Furoxone

A dramatic increase in working mothers and single parents has boosted the number of children enrolled in child care facilities, as well as the illnesses and injuries associated with day care. Today, 7 million children under the age of six are enrolled in day care. Children in day care are 18 times more likely to become ill because of contagious disease and are responsible for many community disease outbreaks. One study showed that at any one time about 16 percent of children who usually attend day care are ill.[1] Of these ill children, 82 percent are still attending day care, and 28 percent of these children are receiving medications. More special-needs children, such as premature infants and children with impairments, are entering community day care programs. Benefits resulting from day care include improved immunization status, parental education about child development and health promotion, and a reduced rate of injury.

Injury and Accidents

Accidents are the leading cause of child hood death and are second to acute illness as reasons for visits to a physician. Children are less likely to be injured in day care facilities than at home. However, many day care programs are still under-prepared to consider and prevent injuries.[2] Toddlers two to three years of age have the highest rate of injury, many of which are self-induced and follow tripping and falling.[3] Many of these accidents are the result of still-developing cognitive and motor skills, curiosity and a high activity level.

About 85 to 99 percent of day care injuries are minor and require only simple first-aid care. Abrasions and contusions are the most common types of day care in jury.[4] The playground is the most common place where injuries occur, with an annual injury rate for all children of 11 to 12 percent.[5] One study found that 25 percent of day care playgrounds are rated as hazardous or very hazardous.[6] Most day care injuries involve head trauma.[3,7] (Table 1). Forty-six percent of injured day care children are bitten by another child.[8]

Adapted from Leland NL, Garrard J, Smith DK. Injuries to preschool-age children in day-care centers. Am J Dis Child 1993;147:826-31.

Three-quarters of injuries related to day care are preventable.[4] Prevention should focus on staff education and on increasing staff numbers during play activities and on the playground. Impact-absorbing surfaces under playground equipment significantly reduces serious injuries (Table 2).

TABLE 2

Injury Reduction Strategies in the Day Care Setting

Apply impact-absorbing material under playground equipment, especially climbing structures

Make high climbing surfaces inaccessible to young children (maximum height of playground equipment should be 165 cm [5.5 ft])

Increase supervision during high-risk activities

Insist that all staff be certified in first aid

Practice fire drills at least once a month

Remove all sharp objects and cleaning supplies from areas accessible to children

Post poisoning instructions and poison-control telephone numbers, and maintain supply of syrup of ipecac

Maintain general repairs, with attention to spring-closing doors and covering electric outlets and sharp corners of furniture

Maintain hot-water temperature at less than 120[degrees]F (48.8[degrees]C)

Apply safety gates for stairs in young-child areas

Avoid using space heaters

Clearly post local ambulance telephone numbers

Document all injuries serious enough to require first aid

File injury reports in a separate log

Infectious Disease

Transmission of infectious disease is enhanced among children in the day care setting for multiple reasons[8,9] (Table 3). Understanding the most common day care-related infectious diseases and their patterns of occurrence is essential to preventing illnesses and developing policies for dealing with ill children (Table 4).[10]

TABLE 3

Reasons for Increased Transmission of Infectious Diseases in Day Care Settings

Children have close physical contact with other children and adults

Children do not know or practice basic hygiene

Adults do not practice careful handwashing techniques

Young children are incontinent of feces

Young children put their hands in their mouths every one to three minutes

Children require frequent hands-on contact from adults

Children have increased susceptibility to a variety of infectious organisms

Highly infectious children may be asymptomatic

Some infections are transmitted before the onset of symptoms

Derived from references 8 and 9.

[TABULAR DATA OMITTED]

RESPIRATORY DISEASE

Acute respiratory infections are by far the most common illnesses experienced by children in the day care setting. In a land mark study, the incidence of respiratory illness among children of preschool age in a day care setting was 6.5 cases per year, with a peak of 10.4 cases per year in the second six months of life.[11] The incidence of disease gradually decreases with age.

Most respiratory infections in day care settings are of viral origin, including respiratory syncytial virus, parainfluenza viruses, adenoviruses, enteroviruses and rhinoviruses. The most common causes of bacterial infections are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, group A Streptococci and Mycoplasma pneumoniae.[11]

While viral isolates were almost invariably associated with active infection, bacterial isolates often were not. The carriage rate for some bacterial isolates was as high as 40 percent. Group A streptococcal infection, once rare in day care centers, now occurs in epidemics and is associated with a significant carrier rate among the noninfected during epidemics.[12] Immunization has reduced the incidence of infection caused by H. influenzae; however, infection caused by Neisseria meningitidis is on the increase.

The incidence of respiratory pathogens is seasonally related in day care settings, as in the general population of children in the community. Recent dusters of infections with invasive S. pneumoniae in day care settings have underscored the need for an effective pneumococcal vaccine in young children.[13]

As opposed to the case with other respiratory illnesses, tuberculosis infection appears to be more closely associated with infected adult caregivers than with fellow children.[14]

Several studies have shown an association between the incidence of otitis media and day care. One study noted differences in tympanograms between three-year-old children cared for at home and those who attended day care facilities: 52 percent of the day care children had normal tympanograms, compared with 74 percent of the home care children.[15]

Children infected with invasive H. influenzae type b and their contacts should receive chemoprophylaxis with rifampin (Rifadin, Rimactane) to eliminate nasopharyngeal carriage. The administration of 20 mg per kg per day for four days has been found to eliminate 95 percent of carriage in contacts of the primary infected person. The dosage for neonates is 10 mg per kg per day for four days.[16] Rifampin chemoprophylaxis is indicated in all close contacts of a child infected with N. meningitidis.

GASTROINTESTINAL ILLNESS

Acute diarrheal diseases are second to respiratory illnesses as the most common group of infections in young children attending day care. Day care center enteric illness is responsible for many community outbreaks. The presence of fecal contamination is directly related to diapering activity and inversely related to the age of the children present. Fecal contamination, through either person-to-person contact, contaminated food or water, or fomites is responsible for diarrheal illness.

Shigellosis has a high rate of infectivity among children in day care centers and their adult contacts.[17] The chronic carrier state is rare. Antimicrobial therapy can decrease the duration of symptoms[18] (Table 5). In day care centers, Salmonella has a higher attack rate for infants less than one year old. An asymptomatic carrier state is possible and can exacerbate an outbreak. Antimicrobial therapy can prolong the carrier state and promote the emergence of resistant strains. Ill children should be isolated until three consecutive stool samples are negative for Salmonella.

Campylobacter is a common cause of gastroenteritis in day care children and adult contacts. An untreated person can be a carrier for about three weeks. The carrier state but not the symptoms, can be shortened with erythromycin (Table 5). Rotavirus and Norwalk-like virus are causes of gastroenteritis in day care settings.[19] Oral hydration therapy is indicated to prevent dehydration (Table 5).

Two parasitic infections commonly found among children in day care centers are giardiasis and Cryptosporidiosis. Giardia lamblia, a flagellate protozoan, may produce an asymptomatic infection. The trophozoite is responsible for symptoms; however, the cyst form is infective. The incubation period is one to four weeks, and the excretion period varies from one to three months. Because Giardia is excreted intermittently, detection should be performed by the Giardia antigen test on several stool samples; three samples increase test sensitivity to 95 percent.[20]

Only symptomatic patients should be treated. Furazolidone (Furoxone) is a less-effective treatment but comes in a liquid suspension that is readily taken by children. Metronidazole (Flagyl) is an alternative drug, but its safety and effectiveness in children have not been established[21](p582) (Table 5).

Cryptosporidiosis is a coccidian protozoan transmitted in day care centers through person-to-person contact and water contamination.[22] Treating water with chlorine or filters does not remove the parasite. The incubation period is five to 10 days. Diagnosis is made by finding oocytes on microscopic examination of the stool. Notification of the laboratory that Cryptosporidium infection is suspected improves detection by less experienced technicians. Treatment of symptomatic patients involves rehydration and correction of electrolyte status (Table 5).

[TABULAR DATA OMITTED]

Diarrheal illness can be significantly decreased through the reduction of microbes of fecal origin on the hands of children and staff members, and environmental surfaces.[23] Strictly enforced hand-washing procedures, especially when hands are soiled, after toileting and before food preparation, can reduce diarrheal illnesses by 50 percent in day care centers[24] (Table 6). Alternative child-care arrangements should be made for children with diarrhea that is not contained by diapers or toilet use, or whose stools contain blood or mucus. Similarly, children who have had two or more episodes of vomiting in the previous 24 hours should be excluded from day care centers.

Strategies for Reducing Diarrheal Illness in Day Care Centers

Segregating infants, toddlers and older children to reduce fecal-oral contamination

Reduce child group size

Food is not prepared by staff who provide diapering service

Posting and stressing hand-washing procedures

Separating toileting and diaper-changing areas from food-preparation areas

Avoiding toileting and diaper changing in proximity to food preparation

Providing toilet areas with adjacent sinks, foot-controlled soap dispensers and disposable towels

Removing children's soiled clothes, storing them in plastic bags and sending them home with the child to be cleaned

Cleaning frequently used objects such as toys with disinfectant after use and at least daily

Cleaning diaper-changing areas with disinfectant after use

Cleaning and disinfecting bedding weekly, removing and sanitizing wet or soiled linens and blankets

No new children should be enrolled in the facility during an outbreak of illness. Stool cultures for detection of bacterial pathogens and parasitic ova should be performed when two or more persons are symptomatic. Physicians should report diarrheal outbreaks to the local health agency when there are three or more cases of illness in a single center.

DERMATOLOGIC ILLNESS

Head lice, or Pediculosis capitis, is endemic ic in day care settings. This infection is spread through casual contact with clothing, bedding and hairbrushes, or through direct contact. Secondary impetigo may afflict skin that is excoriated through scratching. The head of a scratching child should be examined at the nape of the neck for nits. Treatment with 1 percent permethrin cream rinse (Nix) with retreatment in one week (if necessary) is curative. Eyelid infestation should be treated with petroleum jelly applied twice daily for eight days. An alternative eyelid treatment, if needed, is topical crotamiton (Eurax). A nit comb removes nits from the hair shafts. Bedding and clothing should be laundered. The child can return to day care after the initial treatment.

Scabies is transmitted through direct contact between children and staff members. The infestation results in highly pruritic papules and burrows on flexural surfaces two to four weeks after initial contact. In infants and small children, the rash may be found anywhere on the body, including the head, finger webs, axilla, diaper area, palms and soles. Mite parts, feces and eggs can be identified by low-power microscopic visualization of a skin scraping with mineral oil. Although lindane 1 percent cream and lotion (Kwell) have been used extensively in the past, concerns about safety and parasite resistance have led to the use of permethrin 5 percent cream (Elimite). The latter preparation should be applied to the entire body of the infected child and all contacts, and washed off in eight to 14 hours. The child may return to day care 24 hours after treatment. The scabies mite can survive up to two days in clothing and bedding, which should be laundered.[25]

Impetigo, the most common skin infection in children, is also spread by direct contact. Group A Streptococcus is the predominant agent; however, Staphylococcus aureus can also be responsible. Treatment with mupirocin (Bactroban) 2 percent ointment, applied topically to lesions three times daily for five to 10 days, is standard but expensive. For extensive lesions or systemic infection, oral antibiotic therapy is indicated. At times, a single injection of benzathine penicillin is curative. Although erythromycin is inexpensive, emerging resistance to S. aureus may limit its usefulness. Cefadroxil (Duricef), with the advantage of twice-daily dosing, or cephalexin (Keflex) are good choices for treatment. Gentle debridement with warm soap and water also speeds recovery. The child is typically not contagious after 48 hours of treatment.

Tinea capitis and tinea corpora are common superficial fungal infections found among day care children. The presence of these infections should not exclude the child. from day care participation; however, direct lesion contact and the sharing of fomites such as combs should be avoided, periodic inspections for new lesions should be performed, and immediate treatment should be initiated. Tinea capitis can be treated with oral griseofulvin (Fulvicin, Grifulvin, Grisactin), 10 to 20 mg per kg per day in two divided doses for four to six weeks. Tinea corpora can be treated with topical antifungals, such as miconazole (Micatin, Monistat-Derm), clotrimazole (Lotrimin, Mycelex) or ketoconazole (Nizoral) for four weeks.

OTHER VIRAL DISEASES

Varicella (chickenpox) infection is common in day care children. The characteristic rash appears over two to five days, approximately two to three weeks after exposure. The rash progresses from maculopapular to vesicles to crusting. Children with varicella should be excluded from day care for a least six days after initial onset or until all lesions have dried and crusted.

Treatment consists of acetaminophen (Tylenol) for fever and pain, and antihistamines for itching. Acyclovir (Zovirax) should be considered in severe cases, especially when the child is immunocompromised.

The varicella vaccine, now approved in the United Sates, is recommended as part of routine childhood immunization.[26] Vaccination helps prevent cases of chickenpox, and the vaccinated child who develops varicella may have less severe disease. Some concern remains regarding long-term efficacy and unforeseen morbidity in young and middle-aged adults.[27]

The rate of cytomegalovirus (CMV) infection is two to three times greater in children attending day care than among those cared for at home.[28] The virus is spread through direct contact and secretions on fomites. Only 5 percent of those infected have symptoms; these include a mononucleosis-type illness, prolonged fever and hepatosplenomegaly. CMV is, however, the leading cause of congenital infection worldwide.

Approximately 10 percent of infants infected in utero with CMV have significant complications. Thus, the risk that a seronegative mother working in a day care setting will contract CMV is high, and women should be counseled about the risk.[29] Routine screening with viral titer determination and cultures of excretions are not helpful. Following universal precautions for the handling of body fluids is the best prevention. Teachers, staff and parents should be informed about outbreaks of CMV.

Hepatitis A is a common problem in day care, with 40 percent of community outbreaks being traced to a day care setting. Outbreaks occur in 50 percent of centers that enroll children under the age of two. In most cases, young children are asymptomatic or have very mild symptoms. Outbreaks are usually recognized when illness appears in adult workers and contacts.

Hepatitis A is transmitted through the oral-fecal route and has a 28-day incubation period. Treatment is supportive, and the recently approved hepatitis A vaccine (inactivated) is used to prevent and lessen severity of illness. The inactivated vaccine is best suited for preexposure prophylaxis; however, it may be given postexposure for additional protection. The infected child should be excluded from day care until one week after the onset of illness or jaundice, or until immune globulin has been administered to appropriate children and staff in the facility.

Hepatitis B infection is less documented, and infected children are often asymptomatic.[30] Children who are hepatitis B carriers and have aggressive biting behavior or open wounds, or who are not toilet trained, should possibly attend a more restricted environment or be excluded from day care. All day care workers and children attending day care centers should be immunized for hepatitis B.

Following universal precautions for the handling of excreta is mandatory and helps prevent the spread of serious infections such as hepatitis A and hepatitis B, human immunodeficiency virus (HIV) and CMV Contaminated surfaces at the day care center should be cleaned immediately with an appropriate disinfectant or with a 1:64 dilution of freshly prepared household bleach (one-fourth cup [2 oz] of bleach per gallon of water).

All cases of measles, hepatitis A and hepatitis B should be reported. Early identification of hepatitis A is important so that immune globulin can be administered to all contacts.

The number of HIV-infected children is increasing. Two areas of concern surround HIV-infected children in the day care setting: first, risks to the HIV-infected child from other children who may be carrying a pathogen potentially deadly in HIV-infected children, and second, the risk of HIV transmission from the HIV-infected child to other children and day care providers.

The current recommendations of the American Academy of Pediatrics (AAP) state that HIV-infected children may attend day care based on the decision of qualified persons, including the child's physician. Consideration of admission should be based on such questions as whether the child will receive optimal care in the setting being considered, the immune status of the HIV-positive child, the relative risk of acquisition of a life-threatening infection in the HIV-positive child, and whether the infected child poses a risk to others through aggressive behavior, open skin wounds, lack of control of body fluids or biting behavior.[21 (pp87-9),30,31]

Physician's Role

The family physician can play an important role in the health care of children in day care settings by assisting in the development of surveillance, sick-child and outbreak-reporting policies (Table 7). Day care staff often have minimal training in pediatric health care and can benefit from the provision of in-service training. Some day care centers offer screening physical examinations, and most require an up-to-date vaccination status. Developing mechanisms of disease surveillance and reporting to parents and public health officials are essential elements in reducing infectious outbreaks.

TABLE 7

Role of the Family Physician in the Day Care Setting

Improving staff and parent education and communication

In-service training and educational programs

Safety, first aid, medication administration, nutrition, hygiene, and identifying abuse, neglect and substance abuse in families

Guidelines for reporting illness and injury

Notifying public officials of outbreaks and reportable illnesses

Health promotion and disease prevention

Skin cancer prevention

Dental hygiene programs

Assurance of vaccination status

Screening physical examinations

Disease surveillance

Policy formation

Exclusion policy for sick children

"Sick care" programs

Medication administration

Outbreak control policies and protocol

A policy that excludes children with diarrheal illness and dermatologic infections is important, the lines are less clearly defined for the exclusion of children with respiratory illnesses. An innovative approach to sick children is the provision of "get well" rooms, where infectious children can be isolated from healthy children. The physician should be familiar with current guidelines for the control and prevention of infectious diseases and injuries in child day care centers, such as those issued by the AAP.[32] Infectious disease prevention efforts have focused on immunizing children and adults, screening day care workers for communicable disease and instituting good hygiene practices within the day care center.

A patient information handout on choosing a good day care center is provided on page 1267.

The Authors

CYNTHIA G. OLSEN, M.D. is associate professor and executive vice chair of the Department of Family Medicine at Wright State University School of Medicine, Dayton, Ohio, where she graduated from medical school. She completed a family practice residency at Good Samaritan Hospital, also in Dayton. Dr. Olsen completed an Executive Leadership in Academic Medicine Fellowship at the Medical College of Pennsylvania and Hahnemann University School of Medicine, both in Philadelphia.

CARMEN P. WONG, M.D. is an assistant professor in the Department of Family Medicine at Wright State University School of Medicine. She graduated from the University of Texas Medical School at Houston and completed a family practice residency at the Central Texas Medical Foundation, Austin. She completed a fellowship in family medicine through Wright State University School of Medicine at the Faculty Development Center in Waco, Tex.

RICHARD E. GORDON, M.D. is assistant professor in the Department of Family Medicine at Wright State University School of Medicine and medical director for the Yellow Springs (Ohio) Family Health Center and the student health clinics for Wright State University in Dayton and Antioch College in Yellow Springs. He graduated from the Medical College of Ohio, Toledo, and completed a family practice residency through Wright State University School of Medicine at the Yellow Springs Family Health Center.

DAVID J. HARPER, M.D. is a clinical assistant professor in the Department of Family Medicine at Wright State University School of Medicine and has a private practice. He graduated from the University of Cincinnati (Ohio) College of Medicine and completed a family practice residency at the Miami Valley Hospital in Dayton.

PHILIP S. WHITECAR, M.D. is an assistant professor in the Department of Family Medicine at Wright State University School of Medicine. He is also medical director for the family practice module of the Frederick A. White Ambulatory Health Center, Dayton. He graduated from the University of Illinois College of Medicine, Chicago, and completed a residency in family medicine at the University of Missouri-Columbia School of Medicine.

Address correspondence to Cynthia G. Olsen, M.D., Wright State University School of Medicine, Dept. of Family Medicine, 627 Edwin C. Moses Blvd., Dayton, OH 45408.

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[2.] O'Connor MA, Boyle WE Jr, O'Connor GT, Letellier R. Self-reported safety practices in child care facilities. Am J Prev Med 1992;8:14-8.

[3.] Elardo R, Solomons HC, Snider BC. An analysis of accidents at a day care center. Am J Orthopsychiatry 1987;57:60-5.

[4.] Landman PF, Landman GB. Accidental injuries in children in day-care centers. Am J Dis Child 1987;141:292-3.

[5.] Chang A, Lugg MM, Nebedum A. Injuries among preschool children enrolled in day-care centers. Pediatrics 1989;83:272-7.

[6.] Sacks JJ, Brantley MD, Holmgreen P, Rochat RW. Evaluation of an intervention to reduce playground hazards in Atlanta child-care centers. Am J Public Health 1992;82:429-31.

[7.] Leland NL, Garrard J, Smith DK. Injuries to preschool-age children in day-care centers. Am J Dis Child 1993;147:826-31.

[8.] Thacker SB, Addiss DC, Goodman RA, Holloway BR, Spencer HC. Infectious diseases and injuries in child day care. Opportunities for healthier children. JAMA 1992;268:1720-6.

[9.] Ford-James EL, Kim MH, Yaffe BA, Ford-Jones AE, Abelson WH, Issenman RM, et al. Infectious diseses in day-care centers: minimizing the risk. Can Med Assoc J 1987;137:105-7.

[10.] Pickering LK. Infections in day care. Pediatr Infect Dis J 1987;6:614-7.

[11.] Denny FW, Collier AM, Henderson FW. Acute respiratory infections in day care. Rev Infect Dis 1986;8:527-32.

[12.] Falck G, Kjellander J. Outbreak of group A streptococcal infection in a day-care center. Pediatr Infect Dis J 1992;11:914-9.

[13.] Cherian T, Steinhoff MC, Harrison LH, Rohn D, McDougal LK, Dick J. A cluster of invasive pneumococcal disease in young children in child care. JAMA 1994;271:695-7.

[14.] Nolan CM, Barr H, Elarth AM, Boase J. Tuberculosis in a day-care home. Pediatrics 1987;79:630-2.

[15.] Henderson FW, Giebink GS. Otitis media among children in day care: epidemiology and pathogenesis. Rev Infect Dis 1986;8:533-8.

[16.] Carson DS. Infectious diseases in day-care centers: transmission and approaches to prevention. Drug Intell Clin Pharm 1987;21:694-701.

[17.] Laborde DJ, Weigle KA, Weber DJ, Kotch JB. Effect of fecal contamination on diarrheal illness rates in day-care centers. Am J Epidemiol 1993; 138:243-55.

[18.] Shigellosis in child day care centers - Lexington-Fayette County, Kentucky, 1991. MMWR Morb Mortal Weekly Rep 1992;41:440-2.

[19.] Butz AM, Fosarelli P, Dick J, Cusack T, Yolken R. Prevalence of rotavirus on high-risk fomites in daycare facilities. Pediatrics 1993;92:202-5.

[20.] Steketee RW, Reid S, Cheng T, Stoebig JS, Harrington RG, Davis JP. Recurrent outbreaks of giar-diasis in a child day care center, Wisconsin. Am J Public Health 1989;79:485-90.

[21.] 1994 Red book: report of the Committee on Infectious Diseases. 23rd ed rev. Elk Grove Village, Ill.: American Academy of Pediatrics, 1994.

[22.] Crawford FG, Vermund SH. Parasitic infections in day care centers. Pediatr Infect Dis J 1987;6:744-9.

[23.] Addiss DG, Sacks JJ, Kresnow MJ, O'Neil J, Ryan GW. The compliance of licensed U.S. child care centers with national health and safety performance standards. Am J Public Health 1994;84:1161-4.

[24.] Black RE, Dykes AC, Anderson KE, Wells JG, Sinclair SP, Gary GW Jr, et al. Handwashing to prevent diarrhea in day-care centers. Am J Epidemiol 1981;113:445-51.

[25.] Huse DM, Meissner HC, Lacey MJ, Oster G. Childhood vaccination against chickenpox: an analysis of benefits and costs. J Pediatr 1994;124:869-74.

[26.] Halloran ME, Cochi SL, Lieu TA, Wharton M, Fehrs L. Theoretical epidemiologic and morbidity effects of routine varicella immunization of preschool children in the United States. Am J Epidemiol 1994; 140:81-104.

[27.] Pass RF. Day care centers and transmission of cytomegalovirus: new insight into an old problem. Semin Pediatr Infect Dis 1990;1:245-51.

[28.] Pass RF, Hutto C. Group day care and cytomegaloviral infections of mothers and children. Rev Infect Dis 1986;8:599-605.

[29.] Shapiro ED. Lack of transmission of hepatitis B in a day care center. J Pediatr 1987;110:90-2.

[30.] Tsoukas C, Hadjis T, Shuster J, Theberge L, Feorino P, O'Shaughnessy M. Lack of transmission of HIV through human bites and scratches. J Acquir Immune Defic Syndr 1988;1:505-7.

[31.] Shirley LR, Ross SA. Risk of transmission of human immunodeficiency virus by bite of an infected toddler. J Pediatr 1989;114:425-7.

[32.] Caring for our children: national health and safety performance standards: guidelines for out-of-home child care programs. Washington, D.C.: American Public Health Association, American Academy of Pediatrics, 1992.

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