Day Care Directors Are Playing Doctor, and Parents Suffer

The following originally appeared on The Upshot (copyright 2019, The New York Times Company)


Almost anyone with a child in day care or preschool has received the call. They say your child has a minor ailment like pink eye and must go to the doctor. Otherwise, they say, the child won’t be able to return to school or day care. Sometimes, they even say your child can’t come back until they’re on antibiotics.

The best evidence, however, says there should be less treatment for pink eye and other minor illnesses, not more. Day care centers usually ignore this evidence — and parents often pay the price.

This pattern is extremely hard to reverse. There is an understandable urge to be protective when it comes to children (and also an incentive to protect yourself from future criticism should your decision not to act go poorly).

Being overprotective has costs, though. Visits to the doctor aren’t free, nor are drugs. Parents have to skip work to take their children to the doctor. They already pay a lot for day care, and this is a forced expense that often lacks value.

About 30 percent to 40 percent of working mothers pay for child care outside the home. In a recent Upshot article, Claire Cain Miller pointed out that child care can cost a typical family a third of its income. And the current administration keeps adding work requirements to many safety net programs.

Moreover, a visit to the physician is not harm-free. Children are exposed to other potentially ill children in a waiting room. Day care centers seem concerned that children could spread disease to other children in their facilities, but not nearly as concerned that they could spread illnesses to other children in a clinic.

Day care centers sometimes act as medical experts. In 2010, researchers examined the medical policies of day care centers in Pennsylvania. Almost all (97 percent) of them had written policies for when ill children should stay home. In almost all cases, those making decisions about who was too ill to attend were directors or teachers — neither of whom had medical training.

More than 90 percent had policies requiring antibiotics for pink eye with a white or yellow discharge. More than half had policies requiring antibiotics for diarrhea. Neither requirement makes sense.

Pink eye, also known as conjunctivitis, can be highly contagious, which helps explain why day care centers have such strict policies regarding it.

But a lot of pink eye is caused by viruses, which are unaffected by antibiotics.

Even when pink eye is caused by a bacterial infection, antibiotics have a limited effect. They slightly increase the chance that a child will feel better within two to five days. But there’s no promise of a cure the “next day,” as most day care centers seem to believe, and no lessening of infectiousness.

This is not just an American problem. A study of child care centers in Ontario found workers often recommended that parents visit the doctor for a runny nose or cough; they also said antibiotics would be useful for colds (they are not). More than two-thirds had allowed children to return if they were on antibiotics. Studies in England have also found that about half of policies required antibiotics for pink eye, and that such policies influence clinicians’ decisions about whether to prescribe them.

The American Academy of Pediatrics, along with some other major health organizations, has published recommendations on when children should be kept from child care centers. Two main criteria should drive considerations, according to the recommendations. If children are so sick that they cannot participate in activities, they should stay home. If they need more attention than the staff can provide, they should stay home, too.

Otherwise, it should depend not on whether they are sick, but on how sick. Clearly a very ill child should stay home, but each child experiences illness differently. Fever requires staying away only if it causes changes in activity participation or if it’s accompanied by other symptoms like a sore throat or rash. Vomiting requires staying away if it occurs more than once.

Multiple studies have shown that the optimal strategy for managing pink eye is to delay antibiotics — to see if it resolves on its own. There’s certainly no reason to require antibiotics, or to delay a child’s return until they’re on them.

Many schools will probably be too worried about children who spread infections to follow these guidelines. But children are often infectious before they show any symptoms, and we’re never going to be able to prevent all transmission of illness.

Our best bet is still focusing on hygiene, like proper hand washing, covering your mouth when you cough or sneeze, and not sharing food and drink with others.

Instead of relying on antibiotics and after-the-fact measures to prevent the spread of disease at day care, a center’s staffers could focus on disease prevention. A randomized controlled trial published last year in Pediatrics examined a hand hygiene program at child care centers in Spain that focused on more diligent hand washing or sanitizing. The program resulted in a reduction in respiratory infections and antibiotic prescriptions, as well as fewer days missed. Another study from a decade earlier found a similar result.

Unnecessary treatment isn’t just a problem with pink eye. It happens for sore throats. It happens for rashes. Taken together, it essentially amounts to a tax on being a parent, with costs both obvious and hidden: medical fees, missed work, lost time.

The idea is to protect children, but current practices don’t seem to be serving anyone well.



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