available, so that you can hire extra staff as needed?
Have families made alternative arrangements for someone to pick up and care for their ill children if they cannot?”
It’s important that programs recognize the families have to weigh many things when trying to decide whether or not to send a child to child care. They must consider how the child feels (physically and emotionally), whether or not the program can provide care for the specific needs of the child, what alternative care arrangements are available, as well as the income they may lose if they have to stay home.
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Caution
Responding to Illness that Requires Medical Care
“Some conditions, require immediate medical help. If the parents can be reached, tell them to come right away and to notify their medical provider
.
Call Emergency Medical services (9-1-1) immediately and also notify parents if any of the following things happen:
You believe a child needs immediate medical assessment and treatment that cannot wait for parents to take the child for care.
A child has a stiff neck (that limits his ability to put his chin to his chest) or severe headache and fever.
A child has a seizure for the first time.
A child who has a fever as well as difficulty breathing.
A child looks or acts very ill, or seems to be getting worse quickly.
[A child has s]kin or lips that look blue, purple or gray.
A child is having difficulty breathing or breathes so fast or hard that he or she cannot play, talk, cry or drink.

A child complains of a headache or feeling nauseous, or is less alert or more confused, after a hard blow to the head.
Multiple children have injuries or serious illness at the same time.
A child has a large volume of blood in the stools.
A child has a suddenly spreading blood-red or purple rash.
A child acts unusually confused.
[A child is u]nresponsive or [has] decreasing responsiveness.
Tell the parent to come right away, and get medical help immediately, when any of the following things happen. If the parent or the child’s medical provider is not immediately available, call 9-1-1 (EMS) for immediate help:
A fever in any child who appears more than mildly ill.
An infant under 2 months of age has an axillary (“armpit”) temperature above 100.4º F.
An infant under four months of age has two or more forceful vomiting episodes (not the simple return of swallowed milk or spit-up) after eating.
A child has neck pain when the head is moved or touched.
A child has a severe stomach ache that causes the child to double up and scream.
A child has a stomach ache without vomiting or diarrhea after a recent injury, blow to the abdomen or hard fall.
A child has stools that are black or have blood mixed through them.
A child has not urinated in more than eight hours, and the mouth and tongue look dry.
A child has continuous, clear drainage from the nose after a hard blow to the head.
A child has a medical condition outlined in his special care plan as requiring medical attention.
[A child has a]n injury that may require medical treatment such as a cut that does not hold together after it is cleaned.”
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Administering Medications
Some children in your early care and education setting may need to take medications during the hours you provide care for them. It’s important that early care and education programs have a written policy for the use of prescription and nonprescription medication.
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According to licensing, programs that choose to handle medications must abide by the following:
All prescription and nonprescription medications shall be centrally stored in a safe place inaccessible to children, with an unaltered label, and labeled with the child’s name and date
A refrigerator shall be used to store any medication that requires refrigeration.
Prescription medications may be administered with written permission by the child’s authorized representatives in accordance with the label instructions by the physician
Nonprescription medications may be administered without approval or instructions from the child's physician with written approval and instructions from the child’s authorized representative and when administered in accordance with the product label directions.
Valid reasons for an early care and education program to consider administering medication.
Some medication dosing cannot be adjusted to be taken before and after care (and keeping them out of care when otherwise well enough to attend, would be a hardship for families.
Some children may have chronic conditions that may require urgent administration of medication (such as asthma and diabetes).
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Communication with Families
When children are excluded from care, it’s important to provide documentation for families of how the child meets the guidelines in your exclusion policy and what needs to happen before the child can return to care. See Appendix K for a possible form that programs could use.
Programs are also required to inform families when children are exposed to a communicable disease. See Appendix L for an example of a notice of exposure form you can provide to families so they know what signs of illness to watch for and to seek medical advice when necessary.
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Pause to Reflect
Why is it important for early care and education programs to communicate clearly with families regarding communicable illness?
Summary
Becoming familiar with infectious diseases that are common in early childhood enables early care and education program staff to identify illness and respond appropriately. This included knowing when children (and staff) should be excluded from care and what needs to happen before they should come back.
Programs must create policies on how they will handle children that are mildly ill (those that need care before they can be picked up from care and those that do not require exclusion) and children who have illness that requires medical care. Programs who choose to administer medication, must be familiar with the licensing regulations they must follow.
Open communication with families is important when a child becomes ill or is potentially exposed to an illness. Helping families understand and follow policies regarding exclusion is vital to keeping everyone in the program as healthy as possible.


4.9: Summary of the Nursing Process
You have now learned how to perform each step of the nursing process according to the ANA Standards of Professional Nursing Practice. Critical thinking, clinical reasoning, and clinical judgment are used when assessing the patient, creating a nursing care plan, and implementing interventions. Frequent reassessment, with revisions to the care plan as needed, is important to help the patient achieve expected outcomes. Throughout the entire nursing process, the patient always remains the cornerstone of nursing care. Providing individualized, patient-centered care and evaluating whether that care has been successful in achieving patient outcomes are essential for providing safe, professional nursing practice.
- RegisteredNurseRN. (2015, June11). Nursing care plan tutorial | How to complete a care plan in nursing school . [Video]. YouTube. All rights reserved. Video used with permission. https//youtu.be/07Z4ywfmLg8 ↵


18.1: Introduction
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Objectives
After completing this section, you should be able to use the terms “ether,” “diethyl ether ” and “ethyl ether ” appropriately in context.
Key Terms
Make certain that you can define, and use in context, the key terms below.
- ether (\(\ce{R-O-R′}\))
- sulfide (\(\ce{R-S-R′}\))
- thiol (\(\ce{R-S-H}\))
Study Notes
As defined in the textbook, an “ether” is a substance with the general formula (\(\ce{R-O-R′}\)) where \(\ce{R}\) and \(\ce{R′}\) are alkyl, aryl, vinyl or allyl groups. However, the word “ether” is also commonly used to refer to the specific compound, \(\ce{CH3-CH2-O-CH2-CH3}\), which is correctly called “diethyl ether.” Further confusion can arise because some chemists refer to “diethyl ether ” as “ethyl ether.” In this course, “ether ” will be used to refer to the class of compounds with the structure (\(\ce{R-O-R′}\)) ; diethyl ether will refer to the compound, \(\ce{CH3-CH2-O-CH2-CH3}\); and “ethyl ether ” will not be used.
Ethers and Epoxides
While the general formula for ethers is R-O-R′ , keep in mind that there also cyclic ethers like tetrahydrofuran (a common organic solvent) or even epoxides which you first encounter in Section 8.7 in synthesizing diols from alkenes.
Thiols and Sulfides
Thiols (thio alcohols or mercaptans) and sulfides (thioethers) are the sulfur analogues of alcohols and ethers and have the general formulas of R-S-H and R-S-R′, respectively.


10.2: Introduction to Labor Variances
What you’ll learn to do: Discuss different types of labor variances
Variances in labor, like variances in materials are multifaceted. We might have the same number of hours at a different hourly rate, or more hours at the same rate, or some combination of these factors. Why would the hourly rate vary from budget? Why might the hours change? Let’s first look at the standard cost variance analysis chart for labor variances.
At Hupana Running Company, our budget allows for .5 hours of direct labor per pair of shoes produced. The cost of each hour is budgeted at $20 per hour.
If we use more hours at the same rate of pay, it would be called a labor efficiency variance.
If we used the same hours at a higher rate of pay it is called a labor rate variance.
A combination of these may happen as well! We could have fewer hours, but a higher rate of pay. Let’s see what difference these variances make in our direct labor budget!


9.7: Review Questions
What are the different stages in a company’s lifecycle?
2 .How do financing requirements change at different stages of a company’s lifecycle?
3 .What are the two most common categories of financing available to an entrepreneur?
4 .What is the Small Business Administration?
5 .What is an SBA loan?
6 .What is a charitable organization?
7 .What is a sustainable funding strategy?
8 .What is social entrepreneurship?
9 .What is crowdfunding?
10 .What is bartering?
11 .What does the term bootstrapping mean in terms of startups?
12 .What purpose does an accounting system serve?
13 .What key terms are used in the accounting equation?
14 .How does accounting differ from finance?
15 .What are the basic financial statements? What information do they provide?
16 .What are projections used for?
17 .What is a break-even point?


11.0: Introduction
Suppose a friend asked you, “When did you last vote?” What would your answer be? Maybe you would tell your friend that the last time you voted was during the last presidential election, or perhaps you would tell your friend that you prefer not to vote. When thinking about voting, presidential campaigns or advertisements for reelections may come to mind, but you can cast your vote in many ways. Have you liked a post, followed a creator, friended a stranger, or clicked a heart online today? In the digital age, it's possible to vote several times a day. Voting systems are not only the machines that drive every democracy on Earth, but they are also the engines driving social media and many other aspects of life. A deeper understanding of these voting systems will enhance your ability to successfully engage with the world in which we live.
In this chapter, you will become one of the founders of the new democratic country of Imaginaria. You have a great responsibility to the people of this fledgling democracy. You have been tasked with writing the portion of the constitution that lays out voting procedures. In preparation for this important task, you will explore the various types of voting systems, from school board elections to Twitter wars. You will see how these types are alike, how they differ, and how they might be applied in Imaginaria. Most importantly, you will learn about the mathematically inherent advantages and disadvantages of various voting systems so that you can make informed choices to better the lives of the Imaginarians.


11.11: Reproductive System
Reproduction is the process by which organisms make more organisms like themselves. Although the reproductive system is essential to keeping a species alive, unlike other body systems, it’s not essential to keeping an individual alive. Because the endocrine system controls the hormone levels throughout the body, it has a large role in the functioning of the reproductive system. Hormone levels affect growth and development, appetite, mood, body temperature, and stress, along with sexual function and reproductive health. Both the male and female reproductive systems are necessary to reproduce. The organs that are part of both reproductive systems are referred to as genitals. [1]
Female Reproductive System
The external part of the female reproductive organs is called the vulva, which covers the opening to the vagina and other internal reproductive organs. Two pairs of skin flaps called the labia surround the vaginal opening. The clitoris, a small sensory organ, is located toward the front of the vulva where the folds of the labia join. Between the labia are openings to the urethra and vagina. When girls become sexually mature, called puberty, the outer labia and the mons pubis are covered by pubic hair. A female’s internal reproductive organs are the vagina, uterus, Fallopian tubes, and ovaries. See Figure 11.16 [2] for an illustration of the organs of the female reproductive system.
Toward the end of puberty, girls begin to release eggs as part of a monthly period called the menstrual cycle . About once a month, during ovulation, an ovary sends an egg into one of the Fallopian tubes. Unless the egg is fertilized by a male’s sperm while in the Fallopian tube, the egg leaves the body about two weeks later through the uterus in a process called menstruation . During menstruation, blood and tissues from the inner lining of the uterus combine to form the menstrual flow, which in most women lasts from three to five days. [3]
The menstrual cycle continues until menopause, when levels of estrogen decline and the woman no longer releases eggs. This usually occurs sometime around the late forties to early fifties. As estrogen levels decrease, women may experience irregular periods, hot flashes, night sweats, mood swings, and changes in metabolism. [4]
  Internally, the male reproductive system includes the testes, the duct system made up of the epididymis and the vas deferens, and the accessory glands that include the seminal vesicles and prostate gland. Testosterone is a hormone that increases during puberty and is produced in the testes. Testosterone is responsible for causing boys to develop deeper voices, larger muscles, and body and facial hair. It also stimulates the production of sperm that fertilizes the egg of a female. [5] See Figure 11.17 [6] for an illustration of the male reproductive system.
 Some boys are circumcised, which means that a doctor or a clergy member cuts away the foreskin. Circumcision is typically performed during a baby’s first few days of life based on parental religious beliefs, concerns about hygiene, or cultural or social reasons. There is no medical necessity for circumcision. See Figure X for an illustration of the male reproductive organs.
As men age, their prostate enlarges. Because the prostate surrounds the urethra, its enlargement often causes urinary issues such as the decreased ability to dispel urine, frequent urination, an intermittent stream of urine, and retention of urine in the bladder. Urinary retention and incomplete emptying of urine from the bladder increase the male resident’s risk of urinary tract infections, so signs of infection should be monitored by nursing assistants.
- Hirsch, L. (2019, June). Female reproductive system. KidsHealth. https://kidshealth.org/en/teens/female-repro.html ↵
- " Blausen_0399_FemaleReproSystem_01.png " by Blausen.com staff (2014) at " Medical gallery of Blausen Medical 2014 is licensed under CC BY 3.0 ↵
- Hirsch, L. (2019, June). Female reproductive system. KidsHealth. https://kidshealth.org/en/teens/female-repro.html ↵
- Hirsch, L. (2019, June). Female reproductive system. KidsHealth. https://kidshealth.org/en/teens/female-repro.html ↵
- Hirsch, L. (2019, June). Male reproductive system. KidsHealth. https://kidshealth.org/en/teens/male-repro.html ↵
- " 3D_Medical_Animation_Vas_Deferens.jpg " by https://www.scientificanimations.com is licensed under CC BY-SA 4.0 ↵