Day Care, Day Care: Mayday! Mayday!
Trudy Murphy, MD, our Guest Editor for this issue of Pediatrie Annals, has brought together a group of experts on the topic of infection related to day-care attendance. These experts tell us about a variety of infections for which infants and children are at increased risk of contracting compared with the risk they would run if they stayed home. These include viral and bacterial respiratory infections, otitis media, enteric infections, and hepatitis.
Cytomegalovirus and parvovirus B19 are among these day-care-acquired infections that place not only the children attending these centers at risk for illness, but also their pregnant mothers and their pregnant day-care providers at risk for disastrous fetal infections and for stillbirths. These are but a few of the pathogens transmitted in day-care centers (Table).
It is not surprising that these infections are transmitted more readily within day-care centers. After all, when iniants and children under the age of 6 who often have not been exposed to the listed pathogens are placed where they come in close contact with each other directly through play and indirectly through their joint caretakers, transmission of infectious diseases is bound to occur rapidly, even under the best hygienic practices.
The high rates at which infections are transmitted are not the only concern we have about day-care centers. This past June, ABC television aired a two-part series on Prime Time live about the generally poor conditions in America's day-care centers. Hidden cameras recorded little or no supervision of infants and children Left all day in centers that had inadequate numbers of caretakers. Infants were left strapped in their car seats or high chairs or remained in cribs most of the day. Older children were allowed to run wild, screaming and hitting each other - overall, out of control. There were no organized activities, and hygienic practices were abominable. Many infants and children were not fed, and some were physically abused. It is difficult to say how prevalent these conditions are among the thousands of day-care centers operating in this country, most of which are certified by state agencies. However, inspection of day-care centers by certifying agencies is infrequent - less so than the inspection of dog kennels, according to ABC.
Day-care centers are supposed to influence a child's development positively, to stimulate and educate rather than merely supervise and control, that is, babysit. The number of centers that provide the care and educational needs children require or what their parents expect is unknown. More than 11 million children under the age of 6 years currently spend all or part of their day in care outside of their home. By the year 2000, 80% of our nations children will have a working mother; most of these children will require some form of day care.1 Lest we seem too critical of day-care centers and those who work within them, we must remember that there are no guidelines, standards, or requirements for training day-care center personnel. Yet they must assume the roles of educator, entertainer, feeder, changer, "cleaner-upper," tearwiper, and hugger for lots of kids all day long. It's not an easy job, and most of the time, it's not their fault that these kids get sick.
How can parents determine whether the day care their child receives will be adequate and safe for health and development? There are several ways:
* The National Child Care Resource and Referral Agency at (507) 287-2220 will provide the names of good day-care centers operating in the parent's community.
Pathogens Transmitted In Day-Care Centers*
* Parents whose children attend the same day-care center can share the responsibility for making daily unannounced visits to the center to check on what is happening.
* Parents should observe their children carefully for changes in behavior (eg, aggressiveness, depression, reluctance to be left at the center or ravenous appetite upon returning home) and for signs of physical abuse (eg, bruises or abrasions) and neglect (eg, diaper rash or a bald spot on the back of the head - evidence of having been left supine all day long).
How can we as physicians improve day care for our patients and other children? First, we can advise parents whose children must be placed in day care to do the things listed above; second, we can become involved with the state agency responsible for licensing day-care centers in our community to be sure that all of them meet the standards set by the American Academy of Pediatrics and the American Public Health Association.2 These two actions will benefit our preschool patients enrolled in day-care centers and their parents as much as almost anything else we can do for them.
1. Donowitz LG. Preface. In: Donowitz LG, ed. infection Control in the Child Core Center and Preschool. Baltimore, Md: Williams and Wilkins; 1991.
2. Giebink GS. National standards for infection control in out-of-home child care. Seminan in Pediatric Infectious Diseases. 1990; 1:184.
Pathogens Transmitted In Day-Care Centers*