Child Care

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Chapter 15 Child Care

How Pediatricians Can Support Children and Families

With increasing movement of women into the workplace across the globe, child care is a primary developmental context for millions of young children. Child-care providers play a major role in the day-to-day safety, health, and developmental well-being of young children. Given the large proportion of young children in child-care settings, child-care providers are an important potential ally to parents and pediatricians. The provision of child care is complex, with enormous variation across the globe. Child care is affected by many factors including maternal leave policies. The U.S. federal leave program allows for 12 weeks of unpaid job-protected leave during pregnancy or after childbirth, but companies with <50 employees, part-time employees, and those working in informal labor markets are exempt. By contrast, according to the national leave programs in Norway and Sweden, mothers may receive up to 42 and 52 weeks, respectively, of paid benefits after the birth of an infant. Countries vary in terms of the proportion of children being cared for by the extended family. Pediatricians need to understand how child care is structured and utilized in their country or region to appreciate the challenges parents face in finding and accessing high-quality child care and the challenges child-care providers face in maintaining a physically and developmentally healthy environment.

Provision and Regulation of Child Care in America

Sick Children

When children are ill, they may be excluded from out-of-home arrangements, and settings under state licensure are required to exclude children with certain conditions. Guidelines for health and safety in out-of-home care from the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care offer recommendations regarding the conditions under which sick children should and should not be excluded from group programs (Table 15-1). These include fever, vomiting, and diarrhea, as well as certain parasitic conditions. State laws typically mirror these guidelines but may be stricter in some states. Most families need to make arrangements to keep sick children at home (staying home from work). Alternative care arrangements outside the home for sick children are relatively rare but may include either (1) care in the child’s own center, if it offers special provisions designed for the care of ill children (sometimes called the infirmary model or sick daycare); or (2) care in a center that serves only children with illness or temporary conditions. Although it is important that such arrangements emphasize preventing further spread of disease, one study found no occurrence of additional transmission of communicable disease in children attending a sick center. The impact of group care of ill children on their subsequent health and on the health of their families and community is unknown.

Table 15-1 CONDITIONS THAT DO AND DO NOT REQUIRE EXCLUSION FROM GROUP CHILD CARE SETTINGS

CONDITIONS THAT REQUIRE EXCLUSION COMMENTS
Illness preventing the child from participating comfortably in activities as determined by the child-care provider Providers should specify in their policies, approved by the facilities’ health care consultant, what severity level of illness the facility can manage and how much and what types of illness will be addressed.
Severity level 1 consists of children whose health condition is accompanied by high interest and complete involvement in activity associated with an absence of symptoms of illness (such as children recovering from pinkeye, rash, or chickenpox), but who need further recuperation time.
Severity level 2 encompasses children whose health condition is accompanied by a medium activity level because of symptoms (such as children with low-grade fever, children at the beginning of an illness, and children in the early recovery period of an illness).
Severity level 3 is composed of children whose health condition is accompanied by a low activity level because of symptoms that preclude much involvement.
Illness resulting in a greater need for care than the child-care staff can provide without compromising the health and safety of the other children as determined by the child-care provider  
Fever Accompanied by behavior changes or other signs or symptoms of illness until medical professional evaluation finds the child able to be included at the facility
Symptoms and signs of possibly severe illness including lethargy, uncontrolled coughing, inexplicable irritability or persistent crying, difficult breathing, wheezing, or other unusual signs for the child Until evaluation by a medical professional finds the child able to be included at the facility
Diarrhea Children whose stools remain loose but who, otherwise, seem well and whose stool cultures are negative need not be excluded.
Children with diarrheal illness of infectious origin generally may be allowed to return to child care once the diarrhea resolves, except children with positive cultures for Salmonella typhi (3 negative stool cultures required for inclusion), Shigella, or E. coli 0157:H7 (2 negative stool cultures required for inclusion).
Blood in stool Not explained by dietary change, medication, or hard stools
Vomiting illness 2 or more episodes of vomiting in the previous 24 hr until vomiting resolves or until a health care provider determines that the cause of the vomiting is not contagious and the child is not in danger of dehydration
Abdominal pain Persistent (continues more than 2 hr) or intermittent associated with fever or other signs or symptoms
Mouth sores with drooling Unless a health care professional or health department official determines that the child is noninfectious
Rash with fever or behavior changes Until a physician determines that these symptoms do not indicate a communicable disease
Purulent conjunctivitis Defined as pink or red conjunctiva with white or yellow eye discharge, until after treatment has been initiated
Pediculosis (head lice) Exclusion at the end of the day is appropriate
Scabies Until after treatment has been completed
Tuberculosis Until a health care provider or health official states that the child is on appropriate therapy and can attend child care
Impetigo Until 24 hr after treatment has been initiated
Strep throat Or other streptococcal infection until 24 hours after initial antibiotic treatment and cessation of fever
Varicella-zoster (chickenpox) Until all sores have dried and crusted (usually 6 days)
Pertussis Until 5 days of appropriate antibiotic treatment (currently erythromycin, which is given for 14 consecutive days) has been completed
Mumps Until 9 days after onset of parotid gland swelling
Hepatitis A virus Until 1 wk after onset of illness, jaundice, or as directed by the health department when passive immunoprophylaxis (currently, immune serum globulin) has been administered to appropriate children and staff members
Measles Until 4 days after onset of rash
Rubella Until 6 days after onset of rash
Unspecified respiratory tract illness  
Shingles (herpes zoster)  
Herpes simplex  
CONDITIONS THAT DO NOT REQUIRE EXCLUSION COMMENTS
Presence of bacteria or viruses in urine or feces in the absence of illness symptoms, like diarrhea Exceptions include children infected with highly contagious organisms capable of causing serious illness
Nonpurulent conjunctivitis Pink conjunctiva with a clear, watery eye discharge and without fever, eye pain, or eyelid redness
Rash without fever and without behavioral changes  
CMV infection  
Hepatitis B virus carrier state Provided that children who carry HBV chronically have no behavioral or medical risk factors, such as unusually aggressive behavior (biting, frequent scratching), generalized dermatitis, or bleeding problems
HIV infection Provided that the health, neurologic development, behavior, and immune status of an HIV-infected child are appropriate as determined on a case-by-case basis by qualified health professionals, including the child’s health care provider, who are able to evaluate whether the child will receive optimal care in the specific facility being considered and whether that child poses a potential threat to others
Parvovirus B19 infection In a person with a normal immune system

Adapted from American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care: Caring for our children: national health and safety performance standards: guidelines for out-of-home child care,

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