Patient Presentation
A pediatrician was discussing with a colleague that she had seen an 11-month old infant whose mother was distressed because he had had several infections since starting center-based childcare and this week had overheard her child call the childcare professional “ma-ma.” The pediatrician relayed how the mother already felt guilty about using center-based care, and calling the provider ma-ma had had her in tears. The pediatrician said that the child was overall healthy and thriving, with the usual minor infectious disease episodes. The child only called the mother and professional by ma-ma. The child also seemed to say ‘da-da’ for the father, and had another sound for his grandmother. “I reassured the mother that he was doing well and he should have fewer infections as he grew. I also told her that it’s really hard to hear ma-ma being used for someone else, and that him calling her ma-ma probably shows how good he feels about how well the professional cares for him,” she said. The colleague agreed, “I’d much rather hear about a child who is obviously paid attention to and cared for, than the child who isn’t played or interacted with and is withdrawn or not gaining his developmental milestones. I probably would feel the same way though if my son called my carer ma-ma.”

Discussion
Children usually thrive in environments where their physical needs are met, they are encouraged to explore with the world, and where they interact with others who can support their personal growth with other people. In general, a few, consistent caregivers are best for young children. Because of work needs, parents may need other people to help them provide childcare, including family members, non-relative in-home childcare, center-based care or intermittent care (i.e. babysitting). There are many advantages and disadvantages for any of these arrangements and they can be reviewed here. Some families need to have multiple childcare arrangements.

Some US national organizations have excellent information about quality childcare and how to find it. These include:

National Association for Education of the Young Child – What to look for in a program
National Association of Child Care Resource and Referral Agencies – Keys to quality childcare
American Academy of Pediatrics’ HealthyChildren.org – Work and childcare

Brief indicators for quality childcare are include low numbers of children per provider, low staff turnover, accreditation of the in home provider or childcare center.

Learning Point
Note that this discussion does not look at non-parental care in the circumstances of a child in a legal placement situation such as foster or residential care.

The long-term health outcomes for children in childcare are difficult to assess. A systemic review of non-parental childcare and its long-term effects on children’s diet, activity and sleep found “[t]he available, limited, longitudinal literature suggests that attending certain types of non-parental childcare (particularly informal providers) might be related to less breast-feeding, but the evidence regarding other dietary outcomes is mixed, and sometimes contradictory. Moreover, the data reviewed suggest that attending nonparental childcare is unrelated to physical activity, sedentary behaviour, or sleep outcomes. Included studies were of mixed quality with most (92%) not reporting use of valid and reliable outcome measures…”

More specifically the study found:

Item	Number of Studies	Positive Results	Negative Results	Null Results
Diet	63	10	11	59
Increased Physical Activity	9	2 mixed positive and negative	2 mixed positive and negative	7
Decreased Sedentary Behaviors	3	1	0	2
Sleep	15	2	0	13

Another study also found that children whose families relied on multiple childcare arrangements (versus a single arrangement) had increased risks of asthma and infectious diseases (i.e. gastroenteritis, otitis media, upper respiratory infections, etc.), but not for injuries. Other studies have found that the risk for infectious diseases a particular child has is related to the number of other children exposed to and not the length of time in childcare.

Questions for Further Discussion
1. What recommendations do you give families for evaluating quality childcare?
2. What are some of the limitation for quality childcare in your location?
3. How much does childcare cost in your location?

Related Cases

Disease: Child Day Care

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: General Pediatrics

Age: Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Children’s Health

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Chen JH. Multiple Childcare Arrangements and Health Outcomes in Early Childhood. Matern Child Health J. 2013;17(3):448-455. doi:10.1007/s10995-012-1016-9

Costa S, Benjamin-Neelon SE, Winpenny E, Phillips V, Adams J. Relationship Between Early Childhood Non-Parental Childcare and Diet, Physical Activity, Sedentary Behaviour, and Sleep: A Systematic Review of Longitudinal Studies. Int J Environ Res Public Health. 2019;16(23):4652. doi:10.3390/ijerph16234652

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa