What Are Some of the Health Problems Associated with Childcare?

Patient Presentation
A pediatrician was discussing with a colleague that she had seen an 11-month old infant whose mother was distressed because he had had several infections since starting center-based childcare and this week had overheard her child call the childcare professional “ma-ma.” The pediatrician relayed how the mother already felt guilty about using center-based care, and calling the provider ma-ma had had her in tears. The pediatrician said that the child was overall healthy and thriving, with the usual minor infectious disease episodes. The child only called the mother and professional by ma-ma. The child also seemed to say ‘da-da’ for the father, and had another sound for his grandmother. “I reassured the mother that he was doing well and he should have fewer infections as he grew. I also told her that it’s really hard to hear ma-ma being used for someone else, and that him calling her ma-ma probably shows how good he feels about how well the professional cares for him,” she said. The colleague agreed, “I’d much rather hear about a child who is obviously paid attention to and cared for, than the child who isn’t played or interacted with and is withdrawn or not gaining his developmental milestones. I probably would feel the same way though if my son called my carer ma-ma.”

Discussion
Children usually thrive in environments where their physical needs are met, they are encouraged to explore with the world, and where they interact with others who can support their personal growth with other people. In general, a few, consistent caregivers are best for young children. Because of work needs, parents may need other people to help them provide childcare, including family members, non-relative in-home childcare, center-based care or intermittent care (i.e. babysitting). There are many advantages and disadvantages for any of these arrangements and they can be reviewed here. Some families need to have multiple childcare arrangements.

Some US national organizations have excellent information about quality childcare and how to find it. These include:

National Association for Education of the Young Child – What to look for in a program
National Association of Child Care Resource and Referral Agencies – Keys to quality childcare
American Academy of Pediatrics’ HealthyChildren.org – Work and childcare

Brief indicators for quality childcare are include low numbers of children per provider, low staff turnover, accreditation of the in home provider or childcare center.

Learning Point
Note that this discussion does not look at non-parental care in the circumstances of a child in a legal placement situation such as foster or residential care.

The long-term health outcomes for children in childcare are difficult to assess. A systemic review of non-parental childcare and its long-term effects on children’s diet, activity and sleep found “[t]he available, limited, longitudinal literature suggests that attending certain types of non-parental childcare (particularly informal providers) might be related to less breast-feeding, but the evidence regarding other dietary outcomes is mixed, and sometimes contradictory. Moreover, the data reviewed suggest that attending nonparental childcare is unrelated to physical activity, sedentary behaviour, or sleep outcomes. Included studies were of mixed quality with most (92%) not reporting use of valid and reliable outcome measures…”

More specifically the study found:

Item	Number of Studies	Positive Results	Negative Results	Null Results
Diet	63	10	11	59
Increased Physical Activity	9	2 mixed positive and negative	2 mixed positive and negative	7
Decreased Sedentary Behaviors	3	1	0	2
Sleep	15	2	0	13

Another study also found that children whose families relied on multiple childcare arrangements (versus a single arrangement) had increased risks of asthma and infectious diseases (i.e. gastroenteritis, otitis media, upper respiratory infections, etc.), but not for injuries. Other studies have found that the risk for infectious diseases a particular child has is related to the number of other children exposed to and not the length of time in childcare.

Questions for Further Discussion
1. What recommendations do you give families for evaluating quality childcare?
2. What are some of the limitation for quality childcare in your location?
3. How much does childcare cost in your location?

Related Cases

Child Day Care

Health Maintenance and Disease Prevention

General Pediatrics

Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Children’s Health

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Chen JH. Multiple Childcare Arrangements and Health Outcomes in Early Childhood. Matern Child Health J. 2013;17(3):448-455. doi:10.1007/s10995-012-1016-9

Costa S, Benjamin-Neelon SE, Winpenny E, Phillips V, Adams J. Relationship Between Early Childhood Non-Parental Childcare and Diet, Physical Activity, Sedentary Behaviour, and Sleep: A Systematic Review of Longitudinal Studies. Int J Environ Res Public Health. 2019;16(23):4652. doi:10.3390/ijerph16234652

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Common Are Subconjunctival Hemorrhages in Newborns and Infants?

Patient Presentation
A 5-day-old male came to clinic for his well-examination. He was breastfeeding, stooling, and urinating well, and had no concerns for jaundice. The parents were worried about a red spot on his lateral right eye. The past medical history showed a term male born by spontaneous vaginal delivery to a G1P1 26 year old female. The family history and review of systems were non-contributory.

The pertinent physical exam showed an alert male with a weight of 3176 grams (25%), length of 49 cm (50%) and head circumference of 35.5 cm (25-50%). He had mild jaundice of the face. Lateral to the iris of his right eye he had a crescent shaped hemorrhage from ~ 7-10 o’clock. There were normal red reflexes noted and no other abnormalities on external examination of the eyes. The rest of his examination was normal.

The diagnosis of a healthy male with mild jaundice and a subconjunctival hemorrhage was made. The pediatrician had no concerns for possible non-accidental trauma based on the nursery records and the clinical encounter. The parents were concerned because the physicians in the newborn nursery had not said anything about the hemorrhage and they were quite worried. The pediatrician explained that subconjunctival hemorrhages were common, and that it could take a few weeks for it to fade. He noted that sometimes they were difficult to see because the newborn infants’ eyelids were commonly swollen and the hemorrhage was seen a few days later because of this. The hemorrhage was noted again at the 2 week examination but not at the 1 month examination.

Discussion
Newborn infants should have their eye red reflexes examined looking for signs of congenital cataract, retinoblastoma and other ophthalmological problems. This can be complicated by lid edema from birth, and also antibiotic prophylaxis for gonorrhea that may have been applied to the eyes. Sometimes the physician only gets a brief look at the red reflexes. Therefore serial exams over the first days to weeks of life are important.

Trauma and infection are most common in infants and young children, but causes of subconjunctival hemorrhage (SCH) include:

Trauma
- Direct to globe and orbit
- Inadvertent – rubbing, foreign body
- Iatrogenic – surgery
Infection – conjunctivitis
Increased venous pressure – coughing, emesis
Hypertension
Coagulopathy
Tumors

Learning Point
In 2019, the authors of the Neonatal Eye Screen Test (NEST) study reported their results for SCH. The NEST study was a prospective cohort study of 202 terms infants from July 2013-14 that had universally performed newborn ophthalmological screening at birth. They found 9% of newborn infants had SCH, and SCH was more common in high birth weight infants. They noted this was consistent with “…subconjunctival haemorrhages are more likely caused by a chest compression during the passage through the birth canal with a sudden increase of venous pressure in the head and neck.”

SCH are known to resolve over time consistent with other bleeding into tissues. This has also been noted in other studies performed in older age infants and children which have shown a small % of their study population with SCH. Some examples include:

A 2024 study of 2972 full-term infants performed at an average of 49 days (range 10-130 days of life) found 2.3% had retinal hemorrhages and 0.2% had SCH.

A 2022 study of 33,900 children age 2 days to 18 years, found an overall prevalence of SCH of 0.4% and of 0.2% for the 0-1 year olds with 73% due to trauma. Birth related trauma was only one of many traumatic causes.

Questions for Further Discussion
1. What causes red eyes? A review can be found here
2. What causes eyelid edema? A review can be found here
3. What are presentations of non-accidental trauma (i.e. child abuse)? A review can be found here

Related Cases

Eye Diseases

Eye Injuries

Bleeding and Bruising

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Diseases

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Li LH, Li N, Zhao JY, et al. Findings of perinatal ocular examination performed on 3573, healthy full-term newborns. Br J Ophthalmol. 2013;97(5):588-591. doi:10.1136/bjophthalmol-2012-302539

Callaway NF, Ludwig CA, Blumenkranz MS, Jones JM, Fredrick DR, Moshfeghi DM. Retinal and Optic Nerve Hemorrhages in the Newborn Infant: One-year Results of the Newborn Eye Screen Test (NEST) Study. Ophthalmology. 2016;123(5):1043-1052. doi:10.1016/j.ophtha.2016.01.004.

Ji MH, Ludwig CA, Callaway NF, Moshfeghi DM. Birth-related subconjunctival and retinal haemorrhages in the Newborn Eye Screening Test (NEST) Cohort. Eye (Lond). 2019;33(11):1819. doi:10.1038/s41433-019-0523-y

Parikh AO, Christian CW, Forbes BJ, Binenbaum G. Prevalence and Causes of Subconjunctival Hemorrhage in Children. Pediatr Emerg Care. 2022;38(8):e1428-e1432. doi:10.1097/PEC.0000000000002795

Yenice EK, Petricli IS, Kara C. Findings of ocular examinations in healthy full-term newborns. ABO. 2022;87(1). doi:10.5935/0004-2749.2021-0536

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What is the Bristol Stool Scale?

What is the Bristol Stool Scale (BSS)?
A 4-year-old female came to clinic with intermittent abdominal pain for 2-3 weeks. The pain was random and would last for several minutes. She would complain and her mother would have her lie down and then she would go on with her activities within a couple of minutes. The pain did not occur at night. Her bowel movements were reported as normal, but her mother said that usually they occurred at preschool or that she used the restroom by herself and her mother had not seen the stools. She was urinating, eating, and acting normally otherwise.

The past medical history showed at least 2 previous episodes of constipation that were successfully treated with water and increased fiber. Medications had not been used. The review of systems was negative.

The pertinent physical exam showed a healthy female with normal vital signs and growth parameters. The patient indicated that the abdominal pain was periumbilical without radiation, and the abdominal, back, and genitourinary exams were normal. The rest of her examination was normal.

The diagnosis of probable constipation was made after more extensive questioning of the patient and mother. The patient didn’t know how frequently she stooled but thought it “was a long time” between stools. When asked if the stools were like water she said no and answered similarly if they were toothpaste or yogurt-like. When asked if they were more like a stick or a rock she said yes and indicated on a Bristol Stool Scale chart that her stools that were Bristol 1-3 in consistency. She was sure they were not a Bristol 5, 6, or 7. The patient was started on a regiment of Miralax® and the parent was instructed to increase fiber, fluids and monitor her stools.

Discussion
The Bristol Stool Scale (BSS) is a tool to assist patients, family members and health care providers to share common language about stool consistency. The actual language and what that language means has implications both for clinical treatment but also research results. The BSS was originally developed at the Royal Infirmary in Bristol, UK and published in 1997. The study was performed with 66 volunteers aged 15-62 years old where they looked at “normal” stools and transit time and after using senna and loperamide medications.

The original Bristol Stool Form Scale description with notations in brackets:

Type 1 Separate hard lumps, like nuts [constipation/encopresis, difficult to pass]
Type 2 Sausage-shaped but lumpy
Type 3 Like a sausage or snake but with cracks on its surface
Type 4 Like a sausage or snake, smooth and soft [average stool]
Type 5 Soft blobs with clear-cut edges
Type 6 Fluffy pieces with ragged edges, a mushy stool
Type 7 Watery, no solid pieces. [diarrhea, easy to pass and may involuntarily be passed]

Learning Point
The BSS has been used as a standard and also modified for other populations including toilet-trained children and for those in diapers. “Especially the form of soft stools is altered when it is pressed together between the buttocks and is spread out in the diaper. Also the duration that the stools have been in the diaper will change the appearance.”

Use of drawings or pictures does help with clarification and grading of the stools (see To Learn More below for images). However some of the finer grading may not be clear to patients or family members. For example, a Bristol 1 is relatively easy to identify as the hard lumps of stool are pellet-like and separated apart from each other. Bristol 2 and 3 are similar though in that the stool is formed but the difference is in the segmentation. For Bristol 2, the appearance of segmentation occurs as lumps of stool that are adhered together, but with Bristol 3 the segmentation appears because of cracks on the outside of the stool. The parent and/or patient may only see that the stool is formed and there is segmentation. They may not be able to note the difference between the grades. The same is true for the opposite end of the BSS. Parents and patients may not be able to indicate the difference between “soft blobs” of Bristol 5 and “fluffy pieces” of Bristol 6 as both look very soft and mushy to them.

These differences can be very important for outcomes of research studies. They can also be important for monitoring of clinical outcomes of treatment in gastroenterological diseases. In these instances, it would be important to spend time with the patient and family member to help them to be able to accurately indicate the differences between the different levels. In a general pediatrics or similar setting, usually it is close enough to be able to distinguish between probably constipation (hard stools, Bristol 1-2) from normal variations (Bristol 3-5) and probably diarrhea (watery stools, Bristol 6-7). Patients and family members should also be asked about the range of stool consistency they usually encounter and not just the last stool that was produced. Stool consistency is only one factor in assessing clinical or research outcomes, including where the stool was produced (i.e. toilet, diaper), stool frequency, abdominal pain, eating patterns, infectious disease exposure, etc. all can help with patient management. Sometimes parents will also note “watery” stools that occur along with “hard” stools. This pattern may be because of overflow of liquid stool around hard stool that may occur in a constipation or encopresis setting.

Questions for Further Discussion
1. What other questions do you use to help patients provide more accurate grading of their stool consistency?
2. What questions do you use to help patients provide accurate grading for other clinical scales such as pain scales?
3. What causes acute abdominal pain? A review can be found here.
3. What causes recurrent abdominal pain? A review can be found here.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Bowel Movements and Abdominal Pain.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920-924. doi:10.3109/00365529709011203

Vriesman MH, Velasco-Benitez CA, Ramirez CR, Benninga MA, Di Lorenzo C, Saps M. Assessing Children’s Report of Stool Consistency: Agreement Between the Pediatric Rome III Questionnaire and the Bristol Stool Scale. J Pediatr. 2017;190:69-73. doi:10.1016/j.jpeds.2017.07.002

Huysentruyt K, Koppen I, Benninga M, et al. The Brussels Infant and Toddler Stool Scale: A Study on Interobserver Reliability. J Pediatr Gastroenterol Nutr. 2019;68(2):207-213. doi:10.1097/MPG.0000000000002153

Wegh CAM, Hermes GDA, Schoterman MHC, et al. The Modified Bristol Stool Form Scale: A Reliable and Valid Tool to Score Stool Consistency in Dutch (Non)Toilet-trained Toddlers. J Pediatr Gastroenterol Nutr. 2021;73(2):210-216. doi:10.1097/MPG.0000000000003186

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are Treatment Options for EOE?

Patient Presentation

A 9-year-old male came to clinic to establish care. His family had recently moved to the area. Overall he was growing and developing well. His mother was concerned as he had a “sensitive stomach” and seemed to gag and have emesis more easily than she expected. It occurred intermittently usually when he had other illness symptoms but her sister had similar problems as a child and was recently diagnosed with eosinophilic esophagitis. When he was well, he denied any bad taste in mouth, heartburn symptoms, chest pain, abdominal pain and no diarrhea or irregular stools. He ate most foods of all textures and had no irregular eating patterns. He said that sometimes when he was upset or would cry he would throw up. His mother endorsed this and said this was what she had meant by “sensitive stomach.” She also said that he seemed to have a strong gag reflex and gave several examples of this, including that his previous dentist had noted it also. His previous doctor had thought that the emesis was more situational along with a strong gag reflex and was not more concerning. Additional evaluation had not been done.

The past medical history was negative. The family history was positive for the maternal aunt with eosinophilic esophagitis, asthma and allergies. A maternal uncle and mother also had seasonal allergies. The father had gastroesophageal reflux as a child. The review of systems was negative.

The pertinent physical exam showed a healthy appearing male with normal vital signs. Growth parameters were tracking along the 50-75%. HEENT had a sensitive gag reflex but did not provoke emesis. He had some mild dry skin. The rest of his examination was normal.

The diagnosis of a healthy male was made.
The child and parent were counseled about potential ways to avoid triggering the gag reflux. As the child did not seem to have dysphagia, abnormal eating patterns or other gastrointestinal problems the pediatrician noted that eosinophilic esophagitis was a very unlikely cause of the problem. “The eosinophilic esophagitis does occur including in people with more allergy problems and asthma, but he doesn’t have those problems so we can just monitor him for now,” she advised.

Discussion
Eosinophilic esophagitis (EOE) is a clinicopathologic condition of the esophagus where a pediatric or adult patient has clinical symptoms of esophageal dysfunction along with 15 or more eosinophils per high powered field in histological samples. The clinical diagnosis is difficult because many presenting symptoms are consistent with gastroesophageal reflux disease (GERD). Clinical features in children include feeding intolerance or refusal, abdominal pain, emesis or reflux symptoms. Other symptoms include chest pain, diarrhea or failure to thrive. Older children and adolescents may have food impaction or dysphagia similar to adults who report these as their most common symptoms. History may also include strategies to improve symptoms such as “washing the food down” with liquids, avoiding hard food such as meats or cutting the food into smaller pieces, and increasing food mastication to make it softer. Not surprisingly these behavioral changes result in longer meal times.

Endoscopic findings are not specific for EOE. They can include linear furrows, circular rings, stricture, loss of vascular patterns and other findings. Multiple biopsies are needed to make the diagnosis as the eosinophilic infiltration is not uniform. And other diseases can also have esophageal eosinophilia also making the diagnosis more difficult. These include “Crohn’s disease, collagen vascular disease, drug-induced esophagitis, hypereosinophilic syndrome, GERD, and eosinophilic gastroenteritis.” A mild peripheral eosinophilia is more common in children than adults and skin testing for some food allergens is sometimes considered as well.

The pathogenesis appears to be multifactorial and not well understood. “EOE has a strong association with atopy….” Many of these patients have aeroallergen sensitivity and fewer have true food allergy. EOE has an estimated prevalence of about 56-58 cases per 100,000 and is similar for children and adults. High rates are described in Europe and the US and fewer in Asia. There is also data supporting that the diagnosis is increasing since it was first described in 1977. It is more common in males than females.

Learning Point
Treatment for EOE can include PPIs (often used as a first-line treatment), swallowed topical corticosteroids (often using inhaled corticosteroids that are swallowed), and/or food elimination diets. Although true food allergy is less common, treating as if it is a food allergy or sensitivity improves many (but not all) patients’ symptoms. “Multiple studies show that milk tends to be the most common identified trigger in EoE, with wheat, egg, and soy/legumes being other frequent culprits.” In a 2006 study of an empiric 6 food elimination diet in children (milk, soy, egg, wheat, nuts, and seafood) with step-wise reintroduction found that esophageal inflammation was caused by 1 food in 72% of the children, 2 foods in another 8% of children, 3 foods in an additional 8% of children, and 11% tolerated reintroduction of all 6 foods. Newer immunomodulator treatments are also being used for some patients. Oral systemic steroids are also sometimes used but have their own potential side effects.

Longer term, some patients appear to “outgrow” the problem, or the problem is managed without long-term interventions. Some patients do require ongoing treatment along with other management such as esophageal dilation for those patients with significant strictures. Additional other disease (e.g. celiac disease, GERD) or anatomical problems (e.g. tracheoesophageal fistula) may require additional treatment considerations.

Questions for Further Discussion
1. How is GERD diagnosed and treated?
2. What causes abdominal pain?
For recurrent abdominal pain a review can be found here, and
for acute abdominal pain can be found here.
3. What causes failure to thrive?
A review can be found here.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Eosinophilic Esophagitis

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lehman HK, Lam W. Eosinophilic Esophagitis. Pediatr Clin N Am 66 (2019) 955-965. ClinicalKey. Accessed February 19, 2024. https://www-clinicalkey-com.proxy.lib.uiowa.edu/#!/content/journal/1-s2.0-S088985612100062X

Lehman HK, Lam W. Eosinophilic Esophagitis. Immunol Allegy Clin N Am 41 (2021) 587-598. Accessed February 19, 2024. https://www-clinicalkey-com.proxy.lib.uiowa.edu/#!/content/journal/1-s2.0-S0031395519300835

Hirano K, Furuta GT. Approaches and Challenges to Management of Pediatric and Adult Patients With Eosinophilic Esophagitis . Gastroenterology 158 (2020) 840-851. Accessed February 19, 2024. https://www-clinicalkey-com.proxy.lib.uiowa.edu/#!/content/journal/1-s2.0-S001650851941

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa