key: cord-0834575-u7v0es5w
authors: Hashikawa, Andrew; Sells, Jill; DeJonge, Peter; Alkon, Abbey; Martin, Emily T.; Shope, Timothy R.
title: Child Care in the Time of COVID-19: A Period of Challenge and Opportunity.
date: 2020-07-17
journal: J Pediatr
DOI: 10.1016/j.jpeds.2020.07.042
sha: 9238bd804032bfae90688e5f0c670850d461cb1b
doc_id: 834575
cord_uid: u7v0es5w

nan

such as Head Start and military-sponsored programs, receive federal funding, but these represent only a small fraction of ECE arrangements. 1 The high operating costs of ECE are passed onto families in the form of tuition and can represent a substantial proportion of a family's income; in some states, the price approaches or exceeds in-state college tuition. 6 High-quality ECE has become cost-prohibitive to most poor and minority families. 4, 6 The federal government has provided some funding to states that is intended to subsidize ECE costs for low-income families (eg, Child Care and Development Fund, Temporary Assistance for Needy Families, and the Social Services Block Grant), but these funds cover only 30% of total child care expenditures nationally. 1 Similarly, federal tax credits, which only apply to middle-class families, average <10% of the cost of full-time child care. 1 Furthermore, over 50% of the US population lives in child care 'deserts,' or census tract areas that either completely lack ECE services or only have one-third of the licensed child care capacity needed by families. 5 ECE deserts are more frequently found in rural, low-income areas, and also are associated with a high proportion of minority residents. 5 Even in locations with sufficient ECE capacity, many parents report having significant difficulty finding back-up child care when their child is sick and cannot attend their regular ECE program. 7 Parents often rely on non-parental relatives such as the child's grandparents for emergency child care; now, the pandemic has limited this back-up option because of the concern for the spread of COVID-19 to more vulnerable, high-risk family members. 8 The pandemic has impacted the availability of ECE, both in the early months of the pandemic and likely into the future as well. In most states, social-distancing policies shuttered nonessential businesses temporarily, but there was a variety of responses related to ECE programs. Some states closed all organized ECE programs, others allowed exemptions for programs that cared for children of essential workers, and some did not close any programs. ECE program closings varied so markedly from state to state that dashboards were created to track different state closings. 9 During COVID-19, as businesses closed and parents were furloughed or worked from home, demand for ECE from these parents decreased, reducing attendance and decreasing revenue to ECE programs, resulting in further closures of programs for financial reasons. An estimated 60% of ECE programs 8 Closure of ECE programs caused problems for essential workers (e.g., health care workers, first responders, transit workers, grocers). A nationally representative survey of parents found that over one-third of respondents found it "very difficult" to find child care, nearly double that from the same period 6 months prior, and particularly remarkable considering simultaneously decreased demand because of historically high unemployment. 8 Only 22% of essential workers were able to continue their previous ECE arrangements during the pandemic and parents were nearly twice as likely to report difficulties finding quality ECE programs within their budget. 8 Many low-income essential workers were without paid leave, did not have an available family caregiver, or also were less likely than high-income parents to be able to work remotely. 8 However, even among parents who could work from home, a national survey reported that 43% still required child care. 8 The financial unsustainability of ECE programs Typically, the majority of revenue for ECE programs is derived from tuition fees, and 80% of child care program expenses are related to payroll; most experts view this as unsustainable. 6 Indeed, previous regional disasters and societal upheaval consistently have demonstrated the fragility of the ECE infrastructure. 11, 12 For example, most ECE programs are a low-margin business and have limited access to recovery funds. Therefore, if they are closed for relatively brief periods in excess of several weeks, they cannot meet payroll or pay rent, often resulting in permanent closure. 12 Subsequently, the lack of available ECE programs for families after disasters significantly affects recovery efforts by keeping families from working and businesses from rebounding economically. 11, 13 Although ECE is considered a critical service by the Federal Emergency Management Agency for regional recovery, ECE programs are underprepared for emergencies and are usually overlooked during disaster recovery planning. 11,

The COVID-19 pandemic has placed substantial financial strains on the industry, with smaller ECE programs vulnerable to permanent financial collapse, and very little direct federal or state public financial support. One national survey conducted by the National Association for the Education of Young Children in March, 2020 found that many ECE owners questioned the future viability of the ECE industry. 15 The survey revealed that 50% of ECE programs were losing income because families were unable to pay, with another 25% losing additional income because states reimbursed providers based on attendance rather than enrollment for low-income families receiving child care subsidies, and thus these payments decreased as well when children stayed home. 15 This is dire news for a workforce that is overwhelmingly female, minority (40%), significantly underpaid (double the proportion of workers living below the poverty line compared with other industries), and lacking health insurance despite having many underlying chronic health conditions. 6, 16 CCR&R agencies have reported that the attrition of the child care workforce is among the top concerns for ECE programs during the pandemic. 10 The federal government has met some of the immediate ECE needs during the pandemic but fallen short in other areas. Realizing the ECE system's importance to the economic infrastructure, Congress included specific provisions for the ECE sector when passing the two trillion dollar Coronavirus Aid, Relief, and Economic Security (CARES) Act. The CARES Act included $3.5 billion in discretionary funding to states to help support ECE through payment assistance to programs experiencing decreased enrollment, emergency child care for essential workers, financial assistance to parents working in critical sectors, and funding for purchasing supplies to stay open or reopen. 17 Currently, most ECE providers, with little cash reserves and high overhead costs, are unsure if they can remain in business without further financial support from the state or federal government. 15 Other additional legislation to financially support the ECE industry is currently pending in Congress. 18 The ECE system also was not included when the Department of Homeland Security identified sixteen groups of critical infrastructure sectors during the COVID-19 pandemic. 19 The designation as critical essential infrastructure workforce is a way to assist states and local governments in prioritizing accommodations for employees critical to operations so they can continue to work during the pandemic. 19 The lack of standardized regulation, preparation, and health support for ECE There are no comprehensive federal regulations for the safe and healthy operation of ECE programs, other than federally funded Head Start and military programs. Instead, regulations are developed at the state level, resulting in a high degree of national variability in the health and safety requirements for licensed programs. Even within states, ECE practices and policies vary between programs, and a significant proportion of ECE in the US is unlicensed and unregulated. 4 Across states and local jurisdictions, ECE agencies and programs have variable access to support from health professionals such as child care health consultants to discern needs, inform the development of standards for daily operation, disseminate these standards, and support implementation. These standards include adequately detailed and updated emergency, disaster, and pandemic plans, which most licensed ECE businesses lack despite being required for licensing in many states. 10, 20, 21 There has not been a nationally coordinated effort to develop, disseminate, and implement effective, adequately detailed guidance for the ECE system during the COVID-19 pandemic. Initial Centers for Disease Control and Prevention (CDC) recommendations offered guidance for programs that remained open to care for children of essential workers. 22 This guidance was replaced by advice for programs "that remain open" and was complemented by a protocol offered to commercial businesses regarding social distancing, cleaning, and screening as they re-open. 23, 24 These guidelines remain largely insufficient for the day-to-day operational needs of most ECE programs.

National standards for ECE-including those related to emergencies and infection control-exist for health and safety in child care, which are published in Caring for Our Children (CFOC) by the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education. 25 However, there is no mechanism to rapidly modify, update and disseminate these standards to meet the needs of the COVID-19 pandemic. Existing CFOC standards do not address the new concerns expressed by ECE workers during the pandemic, which include: determining the risks for ECE workers, establishing whether physical distancing in young children is feasible and effective, providing more details about cleaning and disinfecting, defining new group size requirements, defining the proper use of SARS-CoV-2 screening tests, handling readmission of children with symptoms or positive COVID-19 tests, and establishing guidelines for temperature checks (type of thermometer, fever threshold for exclusion, when to take temperatures after the initial screening). 26 Without federal or other national guidance, each state government and local health department is left to develop their own ECE health policies.

SARS-CoV-2 is not yet well understood, with a distinct lack of pediatric SARS-CoV-2 epidemiologic studies in group settings to guide policy and practice. 27 In part, this is because a large proportion of infected children have asymptomatic or mild COVID-19 clinical courses.

Although uncommon, childhood cases of COVID-19 can also be severe. The multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 infection, which shares some characteristics with Kawasaki disease, has prompted a recent CDC alert. [28] [29] [30] [31] However, because most children with SARS-CoV-2 infection have mild to no symptoms, childhood cases often are detected only through contact tracing related to an adult clinical case. [30] [31] [32] As a result of under-detection in children, the extent to which children may fuel community spread of SARS-CoV-2, as with other respiratory illnesses , is currently unknown. [32] [33] [34] The recommendations to close ECE programs and schools, however, were derived from epidemiologic transmission studies of influenza, which has disproportionately higher transmission rates and clinical disease in young children. 33, 37 At present, SARS-CoV-2, compared with influenza, appears to infect fewer and cause milder clinical disease in young children, and have higher transmissibility among adults. [30] [31] [32] 38 SARS-CoV-2 surveillance data in group settings are not yet available, but neither are published reports of widespread child-tochild transmission of COVID-19 in ECE or school settings, suggesting transmission in these settings is either uncommon or unrecognized due to mild or asymptomatic infection. [32] [33] [34] However, media reports of COVID-19 outbreaks in schools in Israel and child care centers in Texas require further research to determine the extent of child-to-child transmission from infected adults to children. 35, 36 Modeling for SARS-CoV-2, and other coronavirus epidemics of SARS and MERS demonstrates that the effect of child care and school closures on reducing transmission and mortality in society, in general, is minimal. 37 

Although CDC-informed policies and regulations have been put forth regarding business, industry, and school re-openings, these protocols largely provide insufficient detail for ECE programs. 38 The main challenge is that the proposed reopening procedures hinge on key nonpharmaceutical interventions to combat SARS-CoV-2 transmission-physical distancing, respiratory etiquette, handwashing, and masking. Although effective in the general population, these practices are difficult to implement and maintain in groups of very young children.

Daily health checks: CDC guidance recommends daily screening of children for fever and illness symptoms on arrival, 24 yet this may be challenging for large ECE programs to implement because measuring temperatures in young children is more challenging and time-consuming when compared with older children, staggering of morning arrivals are cumbersome for parents headed to work, and) the less risky outdoor screenings would be problematic during inclement weather.

Personal protective equipment: The CDC recommends that child care workers wear cloth masks and have suggested gowns for extensive contact. Child care workers have questions about the frequency of gown changes because infants and toddlers frequently drool, cry, or spit-up when being held. Similarly, young children do not effectively wear masks for prolonged periods and children under the age of two years should not wear masks because of concerns for suffocation. 24 Respiratory etiquette and hand hygiene: Although it is clear that respiratory etiquette and hand hygiene must be practiced by staff, 24 studies combining respiratory etiquette and hand hygiene for caregivers and children, and environmental cleaning, sanitizing, and disinfecting surfaces in ECE programs show only a modest benefit in the reduction of respiratory virus transmission. [39] [40] [41] [42] The modest effect is likely because these interventions do not reduce droplet spread, the primary transmission mode of most respiratory viruses, including SARS-CoV-2.

Cleaning, sanitizing, and disinfecting: The CDC recommends cleaning and disinfecting frequently touched surfaces. 18 However, the high frequency with which young children touch objects and each other makes this challenging. Time and resources are limited in ECE programs and the ability to do this effectively and repeatedly for all potentially touched surfaces often is not practical.

Group size and ratios: The CDC recommends to "maintain an adequate ratio of staff to children to ensure safety," group cohorting, and avoiding mixing of different ages, but does not give any guidance on group size. 23, 24 A review of all 50 states' individual re-opening guidelines posted online (June 30, 2020) showed that 36% of states (n=18) recommended a group limit of 8-10 children; 20% of states (n=10) a limit between 11-20 children; 8% of states (n=4) a limit of 21-25 children; and 36% of states (n=18) have no suggested group size limits. 9 Challenges to downsizing classroom groups include decreasing available child care access for working parents, not enrolling enough children to keep the ECE program financially viable, having enough staff to maintain adequate child-to-staff ratios, and having enough available rooms or physical space to keep smaller groups apart.

Exclusion and return-to-care: The CDC recommends that programs "require sick children and staff to stay home," 24 yet research indicates that children often experience minor or no symptoms when infected with SARS-CoV-2. On average, children in ECE programs experience ~6 upper respiratory infections per year, with younger children and children in their first year of group child care experiencing substantially more. 43 Excluding all children with runny nose or congestion, symptoms listed by the CDC as potential COVID-19-related symptoms, 44 Guidance for School Re-entry," which is focused predominately on the kindergarten through 12th-grade population and makes recommendations tailored to school settings. 38 ECE programs would benefit from a similar document, with guidelines and operating considerations tailored to their needs. An expedited process to develop such guidance from experts in COVID-19, pediatrics, public health, and child care health is needed and should build from existing CFOC and CDC guidance. Even though there remain gaps in COVID-19 specific information that need further research, there is an important role for pediatric health experts to provide some structured guidance based on both expert group consensus and best available evidence to assist ECE directors in operating their programs and in providing consistent messaging to parents. This guidance should address, as a starting point, the following significant challenges identified to date:

Daily health checks: Guidelines should consider strategies that would facilitate the daily health check in ECE programs (e.g., use of non-contact infrared skin thermometers 46 or screening for symptoms prior to arrival by using numerous available COVID-19 apps). Respiratory etiquette and hand hygiene: Young children cannot be relied upon to practice respiratory etiquette and good hygiene practices consistently. Instead, efforts should focus on effective strategies that improve hand hygiene among ECE providers and children. 48, 49 Cleaning, sanitizing, and disinfecting: Although SARS-CoV-2 transmission is primarily via the respiratory route, some transmission may occur from touching surfaces and fomites contaminated with viable virus. ECE programs would greatly benefit from having more detailed guidance for efficient cleaning, sanitizing and disinfection and alternative strategies (e.g., rotating availability of toys) that address their unique population and environment.

Group size and age group ratios: Smaller group size is an important strategy to reduce viral transmission compared with larger group sizes, especially because physical distancing is not a viable strategy among young children. Although research studies on optimal group size for reduction of SARS-CoV-2 transmission are still necessary, a national recommendation for group size, balanced by the constraints of the ECE environment, is necessary.

Exclusion and return-to-care: Although medical evidence regarding the epidemiology of SARS-CoV2 transmission among children is lacking, there is a role for pediatric health experts to provide structured, consensus guidance based on the best available evidence. Having national exclusion and return-to-care recommendations can guide ECE administrators and directors in operating their programs, provide a better framework for local public health departments to manage outbreaks, and to provide consistent messaging to parents.

Conduct research to answer critical questions about SARS-CoV-2 in young children. The development of best practice guidelines for ECE programs is linked to a better understanding of SARS-CoV-2 epidemiology in young children. We need more high-quality surveillance and transmission studies of children in ECE and school settings.

In addition, we need further studies delineating pediatric attack rates and the likelihood of symptoms after infection. These studies are critical to determine when children, who are infected or exposed, can return to care, and these recommendations may differ from those for adults. 50 The role of antibody testing needs to be explored further to determine which antibodies confer immunity and decreased transmissibility, and for how long. These data will have implications on procedures and practices such as the daily health check, use of PPE, infection control and prevention practices, group size and exclusion, and return-tocare guidelines, all of which may need to be updated as COVID-19 research evolves.

3. Increase health support for child care programs. Many states have CCHCs working in their public health departments who provide regular assessments and consultation to help ECE administrators, directors, and providers improve the quality of health and safety in their programs. 51, 52 CCHCs have ongoing relationships with local ECE programs, public health departments, resource and referral agencies, and primary care pediatric practices. They should be engaged as key partners with pediatric and public health professionals to inform, disseminate, and support the implementation of new guidance for operation during COVID-19. Funding for CCHCs is inconsistent across states and should be supported by local and state health departments or federal programs for improving the health of ECE programs. Pediatric health providers and the national early childhood training and technical assistance systems, including the National Center on Early Childhood Health and Wellness (and its successor National Center on Health, Behavioral Health, and Safety), should support families and ECE providers by translating evidence into common messages and best practices. The designation, although it does not guarantee additional federal funding, would at least bring the necessary awareness to local and state governments of the need to prioritize accommodations for the ECE workforce in addition to other critical infrastructure workers. Designating the ECE system as critical infrastructure may also promote greater collaboration between ECE stakeholders and local government policymakers to facilitate increased disaster preparedness planning to ensure ECE programs are ready to meet the challenges of future emergencies beyond this pandemic.

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There is an urgent need to address the lack of cohesive national guidance for ECE programs through a collaboration of pediatric, public health, and child care experts. Informed by the best science about SARS-CoV-2 in children, stakeholders must work together to develop, disseminate, and implement guidance that thoughtfully considers young children's physical, developmental, and social-emotional needs along with the realities of operating ECE programs.Guidance must build from existing health guidance and leverage systems of consultation and technical assistance to support dissemination and implementation. Further federal funding is needed for COVID-19 that meets the significant knowledge gaps in the pediatric population so that policymakers, public health experts, and health providers can provide science-informed recommendations to ensure the health and safety of children in ECE programs.