October 1997
RALEIGH, N.C. — Germs and infections are often associated with child care centers, but according to Jim M. Poole, MD, things can change with the help of pediatricians.
When choosing a child care center, parents must consider numerous things, Poole said, and pediatricians should take an active role in helping parents evaluate facilities.
Poole is a member of the American Academy of Pediatrics (AAP) Early Childhood, Adoption and Dependent Care Committee, which advises the AAP board of directors on medical and public policy matters related to child care. He is also a practicing pediatrician and medical director of five child care centers serving approximately 1,000 children in the Raleigh area.
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The sanitary conditions, Poole said, are obviously important. Not only the conditions of the room and the toys, but how the staff handles the children.
"The number-one spread of infection is by the hands," said Poole. Children are constantly putting their hands in their mouths, down in their diapers, in other children's mouths and all over toys. Therefore, children should learn how and when to wash their hands and caregivers should do the same.
"Although smaller children put their hands in their mouth more often than older children, adults typically put their hands to their face at least three, four, five times an hour. This is after shaking hands with others, or touching items in a public place. All lend to the spread of infection," said Poole.
Parents must reinforce the issue of hand washing at home and should be aware of infectious disease spread as they come into a child care center.
The easiest way to make hand washing a habit for children is to have easily accessible sinks in each classroom. Having children immediately wash their hands after they come in from the playground — just from a learning standpoint — is also a good way to form a hand washing routine, Poole said.
"There really needs to be a sink in every room," he said. "That should be something we, as pediatricians, should impress upon parents when searching for a child care facility."
In addition to child-size sinks, a separate sink must be used only for food preparation, Poole said.
Aside from hands, carpets and rugs can also harbor dust mites and bacteria. Tile or a covering that can easily be washed is ideal. If carpets are present, regularly scheduled carpet cleaning is extremely important. Poole suggested between one-third and one-half of the room be carpeted, with tile be on the remaining space.
"This allows children to engage in active play where they are allowed to get the floor dirty and it can be washed up easily," he said.
All other items in the rooms also need to be thoroughly sanitized each day and pediatricians can assist the child care provider in some of the health, safety and infectious disease issues within child care settings.
"Everyone misses the underneath of the tables in child care centers, where these little kids have their hands on the underside of the table. We know the top side is often cleaned, but when you turn these tables over, it's really amazing what you find," said Carol Wright, president of The Growing Child daycare centers.
Children's clothing should also be easily washable and children should be provided with at least one change of clothes.
Poole also recommends child care facilities change furnace air filters on a regular basis. Eventually, he said, centers may divide up their circulation patterns so instead of having one large furnace for the entire center, there will be three of four air conditioners and furnace units with their own circulatory patterns, which will decrease infections spreading from room to room.
"Opening a window on occasion is really not a bad idea either. The outside air is much fresher than the air we have inside," Wright said.
Children's group sizes within the center also affect disease spread. A ratio of one teacher to five children around age 2 is ideal; however, 25 children with five providers is the same student to teacher ratio, but the group size lends more to disease spread. "With a smaller group you can somewhat keep colds and things more contained within a classroom," Wright said.
Although both groups want the best for children, some controversy exists between what educators and pediatricians think is necessary in a child care facility. Sometimes the recommended educational exercises for children only aid in the spread of germs.
For example, Poole said, the water tables commonly used as an educational exercise help spread disease. A group of children sit around this table and play with their hands in the water. Unfortunately, it rapidly spreads disease, especially if the children didn't wash their hands before putting them in the water, or wiped their nose and put their hands back into the water, etc.
The water table was a popular exercise until recently, Poole said, when pediatricians began culturing the water.
"The activity is not bad ... but swapping germs can be eliminated by simply preventing children from playing in the same water," Wright explained. "One little wash tub — enough for one child to play in the water — is adequate. When the child is finished, that water can be disposed of and then another child can play."
Stuffed animals and blankets are other contrasting ideas between pediatricians and educators. Although educators suggest having these soft items, they only "harbor disease," Poole said, because children rub against them, slobber on and wipe their nose on them making it impossible to keep them clean. If blankets and stuffed animals, are present, they must be washed routinely.
Not only is washing hands important for care givers, but the clothing worn by staff members is another important issue, Poole said.
Staff clothing should be easily washable. Staff should have a change of clothes available in case their clothes become soiled. Many centers have staff who wear easily removable smocks, Poole mentioned.
"In an infant room, they are constantly picking up as many as 10 babies, who are rubbing their faces into the shoulder of the staff member. We often encourage staff to hold the baby with its face away from them, or at least have a fresh, clean cloth over their shoulder with each baby," Wright said. "Or else, that's just asking for the spread of germs."
Germs are also easily spread during food preparation. Although educators consider it developmentally appropriate for children ages 3 and 4 to help serve lunch, pediatricians feel differently.
"If a spoon is used, then children can learn how to dip their food, but the children's hands should not come in direct contact with the food," Poole said.
Wright suggested that 2- and 3-year-olds can pass out cups and napkins if they want to help, "but when it comes to handling the food, we feel that should be done by an adult."
"A child can contaminate a whole container of broccoli with one sneeze," Wright added.
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