The COVID-19 pandemic was a time of great uncertainty for the early care and education community. Thousands of ECE providers, directors, owners, and preschool teachers were forced to overcome unexpected pandemic-related challenges and barriers in caring for young children in ECE environments. The pandemic revealed to the rest of the country how essential ECE programs were for our society to function, and ECE providers rose to the challenge (Hashikawa et al., 2020).

In the midst of the pandemic, many ECE programs were on the verge of closing due to financial constraints and low enrollment numbers, with many programs forced to close their doors permanently (ChildCareAware, 2020). ECE providers became adept at performing daily health checks, screening for symptoms to ensure children were appropriately excluded and quarantined, cleaning and disinfecting, and implementing mitigation measures such as masking. Fortunately, the SARS-CoV-2 virus affected children less severely compared to adults (Dawood et al., 2022; Laws et al., 2021). While COVID-19 spread occurred in ECE programs and schools, these settings did not seem to accelerate community spread.

However, as we transitioned away from the COVID-19 pandemic this past winter, we saw a resurgence of many cold viruses that were temporarily dormant during the pandemic due to COVID-19 masking, physical distancing, and exclusion strategies. As these mitigation factors were removed, many children, without any previous exposure to these common viruses, were now exposed and became infected in high proportions. In fact, our last winter was labeled as the “tripledemic” because thousands of children were treated in emergency departments or were hospitalized because of RSV, COVID-19, and/or influenza viruses (Furlow, 2023). Many older children, who might have typically been exposed to these common viruses in years past, had not yet developed any immunity, resulting in a larger proportion of children affected more severely by these viruses.

Another effect of the pandemic may be the re-emergence of vaccine-preventable illnesses (Feldman et al., 2021). Pediatric vaccination rates plummeted during the pandemic due to parents’ vaccine hesitancy and disruptions in healthcare services for children. We continue to see a decreasing number of fully vaccinated children, increasing the possibility of vaccine-preventable outbreaks in ECE settings compared to previous years. The recent measles outbreak in Ohio demonstrates how these vaccine-preventable diseases can re-emerge, spread rapidly, and harm children (Abbasi, 2023). ECE providers can encourage and support vaccination for children to help prevent the spread of vaccine-preventable illnesses.


It is now clear that we have transitioned from a pandemic state to an endemic state, where COVID-19 infections have become less severe and similar to other respiratory viruses like influenza. In this post-pandemic environment, ECE providers must now continue to balance the need to safely manage mildly ill children in ECE settings without severely compromising parents’ ability to work or negatively disrupting children’s educational opportunities. ECE settings still remain environments where children have higher exposure to viruses and bacteria. Young children attending ECE also have naïve, developing immune systems and other inherent developmental factors (such as mouthing and sharing toys) that make them more prone to upper respiratory and gastrointestinal illnesses. Finding a balance between appropriately excluding children while allowing well children to participate remains challenging for ECE providers. One key point to remember is that excluding a child with a runny nose and no other symptoms does not necessarily prevent the spread of infection since most illness spread occurs before symptoms become evident. When evaluating whether a child with illness symptoms should be immediately excluded from child care due to illness, ECE providers should also:

  • consider if keeping the child would require a lot more care than usual and become a detriment to being able to watch other children, and
  • determine if the child is well enough to participate, engage, and learn at the program.

Here are some additional tips for managing illnesses in early care and education settings:

Use Reliable Resources

Early care and education providers can utilize reliable resources to manage illnesses effectively. One such resource is the “Caring for Our Children- 4th edition” national guidelines, which provide easy-to-use reference guidelines for managing infectious diseases in child care and schools (American Academy of Pediatrics, 2019). The American Academy of Pediatrics has also recently published the 6th edition of the “Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide” and has been a trusted resource for ECE programs, providing easy-to-understand descriptions of common infectious symptoms in children, how infections are spread, when children need to seek medical attention, and inclusion and exclusion criteria (Shope & Hashikawa, 2023). Finally, the Centers for Disease Control and Prevention Early Care and Education Portal website remains an excellent, updated resource for best-practice recommendations for ECE settings (Center for Disease Control, 2023).

Seek Help from Child Care Health Consultants

Many states have child care health consultants, who are licensed health professionals with training and experience in ECE health practices. These consultants can provide guidance and expertise to help ECE programs establish effective health and safety program policies. They can also provide training for staff, review existing policies, and assist ECE programs in quality improvement initiatives to ensure optimal health conditions that allow children to grow and thrive.

Establish Written, Transparent Policies

Clear and transparent illness policies are critical for early care and education settings. Providers should establish general illness policy guidelines that are easy to interpret, and parents should be familiar with them. Backup options for when a child must stay home should also be in place. The Caring for Our Children website has up-to-date guidelines and references that can assist ECE providers in writing transparent illness-related policies for their program. Policies should include routine scheduling for cleaning, sanitizing, and disinfecting spaces, and ensuring that parents fill out child health assessment forms, medication administration forms, and child emergency information forms.

Foster Good Communication with Staff and Parents

Effective communication is crucial for managing illnesses in early care and education settings. Educating staff, children, and families about best practices can be helpful. Providers should encourage parents to update their child’s immunizations, including the flu and COVID-19 vaccines, and promote healthy habits such as eating nutritious diets, exercise, sleep, and fresh air. Additionally, it is essential to highlight to parents that their children’s frequent illnesses are building and enhancing their immunity, making them less likely to become sick when they reach grade school. Common illness reference sheets can be distributed to staff and parents to facilitate good communication. “Managing Infectious Diseases in Child Care and Schools” includes pictures, strategies, and sample forms and letters to share with parents (Shope & Hashikawa, 2023).

Keep the Focus on the Child

A healthy child who exercises, sleeps well, eats a balanced diet, and is vaccinated will develop an immune system that is optimized to fight infection. While managing illnesses is important in ECE settings, it is also essential to remember that these settings are crucial to children’s development. Providers should ensure that children are healthy but also focus on ensuring children do not have their education disrupted unnecessarily by excluding them for illnesses when it is not medically necessary (e.g., a child with a runny nose who has no other symptoms and is acting fine).

In conclusion, managing illnesses in ECE settings can indeed be a challenging balancing act. While there remains some uncertainty regarding future COVID-19 variants or the emergence of new viruses, ECE providers can continue to be prepared. Using trusted resources to craft policies and make decisions based on best practice recommendations will ensure that children continue to thrive, and parents are able to work. Collaborations with child care health consultants can assist ECE staff in balancing both the health and well-being of children and families, and the educational and financial impacts of exclusions. ECE providers play a critical role in creating a nurturing and supportive environment by prioritizing the safety, health, and development of young children.


Abbasi, J. (2023). Amid Ohio Measles Outbreak, New Global Report Warns of Decreased Vaccination During COVID-19 Pandemic. JAMA, 329(1), 9-11. doi:10.1001/jama.2022.23241

Dawood, F.S., Porucznik, C.A., Veguilla, V., Stanford, J.B., Duque, J., Rolfes, M.A., and Stockwell, M.S. (2022). Incidence Rates, Household Infection Risk, and Clinical Characteristics of SARS-CoV-2 Infection Among Children and Adults in Utah and New York City, New York. JAMA, 176(1), 59-67. doi:10.1001/jamapediatrics.2021.4217

Center for Disease Control. (2023). Early Care and Education Portal: Prevention and control of infectious diseases.

Feldman, A.G., O’Leary, S.T., and Danziger-Isakov, L. (2021). The Risk of Resurgence in Vaccine-Preventable Infections Due to Coronavirus Disease 2019-Related Gaps in Immunization. Clinical Infectious Diseases, 73(10), 1920-1923. doi:10.1093/cid/ciab127

Furlow, B. (2023). Triple-demic overwhelms paediatric units in US hospitals. Lancet Child Adolesc Health, 7(2), 86. doi:10.1016/s2352-4642(22)00372-8

Hashikawa, A.N., Sells, J.M., DeJonge, P.M., Alkon, A., Martin, E.T., and Shope, T.R. (2020). Child Care in the Time of Coronavirus Disease-19: A Period of Challenge and Opportunity. Journal of Pediatrics, 225, 239-245. doi:10.1016/j.jpeds.2020.07.042

Laws, R.L., Chancey, R.J., Rabold, E.M., Chu, V.T., Lewis, N.M., Fajans, M., and Kirking, H.L. (2021). Symptoms and Transmission of SARS-CoV-2 Among Children – Utah and Wisconsin, March-May 2020. Pediatrics, 147(1). doi:10.1542/peds.2020-027268

Shope, T.R. and Hashikawa, A.N. (2023). Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 6th Ed. American Academy of Pediatrics.

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. (2019). Caring for Our Children. American Academy of Pediatrics.

ChildCareAware. (2020). Picking Up the Pieces: Building a Better Child Care System Post COVID-19.

Author, Andrew Hashikawa

Andrew Hashikawa, M.D., is a pediatric emergency medicine physician at the University of Michigan Mott Children's Hospital. Hashikawa trained at the Mayo Clinic and completed a fellowship in pediatric emergency medicine at the Children's Hospital of Wisconsin. He has been the early childhood champion for the American Academy of Pediatrics Michigan chapter since 2011. Hashikawa has substantial experience working with local early learning coalitions, including Head Start and Child Care Network. He also serves as a volunteer child care health consultant for several local child care centers. He is an executive committee member on the AAP's Council of Early Childhood. His research has focused on improving the health and safety of children in early learning environments. He received the Head Start 50th anniversary award in 2015 and the AAP Council of Early Childhood Dr. Susan S. Aronson early education and child advocacy award in 2019 for making significant contributions to improving the health, safety, and development of children in early education and child care settings. He resides near Ann Arbor with his wife and three teenage daughters.

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