Day-care centers have become a way of life in America. More than half of all mothers of children too young to care for themselves hold jobs outside the home. For them--indeed for millions of American families--day-care centers provide a service that is a necessity. If both parents work, a solo parent caring for a child must work, or other family support systems are inadequate, child day care answers a critical need. Unfortunately, though, it often provides something else--a focal point for certain kinds of infectious diseases that can all to easily spread not only to others in the day-care center, but far and wide into the community.
The problem involves illnesses, particularly enteric (small intestine) infections, that usually show themselves as diarrhea and other disturbances in the gastrointestinal tract.
Enteric illnesses are commonly associated with "food poisoning." But in the nation's day-care centers, tainted food is often not the culprit. Rather, the illnesses most often result from fecal contamination because staff and children fail to follow the dictates of ordinary common sense about things like hand washing and cleanliness.
The major contributors to the spread of enteric diseases--person-to-person contact, water and food--are interrelated and part of a persistent cycle. Attacking one part of the problem will have little effect. What's needed is a concerted effort directed at all sources of transmission of enteric pathogens.
Studies show that children under 3 who are cared for in day-care centers are more subject to diarrheal attacks than other youngsters. Likewise, day-care center workers and families of these young day-care children seem to suffer more bouts of diarrhea. L.K. Pickering, M.D., a professor of pediatrics at the University of Texas, noted in an editorial in the American Journal of Public Health that diarrhea was 30 percent more common in day-care children than in children cared for at home.
Another study found that day-care children under 3 had diarrhea twice as often as children remaining at home. A study reported in the September 1988 journal Pediatrics found an average of 3.8 diarrhea outbreaks per child per year in day-care centers in Houston, Texas. Similar findings have been reported from cities throughout the United States.
A recent family survey by Pickering and his colleagues showed that the average head of household or spouse lost 13 workdays because of illness in his or her day-care-center child; just under five of those lost days were due to diarrheal disease.
The spread of enteric illnesses to family members is documented in several surveys, one of which found that 10 of 56 family members of ill children were afflicted but only 1 of 45 family members of well children developed the illness. The episodes can be quite severe. One study reported a median duration of 12 days, while another noted that episodes lasted as long as six weeks. Hospitalizations were not all that infrequent.
The cause of these infections is usually some well-known pathogen such as the hepatitis A virus, rotavirus, Giardia, E. coli, Cryptosporidium, Shigella, or Campytobacter.
The human gut, including that of small children, normally contains many of the pathogenic bacteria and viruses that can cause diarrhea, but the body's natural defenses usually keep them well under control. More important, these potentially dangerous organisms don't ordinarily get spread around. But fecal contamination can be a prime source of disease in centers that care for children under 3--those still in diapers and still being toilet trained. Hands, toys, diaper-changing areas, and just about everything else can be contaminated with fecal matter. Children and adults who touch these contaminated objects and then put their fingers to their mouths are prime candidates for disease.
A microbiologist in FDA's Center for Food Safety and Applied Nutrition, writing in the January/February 1989 issue of the Journal of Environmental Health, cautioned that diarrhea may not be the only consequence of fecal contamination in day-care centers. Noting that children generally have symptoms far longer than adults, he commented that diarrhea persisting a week or more can lead to nutrient losses and can also compromise the immune system. Further, in an important reminder that all of us should heed, he pointed out that both a form of arthritis and certain neuromuscular disorders have been associated with bacteria that cause diarrhea. And he reported the disquieting fact that some of the strains of pathogens causing outbreaks of diarrheal disease are extremely resistant to commonly used disinfectants.
Nevertheless, there are things day-care centers can do to minimize the danger of infection caused by fecal contamination. Preventive measures include:
The U.S. Centers for Disease Control describes proper hand washing as follows:
Day-care staff members should wash their hands when they start work, before preparing or serving food, after diapering a child or wiping his nose or cleaning up messes, and after a trip to the bathroom.
For children, the routine is much the same, CDC advises. Center staff should be sure that children's hands are washed when they arrive, before they eat or drink, and after they use the toilet or have their diapers changed.
It's also important that the diaper-changing area is located well away from food-serving areas and that a separate sink is used for preparing food and washing dishes.
CDC recommends that only washable, preferably hard-surfaced toys be used around children still in diapers. Toys should be washed daily. Stuffed toys, if they're used by children in diapers, should be washed at least once a week.
Obviously, the need for cleanliness is not limited to hands and playthings. All facilities and supplies at day-care centers should be washed with soap and water and then disinfected on a regular, frequent schedule. For disinfectants, CDC recommends either a commercial product that kills bacteria, viruses, and parasites such as Giardia or a bleach solution. To make the bleach solution, mix one-fourth cup of bleach with a gallon of water (or one tablespoon per quart). The solution should be made daily but can be stored in a spray bottle. Disinfectants must be kept out of the reach of children.
Any parent knows how disagreeable even a short bout of diarrhea can be in a young child. But public health workers know that diseases spread from day-care centers can have further, more ominous consequences. A day-care center child who contracts hepatitis A, for example, will probably develop only mild symptoms or none at all. Spread to adult family members, however, the infection carries the risk of more serious illness, as well as the possibility of further transmission to the community, particularly if the adult handles or prepares food. According to the National Restaurant Association, there are 8 million food service workers in 550,000 establishments in this country. It is easy to see how enteric disease in a day-care center child can have far-reaching effects into a wider world. In two studies, 13 percent to 40 percent of reported cases of hepatitis A in the community had some form of association with outbreaks in day-care centers.
FDA has model sanitation and food protection codes to which commercial food establishments must adhere. These same codes should apply to day-care centers that handle food, even though centers are not regulated by FDA. At FDA's urging, the National Environmental Health Association devoted its 1987 annual mid-year conference to day-care problems, particularly those associated with food protection and sanitation. The agency also recently signed a memorandum of understanding with the Department of Health and Human Service's Head Start Bureau. It provides for increased cooperation between Head Start and FDA's Center for Food Safety and Applied Nutrition to ensure that day-care centers follow standard sanitation and food protection requirements. And FDA continues to work closely with local and state regulators of day-care centers who are responsible for inspecting these facilities to help ensure that standard public health guidelines are being met.
My advice to parents of day-care center toddlers is: Make sure the day-care center is on guard against contamination that can make your child, you, and lots of other people needlessly sick. The risk is not just a bout of diarrhea. The risk is serious health problems down the road that can--and should--be prevented.
FDA Consumer, 8/89
Since the publication of the FDA Consumer article in 1989, FDA has updated model codes related to the preparation of food in food establishments. This update is currently embodied in the 1995 FDA Food Code and is intended to apply to child care centers. There are several noteworthy provisions in that Code which can help prevent the spread of foodborne diseases:
Consult the FDA Food Code for specific temperature requirements and for special provisions related to microwave cooking and reheating.
Young children attending child care centers are particularly susceptible to foodborne illness and special precautions apply. For example: individual packages of food, like crackers, must not be reserved if they are not eaten, even if they remain unopened; and pasteurized eggs should be used instead of shell eggs.