The survey was returned by 135 (30%) child care directors. Most directors were female (126 [97.7%] of 129 directors), aged 26 to 45 years (78 [60.0%] of 130), and had received a college degree (92 [70.2%] of 131). They reported that toddlers (age, 13–36 months) accounted for 11% (IQR, 4.5%–22%) of daily enrollment and that preschoolers (age, 37–59 months) accounted for 23% (IQR, 12%–33%) of daily enrollment. A median of 7 (IQR, 3–12) and 4 (IQR, 2–6.5) full-and part-time staff members, respectively, worked in the child care facilities.
Regarding the exclusion of children with acute infectious diseases, 124 (96.9%) of 128 reported that their center had written policies guiding exclusion of children for acute illness. In general, directors (123 [96.9%] of 127) and classroom teachers (80 [63.0%] of 127) were responsible for determining when an ill child should be excluded. The illustrates responses to a series of questions assessing exclusion of children for specific symptoms. Policies requiring receipt of antibiotics prior to returning to the child care center were notable in that most directors reported that children with conjunctivitis with white or yellow pus (114 [91.9%] of 124 directors), conjunctivitis with watery discharge (76 [61.8%] of 123), or diarrhea (62 [50.4%] of 123) were always excluded from the child care center until antibiotics were prescribed. Although receipt of antibiotics prior to the child’s return to a child care center was not always required in other scenarios, directors frequently reported that antibiotics were sometimes required.
Child Care Center Procedures for Sick Children as Reported by Child Care Center Directors
Of note, high percentages of directors reported that antibiotics were never required prior to returning to the child care setting for a runny nose without green or yellow mucous (111 [89.5%] of 124 directors) or for cough without fever (92 [75.4%] of 122) (). The number of children enrolled in each center was associated with child care center directors’ responses on exclusion for children with ear pain until the child receives antibiotics (likelihood of exclude response for every 10 student increase in enrollment; OR, 1.15; 95% CI, 1.04–1.26; P = .005) and director’s perception that parents often demand unnecessary antibiotics so the children can return to the child care center (likelihood of parents demand for every 10 student increase in enrollment; OR, 1.12; 95% CI, 1.02–1.22; P = .02). No significant association was found between directors’ education and responses on exclusion for ear pain or perception regarding parents demand for antibiotics.
Most child care directors disagreed or strongly disagreed that children would be sick for a longer time if they did not receive an antibiotic for cough, cold, or influenza symptoms (114 [89.1%] of 128 directors). Most recognized that exposure to unnecessary antibiotics can promote antimicrobial resistance (101 [80.8%] of 125 agreed or strongly agreed) and denied feeling more comfortable allowing children with colds in child care if the children were receiving antibiotics (29 [22.7%] of 128 agreed or strongly agreed that they felt more comfortable). However, respondents felt that parents frequently demanded unnecessary antibiotics so that their children could return to a child care center (96 [75.6%] of 127 agreed or strongly agreed that this often occurs). Respondents were divided regarding whether doctors often prescribe unnecessary antibiotics so that children can return to a child care center, with 66 of 126 (52.4%) stating that they disagree or strongly disagree that this occurs.