Daycare: Impact and Implications for Our Patients and Families for - - PowerPoint PPT Presentation

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 CI A T E P R O F E S S O R O F P E D I A T R I CS K E N T U CK Y CH 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

regularlyattend some type of out of home child care or regularlyattend 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 t vary 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

• r 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 t 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

• nline at http:/ / nrc.uchsc.edu

Staff-to-child ratio and group size For centers Birth to 12 mo 1:3 with groups 6 g p 13–30 mo 1:4 with groups 8 31–35 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 hild d d children are recommended

Indicators of High Quality in a Child Care Center

Director and staff experience and training College degrees in early childhood education Child development associate’s Child development associate s credential Ongoing inservice training Parent’s first-hand observations of care L t t Low turnover rate Infection Control Hand-washing with soap and running water after diapering, before handling food, and when contaminated by body , y y fluids Children wash hands after toileting and before eating Routinely cleaned facilities toys Routinely cleaned facilities, toys, equipment Up-to-date immunizations of staff and children

Indicators of High Quality in a Child Care Center

Emergency procedures Written policies All t ff d hild f ili ith All staff and children familiar with procedures Up-to-date parent contact lists Injury prevention Play equipment safe, including proper j y p y q p , g p p shock-absorbing materials under climbing toys Universal Back-to-Sleep practices Developmentally appropriate toys and Developmentally appropriate toys and equipment Toxins out of reach Safe administration of medicines

Injuries in the Child Care Setting

 Boys slightly more likely overall than girls to have

y g y y g injuries

 Probably related to behavioral differences in boys and girls.

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

 Incidence of moderate to severe injuries significantly

higher in boys higher in boys

 Younger children ( 2-3.5 years) higher mean and

median rate of injury compared to older j y p children(3.6-6 years)

Characteristics of injuries

 Smaller centers had higher mean and median

g 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%,

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 play

j 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

• rganisms

 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 p is 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 setting child 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 i training and diaper changing

 Review and reinforcement of hand hygiene  Environmental sanitation  Environmental sanitation  Personal hygiene for children and staff  Sanitary preparation and handling of food

Sanitary preparation and handling of food

 Communicable disease surveillance and reporting  Appropriate handling of pets

pp 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 d developed.

 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 Control Enteric Infections

 Enteric pathogens transmitted by the person-to-

person route have been principle organisms implicated in o tbreaks implicated in outbreaks

 Rotaviruses, enteric adenoviruses, astroviruses, norviruses,

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

 Salm onella species, Clostridium difficile, and

Cam pylobacter species have infrequently associated with Cam pylobacter species have infrequently associated with

• utbreaks in child care centers.

Epidemiology and Control Enteric Infections

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 animals children to pathogens harbored by these animals

 Reptiles and many rodents are colonized with Salm onella

• rganisms and lymphocytic choriomeningitis

virus(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

• f 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

• f symptoms of meningitis (for example fever headache and a stiff neck) or
• f 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.

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. 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,

• r 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 weeks

 Rotaviruses, HAV, G intestinalis cysts and Cryptosporidium oocysts

Infectious Diseases- Epidemiology and Control Epidemiology and Control Respiratory Tract Diseases

 Organisms spread by respiratory route include

• rganisms 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,

 Haem philus influenza type b, Streptococcus pneum oniae, Neisseria

m eningitidis, 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 Control Respiratory 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

• f invasive disease.

 N m eningitidis –highest incidence in children under 1 year of age.

Ch h l i i i di t d f d hild t t Chemoprophylaxis is indicated fro exposed child care contacts

 Risk of primary invasive disease secondary to S. pneum oniae is

increased in children in child care settings. Secondary spread has

• ccurred but chemoprophylaxis is not indicated.
• b
• p op y
•  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 Control Respiratory Tract Diseases

Child ith t b l i di t

 Children with tuberculosis disease are not as

contagious as adults (less likely to have cavitary lesions and unable to expel large numbers of lesions and unable to expel large numbers of

• rganisms into the air forcefully)

 They may attend group child care if approved by

y y g p pp y 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 chemotherapy has rendered them noninfectious.

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 present in the respiratory secretions at the time of

• ccurrence of the rash. Also, fewer than 1% of pregnant

teachers during an outbreak would have an adverse fetal

• utcome so exclusion of a pregnant women from
• utcome, so exclusion of a pregnant women from

employment in child care or teaching is not warranted

Other Infectious Conditions

 Varicella-Zoster

Child 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 p unless contraindicated

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

• f 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

• lder)

 Staff or children with shingles that can be covered may stay in

childcare.

Other Infectious Conditions

 Herpes Simplex

p p

 Children with HSV gingivostomatitis who do not have control

• f oral secretions should be excluded from child care when

active lesions are present 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)

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 related CMV infection important 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

g providers 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 p borne 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

• ccurs. Transmission risks of Hepatitis C in child

care settings is unknown care settings is unknown.

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

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 p 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

Bloodborne Virus Infections



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

• ral 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.

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 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 p 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. 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 pneum oniae.

 Children in child care centers have a higher immunization rate than

children cared for at home, probably secondary to licensing i 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 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 ll and varicella.

 Adult child care workers under 65 should receive their next booster

• f Td as Tdap (single dose)