daycare: impact and implications for our patients and families presentation.pdfoo b op op y occurred...

Daycare: Impact and Implications for Our Patients and Families

D O N N A G G R I G S B Y M D

for Our Patients and Families

D O N N A G . G R I G S B Y , M . D .

A S S O C I A T E P R O F E S S O R O F P E D I A T R I C S

K E N T U C K Y C H I L D R E N ’ S H O S P I T A L

Background

At present, 60% to 70% of children younger than 6 years regularly attend some type of out of home child care or regularly attend some type of out-of-home child care or early childhood program.

The arrangements families make for their children can d ti ll i l di b l ti tvary dramatically, including care by relatives; center-

based 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 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 values, affordability, and availability.

For many families, high-quality child care is not affordable, which results in compromises.

Indicators of High Quality in a Child Care C tCenter

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 http://nrc.uchsc.edu

Staff-to-child ratio and group sizeFor centersBirth to 12 mo 1:3 with groups 6g p13–30 mo 1:4 with groups 831–35 mo 1:5 with groups 103 y 1:7 with groups 144 and 5 y 1:8 with groups 16Family 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 hild d dchildren are recommended

Indicators of High Quality in a Child Care Center

Director and staff experience and training

College degrees in early childhood educationChild development associate’s Child development associate s credentialOngoing inservice trainingParent’s first-hand observations of careL t tLow turnover rate

Infection Control Hand-washing with soap and running water after diapering, before handling food, and when contaminated by body , y yfluidsChildren wash hands after toileting and before eatingRoutinely cleaned facilities toys Routinely cleaned facilities, toys, equipmentUp-to-date immunizations of staff and children

Indicators of High Quality in a Child Care Center

Emergency procedures Written policiesAll t ff d hild f ili ith All staff and children familiar with proceduresUp-to-date parent contact lists

Injury prevention Play equipment safe, including proper j y p y q p , g p pshock-absorbing materials under climbing toysUniversal Back-to-Sleep practicesDevelopmentally appropriate toys and Developmentally appropriate toys and equipmentToxins out of reachSafe administration of medicines

Injuries in the Child Care Setting

Boys slightly more likely overall than girls to have y g y y ginjuries Probably related to behavioral differences in boys and girls.

Boys more aggressive and higher activity levelBoys more aggressive and higher activity level

Incidence of moderate to severe injuries significantly higher in boyshigher in boys

Younger children ( 2-3.5 years) higher mean and median rate of injury compared to older j y pchildren(3.6-6 years)

Characteristics of injuries

Smaller centers had higher mean and median ginjuries 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%, b b i %bumps or bruises 34.5%

Moderate to severe injuries-deep cuts 5.8%, crush injuries 2 8% multiple cuts 0 3% burns 0 4% injuries 2.8%, multiple cuts 0.3%, burns 0.4%, chipped teeth 0.4%

Characteristics of injuries

Body parts injured Face, eyes, nose, mouth 31% Head or neck 17% Arms hands or shoulders 27% Arms, hands or shoulders 27%

Location where injury occurs Playground 74% Classroom 17% Field trips 4% Field trips 4% Entry Hall 3% Bathroom 1%

Characteristics of Injuries

81% of injuries occur during free playj g p y

11% transition times

Peak time of day- 11 am to 12 y

Characteristics of Injuries

Child factors alone (falls, another child)- 58.9%( , ) 5 9

Environmental factors- 1.8%

Both- 39.3%39 3

Types of contributing factors For minor injuries- child only

For moderate to severe- child only or combination of child factor and environmental

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 t il ti l t t ith th i t toileting, oral contact with the environment, poor control over their secretions and excretions, have immunity to fewer common pathogens These immunity to fewer common pathogens. These centers should emphasize infection-control measures.

Prevention and Control of Infection

Caregiver’s practice of personal hygiene and immunization status

Environmental sanitation

d h dl d Food handling procedures

Ages and immunization status of children

R ti f hild t i Ratio of children to caregivers

Physical space and quality of facilities

Frequency of use of antibiotics in children in child care Frequency of use of antibiotics in children in child care

Adherence to standard precautions for infection control

Management and Prevention of Illness

Risk of introducing and agent into a child care group g g g pis related directly to the prevalence of that agent in the population and to the number of susceptible hild i th t children in that group

Transmission of an agent within a group depends on the following: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

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 settingchild care setting

Management of ill or infected children in child care and for reducing transmission of pathogens:

A ti i bi l t t t h l i h Antimicrobial treatment or prophylaxis when appropriate

Immunization when appropriate Immunization when appropriate

Exclusion of ill or infected children from facility

Provision of alternative care at a separate site Provision of alternative care at a separate site

Cohorting to provide care

Limiting new admissions Limiting new admissions

Closing the facility( rarely used)

Infection-control procedures

Periodic review of center-maintained child and employee health records, including immunization records

Hygienic and sanitary procedures for toilet use, toilet t i i d di h itraining and diaper changing

Review and reinforcement of hand hygiene

Environmental sanitation Environmental sanitation

Personal hygiene for children and staff

Sanitary preparation and handling of foodSanitary preparation and handling of food

Communicable disease surveillance and reporting

Appropriate handling of petspp p g p

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 d l ddeveloped.

Exclusion of sick children and adults is recommended when exclusion could decrease recommended when exclusion could decrease likelihood of secondary cases.

Illnesses that do not constitute a reason to 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 Cytomegalovirus infection Chronic Hepatitis B virus infection* Conjunctivitis without fever and without behavioral j

change. (unless, if 2 or more children are infected) Human Immunodeficiency virus infection*

K MRSA i hild ith l i ti f Known MRSA carriers or children with colonization of MRSA but without an illness that would require exclusion

Epidemiology and ControlEnteric Infections

Enteric pathogens transmitted by the person-to-person route have been principle organisms implicated in o tbreaksimplicated in outbreaks Rotaviruses, enteric adenoviruses, astroviruses, norviruses,

Hepatits A virus, Shigella species, E. coli O157:H7, Giardia p g pintestinalis, Cryptosporidium species

Salmonella species, Clostridium difficile, and Campylobacter species have infrequently associated with Campylobacter species have infrequently associated with outbreaks in child care centers.


H i l t t i l i f il d Human-animal contact involving family and classroom pets, animal displays and petting zoos children to pathogens harbored by these animalschildren to pathogens harbored by these animals Reptiles and many rodents are colonized with Salmonella

organisms and lymphocytic choriomeningitisvirus(LCMV)(usually in wild mice not in pet rodents)virus(LCMV)(usually in wild mice not in pet rodents)

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 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 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 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 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 of the heart muscles) has been suggested.( a at o o t e ea t usc es) as bee suggested.


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.

Befo e o tine imm ni ations of 12 23 month olds ith HAV child ca e Before routine immunizations of 12-23 month-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 weeksweeks

Rotaviruses, HAV, G intestinalis cysts and Cryptosporidium oocysts

Infectious Diseases-Epidemiology and ControlEpidemiology and ControlRespiratory Tract Diseases

Organisms spread by respiratory route include organisms causing upper respiratory tract infections,

RSV i fl i i fl h t i 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

d f d l d l d l Modes of spread include aerosols, respiratory droplets, direct hand contact with contaminated secretions and fomites.fomites.

Epidemiology and ControlRespiratory Tract Diseases

HIB- may occur in unimmunized children under 2 Rifampin 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. Ch h l i i i di t d f d hild t tChemoprophylaxis is indicated fro exposed child care contacts

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. o b op op y o

Group A streptococcal infection outbreaks have occurred. Infected child should be excluded until on antimicrobial therapy for 24 hours. Chemoprophylaxis is not recommended.

Epidemiology and ControlRespiratory Tract Diseases

Child ith t b l i di t Children with tuberculosis disease are not as contagious as adults (less likely to have cavitarylesions and unable to expel large numbers of lesions and unable to expel large numbers of organisms into the air forcefully)

They may attend group child care if approved by y y g p pp yhealth 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 noninfectiouschemotherapy has rendered them noninfectious.

Other Infectious Conditions

Parvovirus B199 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 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 outcome, so exclusion of a pregnant women from employment in child care or teaching is not warranted


Varicella-ZosterChild i h i ll f ll l i h d i d d Children with varicella may return after all lesions have dried 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 punless contraindicated

Susceptible adults and pregnant women should be notified of the risk of infection

AAP and CDC recommends use of varicella vaccine in nonpregnant AAP and CDC recommends use of varicella vaccine in nonpregnant, immunocompetent susceptible people 12 months or older within 72-96 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 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.


Herpes Simplexp p Children with HSV gingivostomatitis who do not have control

of oral secretions should be excluded from child care when active lesions are presentactive 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)


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 related CMV infectionimportant consequence of child 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 gproviders is 8-20%. ( seroconversion rates in health care workers is about 2% annually).

Bloodborne Virus Infections

HIV, Hepatitis B virus and Hepatitis C are all blood , p pborne pathogens. Risk of contact with one of these in a child care settings is very low, but infection-control

ti ill t t i i if practices will prevent transmission if exposure occurs. Transmission risks of Hepatitis C in child care settings is unknowncare settings is unknown.


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 y y

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 y g pblood 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


Hepatitis B Virus Risk of transmission from a child or child-care worker who has chronic HBV Risk of transmission from a child or child 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 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 Efforts to decrease transmission should focus on precautions for blood exposures and limiting possible saliva contamination of the environment.


HIV Infection Children should not be routinely screened

Children with HIV infection that do not have risk factors for transmission may attend child care 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 y pconditions 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.diseases, so their well being should be considered.

Immunizations in Child Care Centers

Routine immunizations at appropriate ages is important because of the higher age-specific incidence rates of measles rubella HIB 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

irequirements. 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 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

d i lland varicella. Adult child care workers under 65 should receive their next booster

of Td as Tdap (single dose)

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