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Whoever among us has ever sent a young child with a fever to a day care center or kindergarten - perhaps pre-dosing him or her with paracetamol - please raise your hand... I see a lot of hands out there (including mine).
Of course, a responsible parent wouldn't do this if the kid were miserably sick and had a high fever - at least we hope not. But given the difficulty of leaving work and finding a reliable babysitter at the last minute, many Israeli parents take sick children - even year-old babies - to day care.
Is this wrong or right? The dilemma was the subject of a formal university-style debate organized recently by Dr. Brendon Stewart-Freedman, education director of the post-graduate department of family medicine at The Hebrew University-Hadassah Medical School, and pediatric education coordinator Dr. Florice Levy.
The fourth in a series of debates by the pediatrics and family medicine departments, it followed discussions on whether fevers had to be treated at all, whether babies should automatically get iron supplements and whether a pacifier is recommended.
The latest debate, held at Shacht Hall in Hadassah-University Hospital on Jerusalem's Mount Scopus, pitted two family medicine residents against two pediatrics residents, one of each discipline on each side of the issue - whether or not there is anything wrong with sending a feverish child over the age of one to day care if he feels well.
Stewart-Freedman, who declared that the advocates and opponents did not necessarily believe in what they were saying but were asked to represent their positions as an academic exercise, took a vote before the debate.
Twenty-two of the physicians in the audience (including Prof. Amnon Lahad, head of the medical school's family medicine department and this health reporter) raised their hands in favor, while 31 doctors voted against.
Would the arguments presented in five-minute lectures with PowerPoint presentations change their views?
DR. YOSSI BAHAGON, a family medicine resident, said he looked for medical literature on the issue but didn't find much; there were some anecdotal reports and small studies, but very little that was evidence-based. "Fever in and of itself is not infectious," he noted. "A disease could be infectious even before this symptom presents itself. So keeping feverish children out of a day care center could be ineffective," he suggested, "because they have already spread their viruses or bacteria."
Another argument in favor of allowing young children with a fever into day care is that most infectious diseases strike in the winter. If you allow them to come even with a fever, infections could spread among them during a limited period, and then they would gain some immunity. This would be more convenient than someone else getting sick every week.
Not every fever should be regarded with hysteria, he added. "And then you have to think of the financial costs of working parents - almost always the mother - staying home with such children. US research has found that it can range between $500 and $2,500 a year per child in missed income and hiring babysitters. And women who are repeatedly absent from work are at risk of being dismissed," Bahagon said. "When parents spend time with their kids, it's better when it's quality time, and children are well, than when they are sick."
Taking care of a child in a day care setting is not any worse, in most cases, than a child being "hospitalized" at home, said the Hadassah physician. But not every child with a fever should be allowed to come, Bahagon continued. "It should not be automatic. Maybe the child has something more serious. You have to use a safety net - informing the childcare worker or kindergarten teacher that he has a fever and asking her to watch for unusual behavior. In such a case, the parent should be called and asked to take him home."
DR. DALIT KAYAM-RAND, a Hadassah pediatrics resident, was assigned the opposite view. "Fever is not infectious, but it can be a signal of an infectious disease. If there is respiratory or gastrointestinal infection in a day care setting, studies show that the risk of other children getting infected is twice as high. Fever could be a sign of cytomegalovirus or meningitis, both of which can be dangerous."
She urged prevention of the spread of disease in childcare settings, especially rigorous washing of hands by caregivers after changing diapers and before serving food, and by the children. "Studies have shown that when children in day care do get infected, their condition is more serious than in children who are not in day care, as bacteria can build up resistance in such institutions. And mothers can also get infected with pathogens, such as parvovirus or cytomegalovirus that endanger them if they are pregnant."
Kayam-Rand further argued that kindergarten and nursery teachers and day care workers are usually overworked, and having to supervise toddlers and young children who are ill makes it more difficult for them. "They can't meet the needs of children who have a fever."
DR. YISRAEL KATZ, a family medicine resident assigned to the "in favor" side, also scanned the medical literature and found little that was convincing. "So I called Prof. Yona Amitai, head of the Health Ministry's child, youth and women's health department. He said he was currently working on guidelines on this very issue.
At present, the only official guidelines relate to separating a sick child from his peers until his parents pick him up, and sanitizing toys he has played with." The only other thing Amitai was willing to say for the time being is to "use your judgment."
Katz added that not all childcare institutions scrupulously observe rules about keeping sheets and towels of toddlers separate, but this and handwashing should be rigorously carried out.
When some argue that a day care worker can't cope with sick children, Katz suggested that a new mother who is already at her wits' end keeping the house going on little sleep may be less able to cope with a fever than a professional.
Katz recalled that as a child, he was kept at home for days when he was sick. "In retrospect, I suppose I enjoyed myself, but that isn't enough reason for keeping kids with some fever out of day care if they feel well. If a child acts like a rag doll, apathetic, has a fever over 40 Celsius, is vomiting or nauseous, if he has a rash or eye secretions or is disruptive, obviously the child should not be brought in; if he is already there, he should be taken home immediately," Katz declared.
DR. MICHAEL COHEN, a pediatrics resident assigned to sit on the other side of the fence, presented a hypothetical case of a caregiver with six young children in her care. One boy comes in with a fever, hugs another and gives him cytomegalovirus; the recipient of this pathogen has to stay away for a week. Another child comes with red eyes; a boy he plays with gets a viral eye infection. A third toddler shares her milk bottle with another; the recipient gets hepatitis A and has to stay home for a week. This could easily happen, said Cohen, who advised keeping children with a fever at home.
Cohen added that parents who want to send fevered children to a day care center and go to work might give them antibiotics unnecessarily (in the case of their having a virus rather than bacteria proven to exist in a culture); this overuse of antibiotics, he argued, promotes the growth of bacteria that are resistant to antibacterial drugs.
Asked by this reporter why there was a dearth of solid medical research on the subject, Katz suggested that pharmaceutical companies had no interest in sponsoring such a study because they had nothing to gain from them. In addition, it could be immoral to carry out a prospective study on young children - exposing some to infections in day care and keeping others protected, and retrospective studies produced less-accurate results because there were many other factors that could influence results.
Stewart-Freedman asked the audience, whose number had changed somewhat since the original vote, to raise their hands for and against at the end of the debate. The proportion of votes for each side did not change significantly - 19 in favor and 24 opposed. Views may not have changed as a result of the arguments, but it may have been that a nearly equal number changed their opinion from one side to the other.
Prof. Eitan Kerem, head of the pediatrics department at Hadassah University Medical Center on Mount Scopus, congratulated the debating teams on their work. "This is a relevant issue for us, as we physicians are constantly asked to sign authorizations allowing the return of sick children to school or day care. The subject really is worth studying."
Until then, parents, let your conscience, your judgment and your heart be your guide.