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PASSIVE SMOKING AND DAY CARE CAREGIVERS BY TYPE OF CHILD CARE AND AGE OF CHILD Table 3 AGE IN-HOME CARE < 1 Year 1-2 Years 3-4 Years TOTAL Father 13. 9% 15.8% 11.0% 13.9% Grandparent 8.9 % 6.3% 3.6% 5.9% Other Relative 5.1 % 5.0% 5.7% 5.2% Non-relative 6.4 % 6.2% 4.3% 5.5% DAY CARE HOME Grandparent 13. 5% 10.5% 11.0% 11.3% Other Relative 6.2 % 7.3% 7.1% 6.9% Non-relative 23. 0% 25.2% 17.3% 22.0% GROUP CARE Nursery 1.7 % 3.2% 11.7% 5.6% Day Care Center 3.6 % 8.5% 14.1Y. - 9.2% MOTHER 9.2% 8.6% 9.9% 9.1% TOTAL 91.5 % 96.6% 95.7% 94.6% Source; O'Connell and Rogers, 1982 (28)

Future studies controlling for potential confounding factors are urgently needed in this area. The smoking practices of day care workers, particularly family day care homes, may have been a major uncontrolled confounder in past studies. In the interim, parents should be alerted about not only the harmful effects of parental smoking on infants but the potential added exposure from day care workers. The children of nonsmoking parents who are provided day care by smokers could possibly have an exposure to environmental tobacco smoke at a rate similar to that of children with one or more smoking parent. Day care providers must also be educated about the possible compounded effect of passive smoking and day care attendance on the increased risk of respiratory diseases among infants and toddlers. m ~ CL 128 O Ct W -1 N

PASSIVE SMOKING AND DAY CARE CARE GIVER BY AGE OF CHILD Table 2 AGE < 1 Year 1-2 Years 3-4 Years TOTAL FATHER 13.9% 15.8% 11.0% 13.9% MOTHER 9.2% 8.6% 9.9% 9.1% GRANDPARENT 22.4% 16.8% 14.6% 17.2% OTHER RELATIVE 11.3% 12.3% 12.8% 12.1% NONRELATIVE 29.4% 31.4% 21.6% 27.5% GROUP CARE 5.3% 11.7% 25.8% 14.8% TOTAL 91.5% 96.6% 95.7% 94.6% Source: 0'Connell and Rogers, 1982 (28)

PASSIVE SMOKING AND DAY CARE 7. TABLES TYPE OF CHILD CARE BY AGE OF CHILD Table 1 AGE < 1 Year 1-2 Years 3-4 Years TOTAL IN-HOME CARE 34.3% 33.3% 24.6% 30.5% DAYCARE HOME 42.7% 43.0% 35.4% 40.2% GROUP CARE 5.3% 11.7% 25.8% 14.8% MOTHER 9.2% 8.6% . 9.9% 9.1% TOTAL 91.5% 96.6% 95.7% 94.6% Source: O'Connell and Rogers, 1982 (28) CD ~ ~ +W a ~ I34c,, m 0 'A

CEAPTER 9 THE EFFECTS OF PASSIVE SMOKING AND DAY CARE ON RESPIRATORY ILLNESSES IN CHILDREN Glen Bennett, M.P.H. Field Studies Advisor National Heart, Lung, and Blood Institute office of Prevention, Education, and Control Health Education Branch 9000 Rockville Pike Bethesda, MD 20892 1. INTRODUCTION Upper respiratory infections are the most common illnesses affecting children under 5 years of age. They are important causes of childhood morbidity and their treatment consumes a substantial portion of health care resources. (8, 14, 17) Infants average 7-8 acute respiratory illnesses per year and older children, 1-5 years of age, average one or two fewer infections. (17) Acute otitis media (AOM) is the most common complication of upper respiratory diseases in infants and young children. (16, 18, 31, 47) AOM is the largest single cause of morbidity with possible sequelae in children (47) and recurrent episodes are very common in children during the first years of life. (23) AOM account for one-third of pediatric.offiee visits (31) and three-fourths of follow-up visits. (16) Nearly all children have at least one episode of otitis media with effusion (OME) during their first 6 years of life. The majority will recover spontaneously but some will develop chronic OME or chronic otitis media with perforation and discharge. (45) Repeated episodes of OME in early life may lead to developmental or educational delays due to transient or permanent hearing loss and impeded speech. (17, 47) Bronchiolitis is the most common manifestation of lower respiratory tract infections in infants and small children. The true incidence is unknown but the risk of hospitalization for infants with bronchiolitis is estimated at 10 per 1,000. The mean age for respiratory syncytial virus (RSV) bronchiolitis is 7.8 months and the peak age is 2 months. One half of children hospitalized for the condition are under 3 months of age. (42) One benefit-cost analysis study (25) concluded that immunization 117

45. Van Cauwenberge, PB; Kluyskens, PM; "Some Predisposing Factors in Otitis Media With Effusion;" in Lim, DJ; et al; Recent Advances in otitis Media With Effusion; Philadelphia: B C Decker; 1984; 28-32 46. Vinther, B; Elbrond, CB7 "A Population Study of Otitis Media in Childhood," Acta Otolarynqoloqy, (Stockholm] Supplement 360: 135-137; 1979. 47. Visscher, W; Mandel, JSt Batalden, PB; Russ, JM; Giebink; GS; "A Case-Control Study Exploring Possible Risk Factors for Childhood Otitis Mediat" in Lim, DJ; et al; Recent Advances in Otitis Media With Effusion; Philadelphia: B C Decker; 1984; 13-15 48. Ware, JH; Dockery, DO Spiro, A; Speizer, F: Ferris, B. "Passive Smoking, Gas Cooking and Respiratory Health of Children Living in 6 cities;" American Review of Respiratory Diseases; 1984, March; 129(3): 366-374 49. Young, KT and Zigler, E; "Infant and Toddler Day Care: Regulations and Policy Implication," American Journal of Orthopsychiatry, 1986, January; 56(1): 43-55 50. Zigler, E; Muenchow, 5; "Infectious Diseases in Day Care: Parallels Between Psychologically and Physically Healthy Care;" Review of Infectious Diseases; 1986, July-Auqust; 8(4): 514-520 07 ~ m O CO W 133 00 O

wage for care givers was found to be below minimal wage. The discrepancy represents a subsidy for the cost of child care by these care givers. Zigler and Muenchow (50) also reported that 60% of day care workers have income below the poverty level In 1980, the prevalence of smoking among female child care workers was estimated at 28.94. Thus child care workers smoked less than females in general. However, their rates are much higher than those for female elementary school teachers (19.8%) and higher than secondary school teachers (24.82). (44) 2.2.REOULATIONB 2.3.1: Pederal Unlike most other Western nations, the U.S. has no national policy on child care and efforts to develop one have reached a stalemate. (35) Since 1970, there have been several attempts to create federal regulation of at least a portion of the day care market. (17) Minimal conditions for safety were proposed in 1980 but were never enacted. (50) While the 1980 Federal Interagency Day Care Requirements have been withdrawn, they continue to serve as a guideline for minimum standards. (49) 2.3.2. State Each state regulates its own day care facilities. In most states, the requirements are severely written and laxly enforced. (35) All 50 states have enacted regulations which contain some provisions for health and safety but they vary greatly across the country. (17) Licensing practices also vary from state to state. (24) Forty-four (44) states currently regulate family day care homes. (49) A state license, however, does not guarantee that a day care facility meets minimum state requirements. The under-staffing of state licensing bureaus often makes licensing and monitoring a hasty and sporadic effort. (50) children cared for in their own home are generally beyond the reach of federal and state policy (17)• In some states, the physical requirements for day care homes rule out most residences as sites for child care, even though most children are reared in these same homes. The regulations were written for day care centers and not homes. Nevertheless, they are applied to homes, which means that many day care homes go unregulated and unlicensed. (35) This analysis of existing regulations presents a very bleak picture with great variations among the states in standards for day care. The majority of day care facilities are unlicensed. States vary in their policies of periodic inspections, unannounced visits, and procedures for license renewal. (49) ~ ~ 120 m O 07 W Q'+

Fleming and colleagues (14) also found that children in Washington, DC who attended day care were significantly more likely to have an upper respiratory tract infections during a 2-week period prior to the interview. In addition to day care attendance, a second factor, maternal smoking was also associated with an increased risk. The effects of day care attendance and maternal smoking were independent of one another. Age and living in crowded conditions were also risk factors. The researchers estimated that 31% of upper respiratory infections can be attributed to day care attendance. Most studies of bronchiolitis have been restricted to the hospitalized child. Comprehensive studies of this disease in ambulatory patients or day-care centers are lacking. (42) However, the incidence of bronchiolitis in one day care center in Chapel Hill, NC was compared with the rates in a pediatric practice. The rate was much higher in the day care center for children 6 months of age or younger. However, the proportion of cases requiring medical treatment and hospitalization was less among day care attendees. (10) Several reviewers (1, 17, 18) of studies on respiratory illness and day care have identified the following problems which limits the generalization of the findings: 1.Control groups were less than satisfactory in that day care children were often observed on a daily basis whereas those in home care were not. 2.Some studies reported respiratory tract symptoms while others used diagnostic categories. 3.There is little commonalty in either the ages of children studied or the manner of reporting illnesses by age category. 4.The reliability of case-controlled and cohort studies depends on the accurate quantification of disease occurrence in members of all study groups. This raises the questions of whether parents of children in day care seek a physician for their children's illnesses more frequently. The suggestion by a day care provider that a child be taken to a physician might have important effects on parents. Henderson and colleagues (18) warned that the apparent association of day care attendance with otitis media could be accounted for, in part, by these types of bias. Perhaps more importantly, Ingvarsson and colleagues (19) emphasized that most studies have not investigated other factors that probably influence the incidence of respiratory illnesses, i.e., external factors such as type and quality of housing, degree of air humidity and ventilation, and cigarette smoke inhalation and other air 122

2.3.RELATIONSHIP TO RESPIRATORY INFECTIONS Respiratory diseases are the most common illnesses affecting children in day care. (1) Today, infants and pre-school age children acquire infections at earlier ages. The common factor in this changing pattern is the increasing popularity of day-care centers. Today, younger and younger children are spending more and more time outside the home on a daily basis. (24) Day care centers with many children in the same place create favorable conditions for respiratory epidemics, with acute otitis media as a sequelae. (30) However, the total burden of respiratory illnesses appears to be no greater for the day care child. The illnesses simply occur at younger ages. (1) The association of day care and respiratory tract illnesses began in the 1920's. (17) In the 1970's, Scandinavian researchers (19, 23, 31, 32, 39, 41, 45) found an increased incidence of otitis media and/or recurrent otitis media over prolonged periods among children attending day care. The strongest evidence of an increased rate of otitis media was found among children in centers, with family day care holding an intermediate position between centers and in-home care. Moreover, home-reared children with abnormal finding at first testing were significantly more likely to return to normal at each subsequent testing than were children attending centers. While their are obvious difficulties in transferring the results from studies on infections in day care facilities conducted in Scandinavian countries, Haskins (17) concluded that because of the high quality of these studies, especially the epidemiologic studies based on entire birth cohorts, the findings deserve careful attention. Thus, Scandinavian studies provide substantial reasons for concern that children in day care centers, and possibly family day care, are at 2-3 time the risk for persistent otitis media as those reared at home These findings were confirmed in a case-control study by Visscher and colleagues (47) with patients at a large pediatrics group practice in Minneapolis. During a 2-week period in February, 1982, every parent who brought a child into the clinic for any reason was asked to fill out a questionnaire. Cases were defined as presenting with AOM on a study day, regardless of past history. Controls were patients with a diagnosis other than otitis media and who also had no prior history of otitis. A cold in the past week and the symptoms of fever, ear pain, and decreased hearing were prominent in the case group. Attending a day care facility was the second most important risk factor and the risk increased with the number of other children at the facility. Exposure to smokers was not a risk factor. While the study had a number of flaws, 4 bona fide risk factors were identified, i.e., recent upper respiratory tract infection, allergy, day care exposure, and family history of ear infection. - 121