Diarrhea—Child Care and Schools

What is diarrhea?

Diarrhea is an illness in which someone develops more frequent and watery stools than is typical for that person. Diarrhea can result from changes in diet (eg, drinking large amounts of fruit juice, eating certain foods), certain medications, or intestinal issues like the inability to absorb nutrients or allergy to foods. Infections with some viruses, bacteria, parasites, or bacterial toxins can also cause diarrhea.

• Viral (rotaviruses, enteric adenoviruses, astroviruses, Sapovirus, enteroviruses, and noroviruses): Most common in early childhood education (ECE) settings. Rotavirus (more common in the winter) was previously the most common cause of severe diarrhea in young children but is now less common because of routine vaccination of infants starting in 2006. Noroviruses are now the most common cause of diarrhea in children, occur year-round, and often cause outbreaks. Enteroviruses are more common in the summer. Other viral infections may include diarrhea as one symptom (refer to the Quick Reference Sheet for each specific disease for more information).

• Bacterial (Shigella, Salmonella, Campylobacter, Shiga toxin?producing Escherichia coli, Clostridioides difficile): Less common but can cause bloody diarrhea. Anyone with bloody diarrhea should be evaluated by a health professional.

• Parasitic (Giardia duodenalis, Cryptosporidium): Less common but can cause bloody diarrhea. Anyone with bloody diarrhea should be evaluated by a health professional.

• Noninfectious: Caused by intestinal diseases unrelated to infections, foods, juices, or medicines; this type of diarrhea is not contagious and usually not severe enough to cause dehydration.

What are the signs or symptoms?

• Frequent loose or watery stools

• Abdominal cramps and tenderness

• Fever

• Signs of dehydration, including dry mouth, no tears, or no urine for 8 hours

• Malaise

• Blood in stool

Note: Individuals can be infected and infectious with minimal or no signs or symptoms.

What are the incubation and contagious periods?

See the Quick Reference Sheet for each specific disease.

How is it spread?

• Fecal-oral route: Contact with feces from an infected person, typically when the person contaminates their fingers and touches an object another person then touches. Children who have contact with the contaminated surface may place their fingers into their own or another person's mouth.

• Water contaminated by human or animal feces (eg, swimming pools).

• Food contaminated by human or animal feces (eg, raw fruits and vegetables).

• Contact with raw or undercooked poultry or beef.

• Contact with animals in the child's environment (eg, puppies, reptiles, poultry), during trips to sites with animals (eg, farms, pet stores, petting zoos), or in the wild.

How do you control it?

• Ensure immunization of infants for rotavirus according to the most recent immunization schedule.

• Use good hand-hygiene technique at all the times listed in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition, especially after toilet use or handling soiled diapers and before anything to do with food preparation or eating.

• Ensure proper surface disinfection that includes cleaning and rinsing of surfaces that may have become contaminated with stool (feces) with detergent and water and application of a US Environmental Protection Agency?registered disinfectant according to the instructions on the product label. For guidance on disinfectants, refer to Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product in Chapter 8 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition.

• Ensure proper cooking, handling, and storage of food. Avoid using the same cutting boards or utensils for raw and cooked foods without proper cleaning in between.

• Ensure thorough washing of raw fruits and vegetables.

• Exclude infected staff members who handle food. See Safe Food Preparation and Service: Food Handlers in Chapter 2 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition.

• Exclude for specific types of symptoms (see the section Exclude from educational setting?).

What are the roles of the educator and the family?

• If a child becomes ill at school, staff should help prevent dehydration by attempting to have the child drink more fluids than the amount lost through diarrhea until the parent or guardian arrives.

• Report the condition to the staff member designated by the ECE program or school for decision-making and action related to the care of ill children and staff members. That person, in turn, alerts possibly exposed family and staff members to watch for symptoms.

• Ensure staff members follow the control measures listed in the section How do you control it?

• Do not allow a staff member with diarrhea to be involved with food handling or feeding of children.

• Report outbreaks of diarrhea (more than 2 children and/or staff members in the group) to the Child Care Health Consultant, who may report to the local health department.

• Require a medical evaluation for any child or staff member with diarrhea and blood or mucus in the stool.

Exclude from educational setting?

Yes, if

• The local health department determines exclusion is needed to control an outbreak.

• Stool is not contained in the diaper for diapered children.

• Diarrhea is causing "accidents" for toilet-trained children.

• Stool is more watery and frequency exceeds 2 stools above normal for that child during the time the child is in the program because this may cause too much work for EC educators and make it difficult for them to maintain sanitary conditions.

• There is blood or mucus in stool.

• The stool is all black.

• The child has a dry mouth, no tears, or no urine output in 8 hours (suggesting the child's diarrhea may be causing dehydration).

• The child is unable to participate and staff members determine they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group.

• The child meets other exclusion criteria (see Conditions Requiring Temporary Exclusion in Chapter 4 of Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 7th Edition).

Readmit to educational setting?

Yes, when all the following criteria are met:

• For blood or mucus in the stool: A health professional must clear the child or staff member for readmission.

• For a diarrhea outbreak: Readmit according to the requirements of the local health department authorities. State laws may govern exclusion for these conditions and should be followed by the health professional who is clearing the child or staff member for readmission. The following organisms may require negative stool test results before the child or staff member can return:

  • ? Shigella: No need for a negative stool culture result after antibiotic treatment is complete (if prescribed).

  • ? Shiga toxin?producing E coli: 2 negative stool culture results obtained at least 48 hours after antibiotic treatment is complete (if antibiotic is prescribed). Studies have not shown a benefit of antibiotics for this condition.

  • ? Salmonella Typhi and Paratyphi: Typically, 3 negative stool culture results obtained at least 48 hours after antibiotic treatment is complete, but check state or local health department guidelines.

• Once diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children do not have toileting accidents.

• Once stool frequency is no more than 2 stools above normal for that child during the time the child is in the program, even if the stools remain loose.

• A child who has had diarrhea may establish a new normal pattern that may include more frequent stools for a period after the child has recovered from diarrhea and seems otherwise well.

• When exclusion criteria are resolved, the child is able to participate, and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group.