Note to Return to School: Do You Sign It?

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School has been back in session for less than a month, and our office has already had parents come in or call for the “golden ticket” that allows a child to return to school after an illness-the doctor’s note. Often parents want us to write something to the effect that “Johnny is no longer contagious….” Can we ever truly say that about anyone?!

I always refer to the Red Book or other literature from the American Academy of Pediatrics (AAP) for help when addressing such back-to-school questions. An example is the AAP’s recently updated policy statement on head lice, published in last month’s issue of Pediatrics (Frankowski BL et al. Head lice. Pediatrics. 2010;126:392-403). It recommends that healthy children should not miss school because of head lice. My first reaction was “eewwww.” However, after reading the full AAP report, I was much more understanding of the recommendations. (And I probably should not be promoting the “eewwww” factor when it comes to head lice-it doesn’t help with the whole negative social stigma). The section entitled “Control Measures in Schools” contains the most practical information for the clinician. The report indicates that a child with lice is likely to have had the infestation for a month or more before it’s even recognized, and head lice infestations have low contagion in classrooms. For transmission of lice from one student to another, there must be close head-to-head contact. This typically shouldn’t happen in the classroom, but some may argue that it does. Still for the child with lice, scientific reasoning can be provided for writing the doctor’s note; however, a good dose of common sense is also required. For instance, if the child’s head is well-covered with live lice and the child somehow participates in activities that involve head-to-head contact, then he or she should be excluded from those activities until adequately treated.

So, when it comes to signing those coveted doctor’s notes, no matter what the medical situation, we probably have to depend most strongly on our common sense skills. A published guideline won’t be available to help us with every note-seeking situation that we’ll encounter. Although it’s always more effective to have the science and expertise of a large professional organization, such as the AAP, back up our decisions, we often must depend on our own experience. Here’s an example. A pediatric resident asked for my opinion about whether to provide a “golden ticket” to a parent to exonerate the child’s 20 school absences in the last 6 months “for the same asthma problem he always comes to clinic for.” However, the child never made it to clinic for those 20 days, nor did the parent call about those 20 episodes. My advice, to the parent’s dismay, was to vouch for only the phone calls or visits that were documented. How do you handle such a situation? Please share your stories about return-to-school doctor’s notes.