Daycare: Impact and Implications for Our Patients and Families DONNA G. GRIGSBY, M. D. ASSOCIATE PROFESSOR OF PEDIATRICS KENTUCKY CHILDREN S HOSPITAL

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1 Daycare: Impact and Implications for Our Patients and Families DONNA G. GRIGSBY, M. D. ASSOCIATE PROFESSOR OF PEDIATRICS KENTUCKY CHILDREN S HOSPITAL

2 Background At present, 60% to 70% of children younger than 6 years regularly attend some type of out-of-home of child care or early childhood program. The arrangements families make for their children can vary dramatically, including care by relatives; centerbased care, including preschool early education programs; family child care provided in the caregiver s home; and care provided in the child s home by nannies or babysitters. How a family chooses this care is influenced by family values, affordability, and availability. For many families, high-quality child care is not affordable, which results in compromises.

3 Indicators of High Quality in a Child Care Center State licensing and program accreditation The requirements for licensing generally ensure basic health and safety of a program but not necessarily high quality; state licensing requirements can be found online at Staff-to-child ratio and group size For centers Birth to 12 mo 1:3 with groups mo 1:4 with groups mo 1:5 with groups 10 3 y 1:7 with groups 14 4 and 5 y 1:8 with groups 16 Family child care If there are no children <2 y: 1 adult/6 children; when there is 1 child <2 y: 1 adult/4 children; and when there are 2 children <2 y (the maximum), no other children are recommended d

4 Indicators of High Quality in a Child Care Center Director and staff experience and training Infection Control College degrees in early childhood education Child development associate s s credential Ongoing inservice training Parent s first-hand observations of care Low turnover rate Hand-washing with soap and running water after diapering, before handling food, and when contaminated by body fluids Children wash hands after toileting and before eating Routinely cleaned facilities, toys, equipment Up-to-date immunizations of staff and children

5 Indicators of High Quality in a Child Care Center Emergency procedures Written policies All staff and children familiar with procedures Up-to-date parent contact lists Injury yprevention Play equipment safe, including gproper p shock-absorbing materials under climbing toys Universal Back-to-Sleep practices Developmentally appropriate toys and equipment Toxins out of reach Safe administration of medicines

6 Injuries in the Child Care Setting Boys slightly more likely overall than girls to have injuries Probably related to behavioral differences in boys and girls. Boys more aggressive and higher activity level Incidence of moderate to severe injuries significantly higher in boys Younger children ( years) higher mean and median rate of injury compared to older children(3.6-6 years)

7 Characteristics of injuries Smaller centers had higher mean and median injuries rates compared with larger centers Of all injuries, 87% were minor, 12% moderate, only 1% were severe Minor injuries- scrapes or superficial cuts 36.5%, bumps or bruises 34.5% Moderate to severe injuries-deep cuts 5.8%, crush injuries 2.8%, multiple cuts 0.3%, burns 0.4%, chipped teeth 0.4%

8 Characteristics of injuries Body parts injured Face, eyes, nose, mouth 31% Head or neck 17% Arms, hands or shoulders 27% Location where injury occurs Playground 74% Classroom 17% Field trips 4% Entry Hall 3% Bathroom 1%

9 Characteristics of Injuries 81% of injuries occur during free play 11% transition times Peak time of day- 11 am to 12

10 Characteristics of Injuries Child factors alone (falls, another child)- 58.9% Environmental factors- 1.8% Both- 39.3% 3 Types of contributing factors For minor injuries- child only For moderate to severe- child only or combination of child factor and environmental

11 Infections in Day Care Attendees Increased rate of infectious diseases Increased rate of acquiring antimicrobial resistant organisms Centers with infants and toddlers have higher risk because of diapering and need for assistance with toileting, ti oral contact t with the environment, poor control over their secretions and excretions, have immunity to fewer common pathogens. These centers should emphasize infection-control measures.

12 Prevention and Control of Infection Caregiver s practice of personal hygiene and immunization status Environmental sanitation Food dhandling procedures Ages and immunization status of children Ratio of children to caregivers Physical space and quality of facilities Frequency of use of antibiotics in children in child care Adherence to standard precautions for infection control

13 Management and Prevention of Illness Risk of introducing and agent into a child care group is related directly to the prevalence of that agent in the population and to the number of susceptible children in that t group Transmission of an agent within a group depends on the following: Characteristics of the organism Mode of spread, infective dose, survival in the environment Frequency of asymptomatic infection or carrier state Immunity to the pathogen

14 Management and Prevention of Illness Children infected in a child care environment can transmit organisms within the group and within their households and the community Appropriate hand hygiene is the most important factor for decreasing transmission of disease in a child care setting

15 Management of ill or infected children in child care and for reducing transmission of pathogens: Antimicrobial i treatment t t or prophylaxis when appropriate Immunization when appropriate Exclusion of ill or infected children from facility Provision of alternative care at a separate site Cohorting to provide care Limiting new admissions Closing the facility( rarely used)

16 Infection-control procedures Periodic review of center-maintained child and employee health records, including immunization records Hygienic and sanitary procedures for toilet use, toilet training i and diaper changing Review and reinforcement of hand hygiene Environmental sanitation Personal hygiene for children and staff Sanitary preparation and handling of food Communicable disease surveillance and reporting Appropriate p handling of pets

17 Recommendations for Inclusion or Exclusion Most children will not need to be excluded from their regular care for mild respiratory illnesses because transmission likely occurred before symptoms developed. d Exclusion of sick children and adults is recommended when exclusion could decrease likelihood of secondary cases.

18 Illnesses that do not constitute a reason to exclude a child from child care Non-pustular rash without fever or behavioral change Parvovirus B19 in an immunocompetent host Cytomegalovirus infection Chronic Hepatitis B virus infection* Conjunctivitis without fever and without behavioral change. (unless, if 2 or more children are infected) Human Immunodeficiency virus infection* Known MRSA carriers or children with colonization of MRSA but without an illness that would require exclusion

19 Epidemiology and Control Enteric Infections Enteric pathogens transmitted by the person-toperson route have been principle organisms implicated in outbreaks Rotaviruses, enteric adenoviruses, astroviruses, norviruses, Hepatits A virus, Shigella species, E. coli O157:H7, Giardia intestinalis, Cryptosporidium species Salmonella species, Clostridium difficile, and Campylobacter species have infrequently associated with outbreaks in child care centers.

20 Epidemiology and Control Enteric Infections Human-animal contact t involving i family and classroom pets, animal displays and petting zoos children to pathogens harbored by these animals Reptiles and many rodents are colonized with Salmonella organisms and lymphocytic choriomeningitis virus(lcmv)(usually in wild mice not in pet rodents)

21 LCMV Some people infected with LCMV do not become ill. For infected persons who do become ill, onset of symptoms usually occurs 8-13 days after being exposed to the virus. A characteristic biphasic febrile illness then follows. The initial phase, which may last as long as a week, typically begins with any or all of the following symptoms: fever, malaise, lack of appetite, muscle aches, headache, nausea, and vomiting. Other symptoms that appear less frequently include sore throat, cough, joint pain, chest pain, testicular pain, and parotid (salivary gland) pain. Following a few days of recovery, the second phase of the disease occurs, consisting of symptoms of meningitis (for example, fever, headache, and a stiff neck) or characteristics of encephalitis (for example, drowsiness, confusion, sensory disturbances, and/or motor abnormalities, such as paralysis). LCMV has also been known to cause acute hydrocephalus (increased fluid on the brain), which often requires surgical shunting to relieve increased intracranial pressure. In rare instances, infection results in myelitis (inflammation of the spinal cord) and presents with symptoms such as muscle weakness, paralysis, or changes in body sensation. An association between LCMV infection and myocarditis (inflammation at of the heart muscles) has been suggested.

22 Epidemiology and Control Enteric Infections Young children who are not toilet trained have increased frequency of diarrhea and HAV infection. Highest risk in infants and toddlers, particularly those partially toilet trained. Before e routine immunizations of month-olds olds with HAV, child care programs were a source of HAV spread in the community. Children usually asymptomatic, and symptomatic illness occurred in adult contacts of infected children. Immunization should be considered for staff in centers with ongoing or recurrent outbreaks. Enteropathogens are spread by the fecal-oral route, either person-to-person, or indirectly by fomites, environmental surfaces, and food. Risk increased when staff who assist with diaper changes and toileting also serve or prepare food. Several enteric pathogens survive on environmental surfaces for hours to weeks Rotaviruses, HAV, G intestinalis cysts and Cryptosporidium oocysts

23 Infectious Diseases- Epidemiology and Control Respiratory Tract Diseases Organisms spread by respiratory route include organisms causing upper respiratory tract infections, RSV, parainfluenza virus, influenza, human metapneumonvirus, adenovirus and rhinovirus Or bacterial organisms associated with serious infections, Haemphilus influenza type b, Streptococcus pneumoniae, Neisseria meningitidis, Bordetella pertussis, Mycobacterium tuberculosis, and Kingella kingae Modes of spread include aerosols, respiratory droplets, direct hand contact with contaminated secretions and fomites.

24 Epidemiology and Control Respiratory Tract Diseases HIB- may occur in unimmunized children under 2. Rifampin prophylaxis is indicated for all nonpregnant contacts in outbreaks of invasive disease. N meningitidis highest incidence in children under 1 year of age. Chemoprophylaxis hl is indicated td fro exposed child care contacts t Risk of primary invasive disease secondary to S. pneumoniae is increased in children in child care settings. Secondary spread has occurred but chemoprophylaxis is not indicated. Group A streptococcal infection outbreaks have occurred. Infected child should be excluded until on antimicrobial therapy for 24 hours. Chemoprophylaxis is not recommended.

25 Epidemiology and Control Respiratory Tract Diseases Children with tuberculosis disease are not as contagious as adults (less likely to have cavitary lesions and unable to expel large numbers of organisms into the air forcefully) They may attend group child care if approved by health officials and if: All caregivers should have TST prior to initiating caregiving activities. If a caregiver has TB disease, they must be excluded from the center until chemotherapy has rendered them noninfectious.

26 Other Infectious Conditions Parvovirus B19 Isolation or exclusion of immunocompetent people with parvovirus B19 is not warranted because little or no virus is present in the respiratory secretions at the time of occurrence of the rash. Also, fewer than 1% of pregnant teachers during an outbreak would have an adverse fetal outcome, so exclusion of a pregnant women from employment in child care or teaching is not warranted

27 Other Infectious Conditions Varicella-Zoster Children with varicella may return after all lesions have dried d and crusted, usually about the sixth day after onset of rash. All staff and families should be notified when a case occurs. Susceptible adults should be offered two doses of varicella vaccine unless contraindicated Susceptible adults and pregnant women should be notified of the risk of infection AAP and CDC recommends use of varicella vaccine in nonpregnant, immunocompetent susceptible people 12 months or older within hours post exposure. If they have only had 1 dose, they should receive a second dose if an appropriate interval has passed( 3 months for children 12months-12 years, 1 month for people 13 years and older) Staff or children with shingles that can be covered may stay in childcare.

28 Other Infectious Conditions Herpes Simplex Children with HSV gingivostomatitis who do not have control of oral secretions should be excluded from child care when active lesions are present Exposure of a pregnant woman to HSV in a child care setting carries little risk for her fetus Hand hygiene important in limiting transfer of infected material( saliva, tissue fluid, fluid from skin lesion)

29 Other Infectious Conditions CMV Spread of CMV from asymptomatic infected children in child care to their mothers or to child care providers is the most important consequence of child-care care related CMV infection. Children in child care more likely to acquire CMV infection than those cared for at home. Highest rates of shedding(70%) in oral secretions or urine in children 1-3 years and excretion occurs for years. Rates of CMV annualized seroconversion among child care providers is 8-20%. ( seroconversion rates in health care workers is about 2% annually).

30 Bloodborne Virus Infections HIV, Hepatitis B virus and Hepatitis C are all blood borne pathogens. Risk of contact with one of these in a child care settings is very low, but infection-control practices will prevent transmission i if exposure occurs. Transmission risks of Hepatitis C in child care settings is unknown.

31 Bloodborne Virus Infections Hepatitis B Virus Transmission in a child care center has been described but is rare Children who are HBV carriers may attend day care because of the low risk of transmission, high rates of HBV immunization, and implementation of infection-control practices Transmission is most likely to occur through direct exposure to blood after injury or from bites or scratches that break the skin and introduce body secretions from an HBV carrier into another person Indirect transmission through environmental contamination with saliva and blood is possible but has not been documented in a day care setting in the US

32 Bloodborne Virus Infections Hepatitis B Virus Risk of transmission from a child or child-care care worker who has chronic HBV infection but behaves normally, and is without injury, generalized dermatitis, or bleeding problem is minimal. Routine screening of children for HBsAg before admission to day care is not necessary. Children with chronic HBV infection should not be routinely excluded unless they have additional risk factors associated with transmission. Children with chronic HBV infection who bite pose an additional concern. There is a small risk of transmission. For a susceptible child who is bitten, HBIG and subsequent doses of HBV vaccine are indicated. If a susceptible child bites a child with chronic HBV infection, HBIG is not warranted, but subsequent doses of HBV vaccine should be given. If the biter has oral mucosal disease, more aggressive prevention should be considered. Efforts to decrease transmission should focus on precautions for blood exposures and limiting possible saliva contamination of the environment.

33 Bloodborne Virus Infections HIV Infection Children should not be routinely screened Children with HIV infection that do not have risk factors for transmission may attend child care. Children who are immunocompromised are at risk for infections and may need post-exposure prophylaxis if exposed to certain infections. Child care workers who have HIV infections may continue to work unless they have open or uncoverable lesions or other conditions that would allow contact with their body fluids. The worker would be at significant risk of exposure to infectious diseases, so their well-being should be considered.

34 Immunizations in Child Care Centers Routine immunizations at appropriate ages is important because of the higher age-specific incidence rates of measles, rubella, HIB, HAV, varicella, pertussis, rotavirus, influenza and S pneumoniae. Children in child care centers have a higher immunization rate than children cared for at home, probably secondary to licensing requirements. Underimmunized or unimmunized children should be allowed to stay in child care until their immunizations can be given unless a vaccine-preventable disease to which they may be susceptible occurs in the child care program. Adult workers should receive immunizations that are routinely recommended for adults, especially influenza, measles, Hepatitis B and varicella. Adult child care workers under 65 should receive their next booster of Td as Tdap (single dose)