Parents often ask paediatricians for advice about the best way to care for their children. There are discrepancies in the literature on this subject. The objective of this study is to evaluate the influence of attending kindergartens at the risk of acute infections and the use of health care resources in children less than 24 months.
Population and methodsA prospective longitudinal study was conducted on two cohorts of children aged 0–24 months (born between 1 January and 30 September 2010), who were grouped according to whether they attended kindergarten or not, and were usually seen in 33 paediatric clinics of the Principality of Asturias Public Health Service.
Results and conclusionsA total of 975 children were studied, of whom 43.7% attended a kindergarten at 24 months. Attending kindergarten increases the risk of pneumonia by 131%, recurrent wheezing by 69%, bronchitis by 57%, and otitis media by 64%. Early exposure to kindergarten increases the risk of pneumonia from 2.31 to 2.81, and the mean emergency room visits from 1 to 2.3.
The mean antibiotic cycle is 1.7 in children who do not go to kindergarten, 3.4 if started within the first 6 months, and 2 if they start at 18 months.
Care attendance is a factor of risk of infectious diseases increases if they attend at an early age.
Los padres con frecuencia solicitan a los pediatras consejo acerca del mejor sistema para el cuidado de sus hijos. En la literatura existen discrepancias al respecto. El objetivo de este estudio es evaluar la influencia de la asistencia a la guardería sobre el riesgo de infecciones agudas y la utilización de recursos sanitarios en los niños menores de 24 meses.
Población y métodosEstudio longitudinal prospectivo de 2 cohortes de niños de 0–24 meses que se diferencian por la asistencia o no a la guardería, nacidos entre el 1 de enero y el 30 de septiembre de 2010 y que acuden habitualmente a las consultas de 33 pediatras del Servicio Público de Salud del Principado de Asturias.
Resultados y conclusionesSe estudiaron 975 niños. A los 24 meses acuden a la guardería el 43,7%. Asistir a guardería incrementa el riesgo de padecer neumonía en un 131%, el de sibilancias recurrentes en un 69%, el de bronquitis un 57% y el de otitis media en un 64%. La exposición temprana a la guardería incrementa el riesgo de neumonías de 2,31 a 2,81 y la media de visitas a urgencias desde 1 a 2,3.
La media de ciclos de antibióticos es de 1,7 para los que no van a la guardería, de 3,4 si la inician en los 6 primeros meses y de 2 si comienzan a partir de los 18 meses.
La asistencia a guarderías es un factor de riesgo de padecer enfermedades infecciosas que aumenta si asisten desde edades tempranas.
Women and mothers have traditionally adopted the main role in the rearing of their children. At present, in our country, childbirth gives rise to new circumstances in which most citizens require the help of specialised services to take care of their young.1 The maternity leave period in Spain lasts 16 weeks,2 while it lasts 68 weeks in Sweden.3 The law allows working mothers to devote 1h a day to breastfeeding for 9 months. Thus, child care centres become a social need and demand. According to population surveys, in 2010, 25.01% of women employed out of the home in Spain reported engaging specialised services for the care of their children.4
Child care attendance does have an influence on children's health. A literature review published in 20075 concluded that child care attendance was associated with a significant increase in acute infectious disease in childhood, which also has an impact on society and the immediate household environment.6 Furthermore, it has economic consequences through increased health care costs and the cost associated with parental absences from work.7
In recent years, there has been social debate about the best way to care for children during early childhood. Some studies have been published in support of the psychosocial benefits of attending child care centres, although these benefits have not been proven in populations that are not at psychosocial risk.8 In this context, families often ask the paediatrician about the best way to care for their children. Learning the actual facts will better guide decision-making on this subject while taking into account the circumstances of the household and the health status of each child.
Objectives- •
To assess the influence of child care attendance on the risk of acute infection, use of pharmacological agents and use of health resources in children younger than 24 months. To establish the influence of other factors.
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To assess whether the “child care exposure time” factor increases the incidence of infectious diseases and the use of pharmacological agents.
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To learn the reasons for using child care from participant responses.
We conducted a prospective longitudinal study with two cohorts of children 0–24 months of age that differed in that they attended or did not attend child care (exposure factor); the study was adapted for Asturias from the one designed by the working group of the Asociación Española de Pediatría de Atención Primaria (Spanish Association of Primary Care Paediatrics).9
Inclusion criteriaChildren born between January 1 and September 30, 2010, seen regularly at primary care (PC) paediatric clinics of the Servicio Público de Salud del Principado de Asturias (Public Health Service of the Principality of Asturias [SESPA]), and whose families agreed to participate in the study after being fully informed.
Exclusion criteriaChildren with severe immunodeficiencies or respiratory diseases, heart disease requiring surgery, and children that were not seen regularly at the PC paediatric clinics.
ParticipantsThe study engaged the participation of 35 paediatricians and 20 nurses from the 8 health areas of the SESPA that recruited 1139 children.
Study variablesIndependent variable: child care attendance, yes or no (dichotomous variable), which defined the two cohorts. We documented the age the child started attending in months, and the reasons for attendance.
Descriptive variablesPersonal characteristics: inclusion code, date of birth, sex, gestational age, birth weight, neonatal morbidity, breastfeeding, vaccines from the official immunisation schedule of Asturias and optional vaccines (pneumococcal, rotavirus and varicella vaccines).
Household characteristics: number of siblings; parental characteristics: age, educational level, employed yes/no, smoking, allergies, asthma.
Dependent variablesNumber and type of acute infections leading to health visits (to PC paediatricians or emergency services): bacteraemia, bronchiolitis, acute bronchitis, conjunctivitis, exanthematous viral diseases, pharyngitis, pharyngotonsillitis, acute gastroenteritis, influenza, laryngitis, meningitis, pneumonia, acute otitis media, common cold, sepsis, recurrent wheezing episodes, all of them previously defined according to the Nelson Textbook of Pediatrics.10
Used medications: antibiotics, bronchodilators, inhaled and oral corticosteroids and montelukast.
Visits to emergency and paediatrics services: we excluded visits corresponding to the checkups of the well-child programme.
Data collectionWe collected the data from the electronic medical records and from interviews with the adults that accompanied children to scheduled check-up visits at ages 6, 12, 18 and 24 months, which consisted of personal interviews and the collection of data in questionnaires previously designed for this purpose. Data for the descriptive variables were collected at the first visit and data for the outcome variables at 6, 12, 18 and 24 months, and they were recorded in the forms filled out in each visit. The informed consent form (Appendix 1) given to the parents included an explicit statement on the adherence and compliance with legislation and with ethical principles.
Statistical analysisWe performed a descriptive analysis of the data collected for the different variables. To assess whether the age at first enrolment in child care affected the risk of having infectious diseases, we also analysed the sample by age intervals: less than 6 months, 6–11 months, 12–17 months and 18–24 months. To learn whether the “child care attendance” variable influenced the use of health services, we analysed this use by age (using the same age intervals) and the difference in the number of health care visits before and after enrolment in child care.
We used Pearson's chi square test for comparisons of two qualitative variables, and calculated effect measures such as the relative risk, which we present with their 95% confidence intervals. We calculated adjusted risks by means of binary multiple logistic regression models for sex, gestational age, birth weight, neonatal morbidity, breastfeeding, vaccinations, presence or lack of siblings, and parental variables including age, educational level, allergies, asthma and smoking. We used Student's or Welch's t tests for comparisons of two means, and the Kruskal–Wallis test to compare more than two. We tested for normality and equality of variance using the Shapiro–Wilk and the Ansari-Bradley tests, respectively. We set the level of statistical significance at P<.05.
We performed the statistical analysis with the R® software (R Development Core Team, 2012), version 2.15.
ResultsWe collected the data for 1139 children at age 6 months, 1092 at 12 months, and 975 at 24 months. Thus, 14.3% of cases were lost to followup due to three paediatricians changing jobs (7.9%) and participating children moving to new addresses (7.4%).
Individual and family dataTable 1 shows the individual and family characteristics of all the children in the sample and of children in each of the cohorts (attending/not attending child care), with the corresponding percentages and statistical significance.
Comparison (in percentages) of all the variables analysed in the two cohorts (attending and not attending child care) and statistical significance of the comparisons.
| % total | % in child care | % not in child care | Significance | |
|---|---|---|---|---|
| Sex | ||||
| Male | 50.74 | 53.14 | 48.88 | .22 |
| Female | 49.26 | 46.86 | 51.12 | |
| Gestational age | ||||
| <37wks | 9.70 | 11.22 | 8.51 | .35 |
| 37–40wks | 71.80 | 70.00 | 73.16 | |
| >40wks | 18.50 | 18.78 | 18.34 | |
| Birth weight | ||||
| <2kg | 2.20 | 1.47 | 2.86 | .55 |
| 2–2.5kg | 6.30 | 6.60 | 6.11 | |
| 2.5–4kg | 87.50 | 88.02 | 87.02 | |
| >4kg | 4.00 | 3.91 | 4.01 | |
| Neonatal morbidity | ||||
| Yes | 14.60 | 14.46 | 14.71 | .99 |
| Breastfeeding | ||||
| No | 27.12 | 27.99 | 26.46 | .88 |
| Less than 6 months | 39.86 | 40.22 | 39.58 | |
| 6–12 months | 22.05 | 22.55 | 21.67 | |
| More than 12 months | 10.97 | 9.24 | 12.29 | |
| Vaccinated against pneumococcus | ||||
| Yes | 84.31 | 89.20 | 80.33 | <.01 |
| Vaccinated against rotavirus | ||||
| Yes | 22.60 | 27.70 | 18.03 | <.01 |
| Vaccinated against varicella | ||||
| Yes | 25.50 | 27.00 | 24.41 | .39 |
| Father's age | ||||
| <20 years | 0.40 | 0.00 | 0.75 | .15 |
| 21–34 years | 43.30 | 41.77 | 44.53 | |
| 35–40 years | ||||