Influenza—Child Care and Schools

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What is influenza?

A contagious disease caused by a group of respiratory viruses called influenza viruses

What are the signs or symptoms?

  • Sudden onset of fever

  • Headache

  • Chills

  • Muscle aches and pains

  • Sore throat

  • Nasal congestion

  • Cough

  • Mild pinkeye (conjunctivitis)

  • Decreased energy

  • Abdominal pain

  • Nausea and vomiting (These symptoms alone or with fever are often caused by other factors, not influenza virus.)

  • Croup (illness with barky cough and hoarseness), bronchiolitis (illness with wheezing and runny nose), or pneumonia

What are the incubation and contagious periods?

  • Incubation period: 1 to 4 days, with a mean of 2 days

  • Contagious period: From the day before signs or symptoms appear until at least 7 days after the onset of flu, although virus shedding can be longer in young children and those with compromised immune systems

How is it spread?

  • Respiratory (droplet) route: Contact with large droplets that form when a child talks, coughs, or sneezes. These droplets can land on or be rubbed into the eyes, nose, or mouth. The droplets do not stay in the air; they usually travel no more than 3 feet and fall onto the ground.

  • Contact with the respiratory secretions from or objects contaminated by children who carry influenza virus.

How do you control it?

  • Annual immunization according to the most recent immunization schedule at www.cdc.gov/vaccines for all people 6 months and older, including all teachers/ caregivers.

  • Use good hand-hygiene technique at all the times listed in Chapter 2.

  • Prevent contact with respiratory secretions. Teach children and teachers/caregivers to cover their noses and mouths when sneezing or coughing with a disposable facial tissue, if possible, or with an upper sleeve or elbow if no facial tissue is available in time. Teach everyone to remove any mucus or debris on skin or other surfaces and perform hand hygiene right after using facial tissues or having contact with mucus to prevent the spread of disease by contaminated hands. Change or cover clothing with mucus on it.

  • Dispose of facial tissues that contain nasal secretions after each use.

  • Perform hand hygiene after contact with any soiled items.

  • Antiviral medications that treat influenza infection are most helpful if given early in the course of illness (first 48 hours).

  • Reduce crowding as much as possible.

What are the roles of the teacher/caregiver and the family?

  • Influenza is a serious disease that can cause complications, like pneumonia. Every year, children (and adults) die from influenza and its complications in the United States. Follow the recommendation to immunize all people 6 months and older.

  • Avoid aspirin use for anyone with influenza. There is an increased risk of Reye syndrome, a serious complication associated with the use of aspirin in someone infected with influenza.

Exclude from group setting?

Yes, if

  • 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) or, during flu season (when influenza is known to be prevalent in the community), the child has fever and behavior change or fever with other signs or symptoms of influenza illness, like cough, sore throat, sneeze, or runny nose.

Readmit to group setting?

Yes, when all the following criteria are met:

When exclusion criteria are resolved, fever has been absent for 24 hours after any fever-reducing medicines have been given, 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


  • Influenza immunization is very important in young children in early education and child care settings for the following reasons:

    • Influenza can be severe in young children and older adults. Hospitalization rates are similar in these 2 groups.

    • Death can occur in previously healthy children after influenza infection.

    • The risk of spread of influenza is very high among young children, and they bring the infection home to their families as well as spread it into the community.

  • Health professionals can use a test to determine whether an ill person has influenza rather than other common viruses that cause respiratory symptoms. However, it is not practical to test all ill children to determine whether they have common cold viruses or influenza infection. Therefore, exclusion decisions are based on the symptoms and behavior of the child.

  • During flu season, a child excluded with fever and respiratory symptoms (cough, runny nose, sneezing) should remain excluded until 24 hours of no fever without use of fever-reducing medications because children shed more of the influenza virus while they have a fever than when they are afebrile.

  • Most children with flu-like symptoms (fever and respiratory symptoms) during flu season do not have influenza. They likely have infections from other viruses.

  • Management strategies (control, exclusion, readmission) may be different and more stringent for pandemic influenza and under the guidance of the local public health authority. See Chapter 7 for a discussion of outbreaks, epidemics, and pandemics.

Adapted from Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide.

Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.