Trenace Dorsey-Hollins’ 5-year-old daughter was sick a lot last year. Dorsey-Hollins followed school guidelines and kept her home when she had a cough or a sore throat — or worse — until she was completely better.

Near the end of the year, the school in Fort Worth, Texas, called her in to talk about why her daughter had missed so much school.

During the pandemic, schools urged parents and children to stay home at any sign of illness. Even though the emergency has ended, she said no one has clarified that those rules have changed.

“It’s extremely confusing,” she said.

“In the past, if the child didn’t have a fever over 100, then it’s okay to send them to school,” said the mother of a 5- and 13-year-old. “But now it’s like if they have a cough or they’re sneezing, you might want to keep them home. Which is it?”

Widely varying guidance on when to keep children home has only added to the confusion, which many see as a factor in the nationwide epidemic of chronic school absences. Some advocates and school systems — and the state of California — are now encouraging kids to come to class even when they have the sniffles or other nuisance illnesses like lice or pinkeye.

Families need to hear they no longer must keep kids home at any sign of illness, said Hedy Chang, the executive director of Attendance Works. The national nonprofit aimed at improving attendance has issued its own guidance, urging parents to send kids to school if they can participate in daily activities.

“We have to now re-engage kids and families and change their thinking about that,” Chang said.

The American Academy of Pediatrics recommends staying home when there’s fever, vomiting or diarrhea, or when students “are not well enough to participate in class.”

But many districts go far beyond that, delineating a dizzying array of symptoms they say should rule out attendance. Fort Worth Independent School District, where Dorsey-Hollins’ youngest daughter attends kindergarten, advises staying home if a child has a cough, sore throat or rash. A student should be “fever-free” for 24 hours without medication before returning to school, per district guidelines.

Austin Independent School District in Texas lists “eye redness,” “undetermined rash” or “open, draining lesions” as reasons to stay home. Kids with lice can’t attend class in New York City schools. Maryland’s Montgomery County recommends keeping a child home with a stomachache, “pale or flushed face” or “thick yellow discharge from the nose.”

Finding the right balance is difficult, and it’s understandable that different places would approach it differently, said Claire McCarthy, a pediatrician at Boston Children’s Hospital and professor at Harvard Medical School.

“Each school or school district has a different tolerance for illness,” said McCarthy.

It all leaves many parents feeling puzzled.

“It’s a struggle,” said Malika Elwin, a mother of a second grader on New York’s Long Island.

She doesn’t want to expose other children or burden the teacher with her daughter’s runny nose, so she’s kept her daughter home longer even though she’s feeling better because she still has cold symptoms. “Then I regret that because she just runs around here all day perfectly fine,” she said.

For those who test positive for COVID-19, the CDC still calls for staying home and isolating for at least five days. But guidance from states and individual schools varies widely. In some school systems, guidance allows for students who test positive to go to school as long as they are asymptomatic.

Trenace Dorsey-Hollins said it is hard for parents like her to keep track.

“Is it actually OK to sit in school with a cough if you don’t have a fever and haven’t tested positive for COVID?” she said.

When schools closed during the pandemic, kids fell behind academically — and continued chunks of school absences have made it harder for them to catch up. So some authorities have re-evaluated their tolerance for illness. During the 2021-2022 school year, more than a quarter of students missed at least 10% of the school year, up from 15% before the pandemic.

Missing that much school puts students at risk of not learning to read or graduate. Absent students also lose out on meals, socialization with peers and caring adults, physical exercise, and access to mental health counseling and health care. In other words, missing school has its own health effects.

And when a class sees high levels of chronic absenteeism, it hurts the students who are there because a teacher has to spend time reorienting the students who’ve been away.

The state of California, where 25% of students last year missed 10% of the school year, took a new approach to sick-day guidance this fall. Instead of only saying when a child should stay home, the guidance describes circumstances when a child might be slightly unwell but can come to school.

Overall, students should stay home when their symptoms “prevent them from participating meaningfully in routine activities.” But coming to school with diarrhea is all right as long as a child can make it to the toilet in time. Going to school with mild cold symptoms, sore throat, mild rash or pinkeye are all “OK.”

What’s more, California doesn’t insist on waiting 24 hours after a fever or vomiting before returning to school. Going fever-free or without vomiting overnight is enough.

Boston Public Schools took a similar stance in its online recommendations for parents. “Respiratory infections are common,” reads the online guidance. “If the child does not have fever, does not appear to have decreased activity or other symptoms, it is not necessary for the child to stay home.”

The shift in guidance could have a disproportionate impact on low-income communities and people of color, said Noha Aboelata, who leads the Roots Community Health Center in Oakland, California. People in those communities might be more likely to live in multigenerational homes, take crowded public transportation or have poor ventilation in their homes, she said. When people are out and about while sick, vulnerable loved ones could be put at risk.

She had hoped the pandemic’s lessons about staying home when contagious and taking care of yourself and your family when sick would outlast the public health emergency. Instead, she said, “it feels like the pendulum is swinging fiercely back in the other direction.”

But changing the culture around school absences goes beyond just issuing guidance.

Some schools in San Diego County seem unaware of California’s new guidance allowing kids to attend school while mildly sick, said Tracy Schmidt, who oversees attendance for the county Office of Education.

Still, others have adopted and it and have begun talking through symptoms with parents who call to report their children are sick, urging them to bring them in and see how it goes. It gives her hope that as more schools and parents learn about this guidance, students will miss less school.

“The most important place for our kids to be is school,” she said. “We need to leave behind this mindset that we had to adopt during the pandemic because we were in a public safety emergency.”

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