Patient Presentation
A 27-year-old female came to clinic with her husband at 36 weeks gestation for a prenatal appointment. This was their first pregancy and there were no problems to date.
The parents had several questions regarding immunizations, car seats and circumcision. Their biggest concern was appropriate child care when the mother returned to work part-time after the delivery.
The diagnosis of a healthy near-term pregnancy was made. The physician talked about some of the potential options based upon the family’s description of their needs, gave the family a handout which included an information prescription for authoritative information on the Internet about child care options, and gave them the phone number for the local child care resource and referral agency.
After delivery, the family returned for health maintenance visits and reported that the child care resource and referral agency had been very helpful in locating a family-based child care placement for their daughter. Over time, the family continued to be very happy and expressed continued confidence with their daughter’s caregiver.
Discussion
There are 5 steps to choosing quality child care. The steps may seem simple but the decision is a difficult one:
- Starting early – finding the right care takes time
- Researching and calling caregivers
- Contact the experts at the local child care resource and referral center. They can help a parent to learn more about child care options and what may be right for the child and family.
- The resource and referral agency can also provide lists of accredited child care centers, family care caregivers, financial assistance programs, emergency child care options, sick child care options, etc.
- The resource and referral agency can also offer information about accreditation and licensing requirements, where the parent can get information about complaints and/or violations, etc.
- Visiting and asking questions
- The location and the caregivers should be visited and talked with.
- Some key indicators of quality include:
- Adult to child ratios or how many children does each adult take care of. The fewer the children, the better. The younger the child is the fewer number of children an adult should take care of.
For babies it should be no more than 1:4, but for four year olds it can be 1:10. - Group size or how many children are in the group. Again, the smaller the group the better. Compare a group of 10 children with 2 adults, versus 25 children with 5 adults.
- Caregiver qualifications – The parent should inquire about the caregiver’s training and education. What training and classes have they attended or are attending? Do they have first aid and CPR training?
Obviously a caregiver with special training or education for young children will be better able to help the child learn. Ongoing education also helps to support the caregiver and they can receive new information. - Turnover – It is a reality of the child care industry that there is higher turnover than in some other businesses. It is best to stay with one caregiver for at least 1 year if possible. Ask about ways that the business is structured to decrease the turnover and help the children
in transitioning from one care caregiver to another. - Licensing and accreditation – The parents should inquire if the caregiver and/or the business has been licensed and/or accredited by the state government and/or national organization. Caregivers that are voluntarily accredited often must meet higher standards than most state licensing requirements.
- Adult to child ratios or how many children does each adult take care of. The fewer the children, the better. The younger the child is the fewer number of children an adult should take care of.
- Making a choice
- Parents make this choice over and over each day as they leave their child and come back to thir child. It is not a one time choice.
- Parents need to remain flexible because what may be the perfect choice now may not be the perfect choice in the future as circumstances change, (e.g. caregiver goes out of business, family member moves to town, new center opens at work, etc.)
- Staying involved
- Parents must continue to communicate with their caregiver through talking, written notes, e-mail, phone calls, parent-caregiver meetings, etc.
- Parents can stay involved by volunteering in the classroom, going to special events such as birthday parties, coming early and visiting/observing their child, the other children and the caregivers, etc.
- Parents can provide curriculular materials and expertise such as loaning books, talking about their careers/hobbies, providing ingredients for simple cooking activities, etc.
- Parents can remember to say thank you to their caregiver for the good and often difficult job they do in helping to care for and teach their child.
Learning Point
Types of child care generally fall into four categories:
Center-based child care – care for children in groups, generally in a location seperate from a home and operated as a business
- Advantages
- Larger groups – children can learn from more than one child, and learn in larger group situations.
- Multiple caregivers – children can learn from more than one person, more caregivers are available to the child, caregivers can help support each other.
- Licensing – done by state agencies, potentially safer but does not insure quality. Regulation does set minimum health, safety and caregiver training standards that must be maintained. Centers are inspected yearly.
- Curriculum – more options are potentially available because more resources are available such as staff, toys, equipment, etc.
- Cost – potentially less expensive especially for a single child because more families support the business.
- Dependability – this is a business and therefore the hours, days of operation, policies etc. are known in advance and can be depended on by the parents.
- Reputation – this is a business and therefore people in the community have had experience with the business and can give their point of view to parents.
- Disadvantages
- Larger groups – there are more children to take care of.
- Multiple caregivers – there may not be one specific caregiver for an individual child or the usual caregiver may not be available.
- Cost – potentially more expensive, especially if there are multiple children.
- Operating hours/Flexibility – the business operating hours may not work with the parental work hours, there may be no flexibility in picking a child up late, or for occasional care, etc.
- Sick children – sick children are generally excluded from center-based child care.
Family-based child care – care for children in smaller groups, generally located in the caregiver’s home and operated as a small business
- Advantages
- Smaller groups – there are fewer children to take care of.
- Single or small number of caregivers – fewer caregivers to take care of the child, may increase consistency.
- Licensing – possibly licensed by state agencies.
- Cost – potentially less expensive because there are fewer business costs.
- Operating hours/Flexibility – potentially hours and days of operation can be tailored to parents work schedule.
- Sick children – may be available for occasional child care and for emergencies such as sick children.
- Reputation – this is a business and therefore people in the community have had experience with the business and can give their point of view to parents.
- Disadvantages
- Smaller groups – not as many children to interact with and learn from.
- Single or small number of caregivers – fewer caregivers to provide the care, less support for the caregiver.
- Licensing – caregivers may be required to be licensed but often there is less oversight for continued compliance, and fewer incentives for exceeding the minimum standards.
- Curriculum – may not be as diverse or have as many opportunities because of fewer resources available.
- Dependability – potentially the caregiver can stop providing care with no or little advanced notice.
In-home child care – provides care in the child’s home. This includes live-in or live-out caregivers such as nannys and housekeepers
- Advantages
- Smaller groups – generally only the siblings are cared for.
- Single caregiver- often a single care caregiver which may increase consistency.
- Cost – can be less expensive, especially if there is more than one child.
- Operating hours/Flexibility – this is often cited as a major advantage for parents using this type of child care.
- Other caregiver duties – the caregiver may also provide other services such as housekeeping, errands, transporting children, etc.
- Confidence – parents often feel comfortable with care being provided in their own home.
- Disadvantages
- Smaller groups – not as many children to interact with and learn from
- Single caregiver – single caregiver to provide the care and may not be available, less support for the caregiver.
- Licensing – generally not licensed.
- Cost – can be more expensive for fewer children.
- Curriculum – may not be as diverse or have as many opportunities because of fewer resources available.
- Dependability – potentially the caregiver can stop providing care with no or little advanced notice.
Relatives, Friends and Neighbors – care provided in the child’s or caregiver home by a caregiver with a familial relationship
- Advantages
- Smaller groups – generally only the siblings or other relatives are cared for.
- Single or small number of caregivers – often a single caregiver which may increase consistency.
- Cost – can be less expensive, especially if there is more than one child.
- Dependability – caregivers with close relationships can often provide more dependable care.
- Reputation – parents know the caregiver usually very closely.
- Operating hours/Flexibility – this is often cited as a major advantage for parents using this type of child care.
- Sick children – may be available for occasional child care and for emergencies such as sick children.
- Disadvantages
- Smaller groups – not as many children to interact with and learn from
- Single or small number of caregivers – single caregiver to provide the care and may not be available, less support for the caregiver, may be difficult to resolve differences because of the close relationship with the caregiver.
- Licensing – generally not licensed.
- Curriculum – may not be as diverse or have as many opportunities because of fewer resources available.
Questions for Further Discussion
1. What are the appropriate adult to child ratios for different ages of children?
2. List some of the national organizations that voluntarily accredit child care centers?
3. Where can a parent find their local child care resource and referral agency?
Related Cases
- Disease
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MEDLINEplus for this topic: Child Care
and at Pediatric Common Questions, Quick Answers for this topic: Finding the Right Child Care
To view current news articles on this topic check Google News.
Child Care Aware. Steps to Choosing Quality Child Care.
Available from the Internet at http://www.childcareaware.org/en/5steps/ (cited 7/17/2006).
National Child Care Information Center. Available from the Internet at http://nccic.org/ (cited 7/17/2006).
National Network for Child Care. Available from the Internet at http://www.nncc.org/homepage.html (cited 7/17/2006).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
August 7, 2006
Pediatric Education 