Risk of Infectious Diseases in Children Attending Different Types of Day-Care Setting

Abstract

This population-based prospective cohort study compared the risk of recurrent infections in children attending family day care ( < 3 children per family), small (10-20 children) day-care centers (DCCs), and large ( > 40 children) DCCs. The parents of a total of 1,242 children participated in the study (97% of the families initially contacted). An infectious episode was defined as the acute occurrence of a new symptom lasting for at least 48 h and resulting in specific treatment. Two episodes were counted as such only if they were separated by a symptom-free week. Surveillance was under the responsibility of a nursing director and was similar for all three types of DCCs. During the 8.5-month follow-up period, 3,639 infectious episodes were recorded. Compared to those in family day-care, children attending small DCCs presented a higher risk for > 6 total infectious episodes [odds ratio (OR) = 2.4; 95% confidence interval (CI) = 1.6-3.7]; > 5 upper respiratory tract infections (OR = 2.2; 95% CI = 1.4-3.4); > 2episodes of otitis media (OR = 2.6; 95% CI = 1.0-2.6); > 2 episodes of conjunctivitis (OR = 4.1; 95% CI = 2.1-8.2); and > 2 episodes of croup (OR = 4.1; 95% CI = 1.6-10.9). The risk for children attending large DCCs was intermediate between those in family day care and those in small DCCs. Apart from sampling variation, one explanation for this result could be that children in large DCCs are divided into groups according to their age (i.e. < 12,12-24, and > 24 months). It is possible that the homogeneity of age within each group and the absence of direct contact between groups confers some protection against the spread of infections. Children who had been in day care for at least 6 months at the beginning of the study were at a lower risk for recurrent infections than those who had entered day care earlier. This result might be explained by the acquisition of specific immunity as well as by nonspecific immunity that protects against microorganisms not previously encountered by the body. These results suggest that, for children with repeated infections in DCCs, a move to the family day-care setting, when feasible, should be contemplated. It also suggests that the development of family day-care settings should be encouraged. However, the decision of promoting one type of day-care setting rather than another requires further studies focusing on different outcomes such as the long-term health consequences, the psychological development, and also the total economic consequences related to attendance of each type of structure.

Child-care attendance and common morbidity: evidence of association in the literature and questions of design

“…A longitudinal study carried out in France 6 , already discussed in a previous section, found a risk of diarrhea approximately 5 times higher among children attending small child-care centers compared to that of children in child-care homes. The relative risk for children in large child-care centers was about half that for small child-care centers.…”

“…All the studies 6,7,10,19,23,27,33,34 but two 4,12 found an increased risk of URI among children attending childcare centers. Despite the variety of methods used, the relative risks reported did not vary widely, most studies reporting a relative risk below two.…”

“…A third cohort study was carried out in France, by Collet et al 6 , primarily to assess the effect of different types and sizes of child care settings on the occurrence of repeated infections in the children. Differently from other studies, children in child-care homes were used as the comparison group, as the data for home children were not comparable to those for the other groups.…”

“…In relation to children attending child-care homes, however, the results are less clear. From the five studies that reported risks separately for child-care centers and child-care homes 4,6,23,27,33 , three of them found that child-care homes presented an intermediate risk 6,27,33 , between child-care centers and home care, one found similar risks for home care and child-care homes 23 , and one found no association at al 4 . Taken together, these studies suggest that child-care homes offer a lower risk of URI than child-care centers, although stronger evidence of where this risk lies in relation to home care is still lacking.…”

“…The most basic problem relates to the very definition of the exposure. Some studies did not define clearly what attendance at child-care centers or in other settings was, especially in terms of the time spent in child care 4,6,11,27,32 . In the other studies, a variety of definitions was used.…”