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an organized educational program and scheduled activities for children. There is a wide variety of play materials, child-size furnishings, outdoor space and equipment, and a school-like atmosphere. Careqivers are also more likely to have some training in child development. (35) In the typical day care center, children spend a major portion of their time grouped by age in separate rooms and under the supervision of one or more adults. This sector is almost always subject to government regulation and is the smallest of the 3 sectors. (17) However, centers are the fastest growing segment in the day care market. (1, 24, 28) 2.1.2. Dsaqe The most drastic change in infant care has been the return of parents to work while their children are infants. (26) In a 1982 report, Child Care Arrancements of Working Mothers (28), 6 million women aged 18 to 44 with a child under 5 years of age were in the civilian labor force. Table 1 list the percent distribution of the type of child day care used by the age of the child. Nine percent (9f) of working mothers were able to care for their children while working. Almost one-third (30.5%) arranged for.in-home care of their children. However, day care homes were the predominate source of care selected ,i.e., 40.2%. The use of day care centers increases with the age of the child. Table 2 describes the percent distribution of care-givers by the age of the child. Fathers were the primary care-qivers to 14% of the children of working mothers. Among husbands who were the principal caretakers, 71% were employed, 24% unemployed and 5% were not in labor force. (28) Relatives provided child care to 29% of the children of working mothers. Grandparents were the principal care-givers among relatives. Seventeen percent (17%) of all pre-schoolers and 22.4% of infants received day care from their grandparents. Other relatives cared for 12% of the children. Grandparent or otlier relative, however, provided care for the children of 40% of unmarried mothers. (28) Non-relatives provided 27.5% of all day care to children of working mothers. This makes non-relatives the single largest source of care-givers. Data in Table 3 show that care was given in the home of a non-relative to 22% of all children and about 25% of infants and toddlers. (28) 2.1.3. Personnel In the National Day Care Center Study (33), the average weekly fee in day care homes was $20.85 per child. The fees were $17.80, $22.65, and $26.36 in non-regulated, regulated, and sponsored homes respectively. In both day care homes and many centers, the mean 119

against the four most common respiratory viruses would appear to be a reasonable step. However, Denny (9) cautioned that the two commercially available vaccines, S. pneumoniae and type b H. influenzae, are not very effective in children under two years of age where most infections occur. He also noted that while current efforts to produce effective respiratory vaccines are extensive, the problems associated with their development are very great. 2. DAY CARE IN THE U. 8. 2 . 1. 6ENER7IL CHARACTERISTICS 2.1.1. Types In 1982, 6 million mothers (48.2%) with a child under the age of 5 were in the civilian work force and the upward trend is continuing (28). Their children are cared for in three basic types of day care delivery systems. They are in-home care, family day care, and group day care. In-home care is provided in the child's home by a parents, relative, or non-relative. In 1982, 30.6% 'of the children of working mothers received in-home day care. Fathers and others relatives provided most of this type of care. (28, 50) In-home care by a non-relatives is the most expensive form of care and is used by only 5.5% of working mothers. (35) Family day care (day care homes) is given by a non-relative in a private home other than the child's. (2, 50) Day care homes include more children than any other form of day care. These homes are generally divided into three basic types: informal homes, registered/licensed homes and network homes. Informal homes - which are not regulated, registered, or linked to any sponsoring agency - are the most common. Ninety-four percent (94%) of all children in family day care attend these homes. Registered or licensed day care home are required to meet state/local regulation. The smallest subset of day care homes operate within networks administered by a sponsoring agency that is either for profit or nonprofit. The average number of children per day care home is 3.5. Non-regulated homes average 3.6 children compared to 4.5 in regulated homes. (2, 15) Day care homes offer a cozier settings with more adult attention and fewer pears. Individual discipline and training for compliance are usually better. They are well suited for the care of infants, toddlers, and slow-to-mature older children. This form of care is also the least expensive. However, most providers have little or no training (17, 35) and there is no assurance that providers place children's needs above the desire to earn a living. (17) Day care centers, including nurseries, provide care for 12 or more children in nonresidential buildings. (17, 49) They usually offer 118

Much more needs to be known about the impact on child health and the practice of family day care before this approach can be knowledgeably recommended. (2) The smoking patterns of day care workers, particular those in day care homes, should be identified. Data from the National Health Interview Surveys, 1978-1980 put the prevalence of smoking among female child care workers at 28.9t. These data excluded private household child care workers with whom most children, particularly infants and toddlers, are cared. 1. 3. EDIIC7ITION At the moment, Parents must judge for themselves the quality of care given to their children. However, most parents do not know what to look for in a day care setting and there are no federally sanctioned standards. (35, 50) There are, however, guidelines that are generally agreed upon within the child development community. (35) A checklist for quality of care has also been developed and found to differentiate between centers of high quality and low quality. The checklist includes one item on smoking: "Adults do not smoke in rooms where children are." (7, 35) The body of information now available on the prevention and management of infectious diseases in day care should be widely disseminated to day care providers, public health workers, health care providers, and parents. Public health authorities must be armed with low-cost materials to distribute to day care providers. (1) S. sQ)D1ARY AND COHCLflBION The children of working parents are receiving day care primarily in their own home, family day care homes, and day care centers. Family day care is the largest of the three sectors but day care centers represent the fastest growing segment. Studies, mostly in Scandinavian countries, have demonstrated that children attending day care centers and probably family day care have more respiratory infections than children receiving in-home care. The effect is greatest among infants and toddlers. Another group of studies have linked parental smoking, primarily maternal smoking, with an increase in respiratory diseases among infants. However, most of these studies did not control for day care attendance. The few studies that controlled for parental smoking and day care attendance shoved a consistent and positive association for day care attendance. The results were mixed for parental smoking. None of the studies, however, controlled for the possible confounding factor of exposure to environment tobacco smoke by children who were cared for by day care workers who smoked cigarettes. 127 ~ Go O 00 W ~ ~A

Emergency Room Visits of Urban Children With Asthma," American Review of Respiratory Diseases; 1987; 135: 567-572 12. Fergusson, DM; Horwood, LJi Shannon, FT7 Taylor, B. "Parental Smoking and Lower respiratory Illness in the First Three Years of Life," Journal of Epidemiology and Community Health, 35(3): 180-184; September, 1981 13. Ferris, BGt Ware, JH; Berkey, CSi Dockery, DW; Spiro III, A; Speizer, FE; "Effects of Passive Smoking on Health of Children," Environmental Health Perspectives, 62: 289-295; 1985 14. Fleming, DW; et al; "Childhood Upper Respiratory Tract Infections: To What Degree is Incidence Affected By Day Care Attendances!" Pediatrics; 1987, January; 79(1): 55-60 15. Fosburg, S: Family Day Care In The United States: Summary of Findings; Government Printing Office, 1981 16. Giebink, GSO "Epidemiology and Natural History of otitis Media;" in Lim, DJ; et al; Recent Advances in Otitis Media With Effusion; 1984; 5-8 17. Haskins, R; "Day Care and Illness: Evidence, Costs, and Public Policy;" Pediatrics; 1986; 77: 951-982 18. Henderson, FWp Giebink, GSf "Otitis Media Among Children in Day Care: Epidemiology and Pathogenesis;" Review of Infectious Diseases; 1986, July-August; 8(4): 533-538 19. Ingvarsson, L; Lundgren, K7 Olofsson, B; "Epidemiology of Acute Otitis Media in Children-A Cohort Study in an Urban Population;" in Lim, DJt et ali Recent Advances in Otitis Media With Effusion; Philadelphia: B C Decker; 1984; 19-22 20. Iverson, M; Birch, L7 Lundqvist, G; Elbrond, 0. "Middle Ear Effusion in Children and the Indoor Environment: An Epidemiological Study," Archives of Environmental Health 40(2): 74-79; March-April, 1985 21. Kraemer, MJP "Risk Factor for Persistent Middle Ear Effusions;" Journal of American Medical Association; 1983, February 25; 249(8): 1022-1025 22. Leeder, SR; Corkhill, RT; Irwig, LM; Holland, WW. "Influence of Family Factors on the Incidence of Lower Respiratory Illness During the First Year of Life," British Journal of Preventive and Social Medicine, 30(4): 203-212, December, 1976 130

now work outside the home, (28, 37) the smoking habits of private day care givers must be considered as an important variable in the development of childhood respiratory infections. (37). The Section on Allergy of the Canadian Pediatric Association (6) reported that infants admitted to hospitals for chest problems had been found to have significantly more day care givers who smoke than did control infants. The smoking practices of workers in day care homes deserves immediate attention because this sector includes more children than the others and its popularity with mothers of infants and toddlers. Day care mothers who smoke and care for infant and toddlers probably spend as much time if not more with these children as their mothers. Thus, the smoking habits of these day care workers potentially confound the results of studies of the effect of parental smoking on the health of children. 4. RECOMMSND1lTIONa 4.1.REOULATIONB Existing day care regulations clearly are deficient in mandating a safe and healthy day care environment. Federal regulation, while desirable, is not feasible at this time since the prevailing attitude today is away from federal intervention and toward state and personal responsibility. (49) Before proposing solutions, Haskins (17) recommend that one should determine if the current state of day care regulation is causing the market to function improperly. He also warned that the scientific data necessary for a convincing case of market failure and an accurate assessment of benefits and costs are currently inadequate. Thus, the policy problems cannot receive a complete assessment until the state of knowledge improves. Meanwhile, he suggested that the most important interim steps are to give parents better information about day care and strengthen state regulations that are clearly related to health outcomes. In designing health policies for day care, it is important to approach the problems comprehensively and constructively. (24) We must keep in mind the potentially positive as well as negative effects of substitute care on children's health (49, 50) and the reasons families turn to day care in the first place, namely, because both parents must have child care during work hours. (35, 50) The regulation of day care homes, which contain the most children is an especially delicate issue. Bartlett and colleagues (2) warns that increased regulation of homes might have the effect of actually decreasing the availability of this mode of child care. Haskins (2) also cautioned that the sheer number of providers and the small size of these units would make effective oversight a 125

pollution. Nonetheless, reviewers have concluded that most studies have shown an increase in mild acute respiratory illnesses among children in day care and this effect occurred primarily in younger children. There is stronger evidence for initial and recurrent otitis media. (17) Large group day care centers and probably smaller day care homes are settings in which the incidence of otitis media is increased for young children. (2, 17, 18, 31) Studies also show reduced rates of both symptoms and acute illnesses with increasing age in all sites and there is very little evidence of an excessive rate of illness in day care children for the more serious respiratory illnesses. (17) Although most studies have found increased rates of acute, minor, respiratory illnesses among children in day care, asymptomatic children in day care do not have higher levels of respiratory tract pathogens or even different pathogens than children reared at home. (1, 17, 40) However, The true incidence of infectious disease in family day care is unknown since most of it is unlicensed. Therefore, conclusions cannot be made on this mode of care. (2) 3. PASSIVE 8NO1CIN0 3.1.RELATIONBHIP TO DISEASES IN INFANTS AND CHILDREN A number of studies have demonstrated a positive association between passive smoking and lower respiratory symptoms (4, 5, 13, 36) and lower respiratory diseases (11, 12, 22, 29, 48) in infants and young children. Maternal smoking, when measured, showed a high correlation with respiratory symptoms and diseases in the above studies whereas, paternal smoking was rarely significant. Studies on the relationship of passive smoking to the development of bronchiolitis are less clear. Two studies (32, 38) show a positive association with maternal smoking. However, Pedreira and colleagues (29) did not find a relationship. Otitis media is the only upper respiratory disease reported in the literature as being associated with passive smoking. Six studies (3, 20:, 21, 30, 34) showed an increase incidence of otitis media with maternal smoking. However, in four other studies (39, 45, 46, 47) parental smoking was not significant. Pukander and colleagues (30) suggest that these studies may not have found a relationship because of the maskinq effect of day care attendance and other confounding variables. Two comprehensive reviews (27, 43) have concluded that bronchitis, pneumonia, other lower respiratory tract illnesses and otitis media occur more frequently during the first year of life in children with mothers who smoke. The National Research Council (27), however, emphasized the need for caution in the interpretation of the results of the studies on the effect of involuntary smoking. 123

34. Said, G; Zalokar, J; Lellouch, J; Patois, E; "Parental Smoking Related To Adenoidectomy and Tonsillectomy in Children," Journal of Epidemiology and Community Health, 32(2): 97-101; June, 1978 35. Scarr, St Mother Care, Other Care; New York: Basic Books; 1984 36. Schenker, MB; Samet, JM; Speizer, FE "Risk Factors for Childhood Respiratory Disease: The Effect of Host Factors and Home Environmental Exposure," American Respiratory Disease, 128: 1038-1043; 1983 37. Section Allergy, Canadian Pediatric Association; "Secondhand Smoke Worsens Symptoms in Children With Asthma;" Canadian Medical Association Journal; 1986, August 2; 135(4): 321-323 38. Sims, DG; Downham, M7 Gardner, PS; Webb, J; Weightman, D. "Study of 8-Year-Old Children With A History of Respiratory 39. 40. 41. Syncytial Virus Bronchiolitis in Infancy," British Journal of Medicine, 1(6104): 11-14, January 7, 1978 Stahlberg, MR; "The Influence of Form Day Care on the Occurrence of Acute Respiratory Tract Infections Among Children;" Acta Paediatric Scandinavia [Supplement]7 1980; 282: 1-87 Strangert, K; Carlstrom, G; Jeansson, S; Nord, CE; "Infections in Preschool Children In Group Day Care," Acta Paediatric Scandinavia, 65: 455-463, 1976 Strangert, K; "Respiratory Illness in Preschool Children With Different Forms of Day Care," Pediatrics, 57(2): 191-196; February, 1976 42. Task Force on Epidemiology of Respiratory Diseases; Epidemiology of Respiratory Diseases; Division of Lung Diseases, National Heart, Lung & Blood Institute; November, 1981 43. Public Health Service, The Health Consequences of Involuntary Smoking: A Report of the Surgeon General, U.S. Department of Health and Human Services, Rockville, MD: Government Printing Office, 1986 44. Public Health Service, The Health Consequences of Smoking: Cancer and Chronic Lung Disease in the Workplace, U.S. Department of Health and Human Services, DHHS (PHS) 85-50207, 1985 132

independent risk factors, such as age and sex, were not always taken into account. Interpretation of epidemiological studies is hampered by the existence of factors that interact with and modify the response to exposure and by confounding factors that are associated with the same symptom complex. While several statistical approaches were used to control for potentially confounding variables, however, researchers do not agree on the nature of the roles of the variables as confounders and the appropriate ways to introduce these variables into the data analysis. The use of questionnaires to collect information on symptoms are prone to recall bias. Most studies examined only the effects of exposure to parental smoking, excluding exposures outside the immediate family, and found significant association only for the effect of maternal.smoking. In future studies, great care must be taken to account for potential confounding variables in the analyses. Two researchers offered explanation for the observed association with only maternal smoking. Pedreira and colleagues (29) postulated that the mother, more often than the father, remained at home with the child. This also suggest that the duration of exposure rather than the presence of a smoker is the important factor in infant-related respiratory diseases. Ware and colleagues (48) also suggested that this somewhat stronger association need not imply any special risk associated with maternal smoking. They argued that a more plausible interpretation is that children are more likely to be with their mothers than with their fathers at the times smoking occurs. 3.2.DAY CIIRE 718 A CONFOVNDSNG 7ARIABLE Reviewers have concluded that exposure to parental smoking increases the risk of upper and lower respiratory diseases in infants. Day care attendance also greatly increase the occurrence of upper respiratory infections and perhaps some lower respiratory illnesses in infants and toddlers. However, studies focusing primarily on the effects of passive smoking have failed to control for day care attendance and many of the studies on day care infections did not consider parental smoking as a possible confounding variable. Moreover, none of the studies in either area considered the smoking habits of day care workers. Seven of the day care studies (14, 19, 30, 39, 45, 46, 47) did consider parental smoking. Two of these studies (14, 30) found a positive and independent effect for both day care attendance and maternal smoking. The effect of day care had the strongest in both cases. The remainder showed a statistical significance for day care attendance only. Pukander and colleagues (30) argued that the effect of day care attendance may have masked the effects of maternal smoking in these studies. Given that almost 50% of mothers of children under 5 years of age 124

23. Lundgren, K; Ingvarsson, L7 Olofsson, B; "Epidemiological Aspect in Children With Recurrent Acute Otitis Media;" in Lim, DJ; et al; Recent Advances in Otitis Media With Effusion; Philadelphia: B C Decker; 1984; 22-25 24. Marwick, C1 Simmons, K; "Changing Childhood Disease Pattern Linked With Day-Care Boom;" Journal of American Medical Association; 1984, March 9; 251(10): 1245-1247, 1250-1251 25. McConnochie, K; Hall, CP Barker, Wf "Lower Respiratory Tract Illness in the First Two Years of Life: Epidemiologic Patterns and Costs in a Suburban Pediatric Practice;" American Journal of Public Health; 1988, January; 78(1): 34-39 26. Morgan, G7 Stevenson, C; Fiena, Rf Stephens, K; "Gaps and Excesses in the Regulation of Child Care: Report of a Panel;" Review of Infectious Diseases; 1986, July-August: 8(4): 634-643 27. National Research Council; Environmental Tobacco Smoke - Measuring Exposure and Assessing Health Effects; Washington, DC: National Academy Press; 1986 28. O'Connell, Hi Rogers, CCJ "Child Care Arrangements of Working Mothers: June 19827" Current Population Reports (Bureau of Census); 1982; Special Studies P-23; No. 129 29. Pedreira, F; Guandolo, V; Feroli, E; Mella, G; Weiss, I; "Involuntary Smoking and Incidence of Respiratory Illness During the First Year of Live," Pediatrics, 1985; 75: 594-597. 30. Pukander, J; Luotonen, J; Timonen, M; Karma, P; "Risk Factors Affecting the Occurrence of Otitis Media Among 2-3 Year Old Urban Children;" Acta Otolaryngology [Stockholm]; 1985, September-October; 100(3-4): 260-265 31. Pukander, J7 Sipira, M; Karma, P; "Occurrence of and Risk Factors in Acute Otitis Mediai" in Lim, DJ; et al; Recent Advances in Otitis Media With Effusion; Philadelphia: B C Decker; 1984; 9-13 32. Pullan, CRr Hey, EN. "Wheezing, Asthma, and Pulmonary Dysfunction 10 Years After Infection With Respiratory Syncytial Virus in Infancy," British Journal of Medicine, 284(6330): 1665-1669, June 5, 1982 33. Ruopp, Rt Travers, J; Glantz, F; Coelen, C. Children At the Center: Summary Findings and their Implications; Cambridge, MA: Abt Books; 1979 131

formidable and expensive task. Furthermore, if regulations are made too strict, costs will go up and day care centers will be put beyond the means of those who need them the most. The results might send day-care underground where it could operate without proper health supervision. (24) Haskins (2) proposed the following steps to help parent get information: 1.Require homes and centers to permit unlimited and unscheduled visits by parents; 2.Put parents in a position of power and authority in the operation of day care through membership on boards; 3.Require all facilities to have written policies on health and that a copy be given to parentst and 4.Community Coordinated Child Care (4-C) be the primary actor in providing training and providing parents with information on child care. The Symposium of Infectious Diseases in Child Day Care: Management and Prevention voiced unanimous support for strict adherence to a policy of frequent hand washing; and at least daily cleaning and sanitization of surfaces used for diapering, food preparation, and those that are mouthed by infants and toddlers. (1) Fleming and colleagues (14) addressed the issue of passive smoking. They noted that the major difference between maternal smoking and day care attendance, is that maternal smoking is preventable, whereas day care attendance is not. Child care is an irreplaceable service which also results in the transmission of disease. Therefore, reduction of other risks among children who attend day eare is the most practical approach. 4.2.RESEARCH Little is known about the actual practices of licensing agencies and the effectiveness of regulation. Do children in day care visit health professional more often for infectious diseases? If they do, is it because day care programs are urging more frequent consultations, because the parents are more anxious about the threat that their children will be excluded from day care if sick, or because there actually are more infections. (1) The sparse data available regarding family day care make it important to pay more attention to this mode. Since day care homes includes more children, particularly infants and toddlers, it is important to understand the disease experiences in these homes. 126