Work-Family Crunch: Parents Resort To ER To Get Kids Back Into Daycare

Some of the tension between work and family is inevitable. If your child comes down with the flu on the very day you’re supposed to give a major presentation, there’s just no way you can be everywhere you're needed at the same time.

But a study just out in the journal Pediatrics shows that the discrepancy between the sick-child policies at many daycare centers and accepted medical wisdom could often make the work-family crunch harder than it has to be. (Meanwhile, a day-long White House "summit" today is looking at ways to ease that crunch for American parents, from promoting more flexible work schedules to paid maternity leaves.)

From the study's press release:

Substantial proportions of parents chose urgent care or emergency department visits when their sick children were excluded from attending child care, according to a new study by University of Michigan researchers.

The study, to be published June 23 in Pediatrics, also found that use of the emergency department or urgent care was significantly higher among parents who are single or divorced, African American, have job concerns or needed a doctor’s note for the child to return.

Previous studies have shown children in child care are frequently ill with mild illness and are unnecessarily excluded from child care at high rates, says Andrew N. Hashikawa, M.D., M.S., an emergency physician at  C.S. Mott Children’s Hospital. This is the first national study to examine the impact of illness for children in child care on parents’ need for urgent medical evaluations, says Hashikawa.

In the study, 80 percent of parents took their children to a primary care provider when their sick children were unable to attend child care. Twenty-six percent of parents also said they had used urgent care and 25 percent had taken their children to an emergency room.

“These parents may view the situation as a socioeconomic emergency," Dr. Hashikawa says.

He got interested in this topic, he told me, when he was a med student working in an ER, and one night, a family brought in children who looked fine, they just had a little bit of red in their eyes. "And it was midnight, and I asked them, 'Why are you here?' I was just so curious. And they said 'Well, I've got to work, I'm not going to get paid, and I really need a doctor's note for both my work and for my daycare so I can send them back.'"

A bit more of our conversation, lightly edited:

How much does daycare keep kids out unnecessarily?

There are different ways to look at it...A Maryland study showed that for every one appropriate exclusion (from daycare) approximately five or six were inappropriate exclusions. I did a study from a daycare provider standpoint: If we gave you a hypothetical scenario, how many of these kids would you send home that probably didn't need to be excluded? It seemed that 57% of kids would be unnecessarily excluded at that point.

The American Academy of Pediatrics has guidelines on when children should actually be kept home, right?

Yes, the AAP has had those guidelines since about 1992. They're guidelines to help daycare providers decide about generally well-appearing children but with some minor symptoms. And the underlying theme for that has always been that if the child is lethargic and just sitting there, no matter what the symptoms are, they should go home. And secondly, if the childcare provider is spending so much resources and time trying to care for this one child that they’re actually neglecting the other children, that’s definitely a reason the child should be sent home.

That being said, the AAP guidelines say in friendly, easy-to-understand language: if a child is well-appearing but has a slight cold or a cough and is active, running around, that child doesn’t need to be necessarily sent home. Another one that's very common is pink-eye, conjunctivitis. For a long time, the fear has been that all pink-eye is bacterial, but we now know that much of pink-eye is a virus, or a cold of the eye. So those kids that are well-appearing and have a little bit of red in their eyes don’t necessarily need to be sent home urgently.

What policy recommendations do you see stemming from the report?

One of the biggest disconnects we have is that we have these easy-to-understand guidelines for child-care providers that give the providers the ultimate decision-making — because these are just guidelines, and if they really feel the child needs to be sent home, that's what they should do. But the disconnect comes in that we do not offer standardized training for childcare providers in many states. We don't have a standard way for childcare providers to learn about infectious disease issues.

I can tell you that childcare providers are very eager, hungry to look for these type of trainings. When I do offer these types of trainings out in the community, they're just packed. So there's a definite need out there.

So should parents advocate for the AAP guidelines with child care providers?

I’ve been a parent and a physician and I’ve also seen this from the childcare provider's point of view. It’s hard for the childcare provider: They're between a rock and a hard place. You have some parents who say, 'I don’t want any child in there with a runny nose or cough, I don’t want children with any symptoms of illness in child care,' and you can't run a business like that because as we know, most of the illnesses spread even before they show symptoms. Then you have parents who really want the childcare provider to provide a sick child care; even if the kid’s not feeling well at all they want to keep them there. So the providers are really in a hard spot.

I’d encourage parents to talk to your childcare provider to find out about what the policies are, to know ahead of time, and what happens when we have these types of symptoms. And the second thing I’d ask if I were a parent is: Are the center's guidelines based on the AAP guidelines? And have the providers been trained on these guidelines so everyone’s on the same page?

The AAP does have very nice resources, like the 'Managing Infectious Diseases in Childcare and Schools" book that was recently updated. There’s a free online course that the AAP offers for childcare providers as well. So we just need to get the word out there.

What we really seem to need is a child care provider for sick kids...

Those exist but they're very limited for reasons I'm not sure about. They're quite expensive, but I think that large corporations do tend to have them. From an economic point of view, we know that billions of dollars are lost from lost parent productivity when their kids are sick, sometimes for something really minor.

So the overall picture?

I think it's definitely a difficult subject. I think we need to come to a consensus at some point where we can't have all kids be sent home but there needs to be a better compromise.

And also I think looking forward, there needs to be some type of policy for parents that gives them the opportunity to take a couple of sick days off and be paid for them. There's a family health act that’s been sitting in Congress for a long time that may require businesses to have some paid sick leave for parents if their kids are sick.  I think that could help parents mitigate the need to go in to the emergency department.