Is it safe for day care centers to be open right now?

Children under 5 are not known for respecting personal space or keeping germs to themselves — even in the best of circumstances. And when you get lots of these little drooling, hugging, shouting humans together in one space, such as day care, illnesses tend to spread rapidly, bouncing among children, their families, and back again.

While some child care centers around the country have remained open in the Covid-19 pandemic, many US states and localities have required them to close or limit services to health care worker parents only. According to an April poll, about half of child care centers across the country were entirely closed, the Wall Street Journal reported.

An estimated 12.5 million children younger than 6 attend some sort of child care each year in the US, according to the Center for the Study of Child Care Employment (CSCCE) at the University of California Berkeley. So the closures have created a crisis for millions of families who have previously depended on care outside of the home.

Now, the question of how to restore child care is critical for helping millions of families get back to work, because “as states rush to reopen, child care is expected to be available,” Lea Austin, director of the CSCCE, told Vox.

Although the rate of severe Covid-19 in very small children is low, the illness does not entirely spare them. And a spate of pediatric inflammatory illnesses have doctors concerned about more negative outcomes for the very youngest patients. They also might be carriers of the virus who can infect others even without getting sick themselves.

With so much still unknown about the role of children in the pandemic, day care centers and home-based care operators also have to consider the needs of essential workers (and those of workers who might not be essential but depend on child care to earn money to work) with the largely unknown health risk for their staff, students, and families — all with their own often-precarious finances. And the federal government hasn’t exactly made the process easy.

“There is lots of angst about exposure and making sure [child care centers] do things ‘right,’” says Lucy Mullen Davis, consultant and coach at Denver’s Early Childhood Council. Let’s walk through why weighing the risks, and benefits, of reopening remains so tricky.

What are the rules for reopening day care?

The US federal government has essentially left it up to states, localities, and even individual care center owners to decide if they will be open — and if they choose to be, in what capacity.

This has resulted in a patchwork of changing policies across the country, as the Hunt Institute, an education research group affiliated with Duke University, documents in a detailed report of states’ rules and recommendations for child care operations.

California, for example, has allowed care centers to stay open but issued the guidance that they should only be for children of essential workers, and group sizes are limited to 10. Illinois closed all centers March 20 with the exception of facilities that obtained emergency licenses to care for children of essential workers. South Carolina, on the other hand, let its child care centers know, “it remains your decision as a provider whether to remain open,” and the state currently has no Covid-19-specific group size limitations for child care.

Astrid Riecken/Washington Post via Getty Images

So, especially in states that have closed or drastically limited child care center availability, many families have been scrambling to either do without child care or to try to find alternative care so they can work. (And many older relatives that might previously have been first choice for that role are at a higher risk for severe Covid-19 infection and advised to limit contact with others.)

Rhode Island, which closed its day cares, recommends finding a single in-home care provider, such as a nanny. But such individualized care can cost a good deal more than day care. (And even standard day care is a huge financial strain on many families.)

So that leaves potentially millions of families wondering when their usual child care will be back up and running. And when it is, if it will be safe.

In mid-May, the Centers for Disease Control and Prevention (CDC) finally issued guidance (which still defers largely to local guidelines) to help child care centers, as well as camps, restaurants, bars, and other operations decide if they can safely reopen. (These documents had been expected weeks earlier but had been held back by the White House.)

The newly published decision-making chart for child care facilities doesn’t add too much in the way of clarity. It includes a lot of non-binding language, such as “as feasible” and “encourage.”

“The CDC [decision] tree is extremely basic,” says Mullen Davis, whose group in Denver has created its own additional decision-making tool for centers that also helps them evaluate their financial situation.

Austin also points to key differences between the new CDC guidance and earlier versions that were leaked but never published. For example, in a previous version, the CDC recommended centers close if they were in a community that was still in the midst of significant spread of the virus. “Further, the decision [-making chart] does not require increased screening for children or staff in such communities and instead recommends they should do this if feasible,” she notes. To boot, such guidelines can “provide a false sense of security.”

This scattered response for child care programs has been vastly different from that for schools, which have been closed across the country, with many discussing switching to online learning for the fall as well.

These programs are also quite different from schools — and not always in ways that make infection control easier. “Because we’re talking about children at very different developmental stages, it’s important that we recognize some of the unique challenges being faced by child care centers,” Dan Wuori, director of Early Learning at the Hunt Institute, told Vox. “Child care has some very different health and safety considerations that need to be approached with real deliberation.”

For centers that have stayed open or are reopening, the CDC published relatively detailed guidance in April. Some of these recommendations include taking children’s temperature each day upon arrival (possibly while staff are in full personal protective gear), not using toys that cannot be sanitized, and using cloth masks for children over 2.

Many of these recommendations, such as changing gloves for every child temperature upon entry, are not always feasible due to supply availability and prices. (An April survey of more than 2,000 child care programs in California found that 62 percent were having difficulty obtaining cleaning supplies or personal protective equipment.)

And many other guidelines seem incongruous with young kids’ behavior and abilities, such as expecting 3-year-olds to keep masks on all day.

“It would be difficult to have children 3-5 wear [masks] all day with any reliability,” Allison Bartlett, associate medical director of the Infection Control Program and a pediatric infectious disease specialist at University of Chicago Medicine, told Vox. “In addition, kids with masks may be prone to remove them, touch their faces, reposition the masks, etc., contaminating themselves in the process.”

As the authors of a letter in the European Journal of Pediatrics concluded, “If compliance is difficult, it is better that the child does not wear the mask, and other measures for reducing infection risk, including remaining at home, are practiced.”

We still don’t know much about the coronavirus in babies and very young children

Part of the trouble with deciding on best practices for child care centers — as well as schools — is that we don’t know very much about the risk of the virus in children.

It’s been clear since the beginning of the pandemic that kids are at a lower risk of getting severely ill and dying from Covid-19 than adults are. But some do still get sick, and some die. Children with underlying health conditions, such as respiratory issues, are at higher risk, as are the very youngest children. For example, those under the age of 1 had the highest rate of hospitalization for Covid-19 among those under the age of 18, according to a report from the CDC. The same analysis found that these infants accounted for a full 30 percent of documented pediatric ICU admissions.

“Children of all ages appeared susceptible to Covid-19,” wrote the authors of an April article in Pediatrics that analyzed data from more than 2,100 pediatric Covid-19 patients in China. From the children in their study, 7 percent of infant cases required critical care — compared with 0 percent of children ages 6-10.

Pediatrics, Yuanyuan Dong, et al.

And there are also the increasing reports of severe inflammatory illness in children who have had the virus — even if they never appeared sick. In New York state, more than 100 children — including some as young as infants and toddlers — have been diagnosed with this serious condition, and at least three have died from it.

And we also don’t have a good sense of how many very young children might be carriers of the virus without ever getting sick at all.

What role do very young children play in transmitting the coronavirus?

In general, “young children are well-known culprits in transmission of other respiratory viruses,” Bartlett says. “The safest assumption until we have good data is that they are vectors for Covid-19 transmission as well.”

Research has shown that adults can have a lot of the coronavirus in their system and still feel fine, suggesting that the illness can spread even from those who do not have symptoms.

“While we are thankful that children are relatively spared in the SARS-CoV-2 pandemic, they are potential vectors of spread to other members in the community,” Bartlett says. “We don’t know a lot about transmission among young children, but their propensity to put things in their mouths could increase risk of spread among children,” she noted.

This liberalness with germ sharing is compounded with peer interactions at child care centers. An April report in Science looked at the change in the number of daily contacts infants and young children had before and during pandemic restrictions in Wuhan and Shanghai, China. They found there was a drop in the daily number of contacts children ages 0-6 had from about 12 to 2 in Wuhan and from about 14 to 2 in Shanghai. Reducing the number of people everyone comes into contact with has been a cornerstone of efforts to slow the pandemic.

Looking at their data from children overall, the authors noted, “while proactive school closures cannot interrupt transmission on their own, they can reduce peak incidence by 40-60 percent and delay the epidemic.”

Protecting the safety of child care workers

Conversations about day cares also often leave off the question of staff exposure. Given that babies and young children need such hands-on care — pretty much all day — Austin says, there’s essentially no way for educators to physically distance themselves from the kids they are caring for.

Some precautions can help mitigate risk of Covid-19 transmission in close contact, such as “making sure child care workers change clothes if they get spit up on, etc., and having them wash their necks/arms if they are in contact with children’s secretions can help as well,” Bartlett says. But these steps will need to be taken dozens of times a day, especially for those caring for babies.

To add to the difficult situation, Austin notes, caregivers are frequently “among the black and brown communities that are being disproportionately impacted by Covid-19.” In California, for example, the majority of these roles are filled by people of color.

Austin and others have suggested child care workers who have underlying health conditions and those who are over 65 might consider not returning to work — or doing so in a capacity in which they do not interact with children. But these options are not always feasible or financially possible.

“Pre-pandemic child care programs operated on thin margins, and staff were earning poverty wages,” Austin says. “This crisis is exacerbating these conditions, leading many early educators to risk their lives by continuing work under the current conditions — or risk losing their livelihoods if they don’t work.” Early education workers earn a national average of about $12 an hour, her group has determined.

Some child care staff have requested testing if they are to return to work, while others have left their jobs.

Families who still have access to care are worried

There are also numerous concerns coming from families who have previously relied on group child care so they could earn money themselves.

In Colorado, Mullen Davis says they have seen an increase in families requesting tuition aid for their child care — “many of whom have never asked for this aid before,” she says. “It’s clear that many families are facing additional financial pressures right now.”

In addition, she says, “some parents are anxious to bring their children, while others ask for assurances that are often beyond the center’s control.”

The stress of the situation has trickled down to the children as well, who “have their own fears and anxieties, which can add to behavior challenges in the classroom,” says her colleague Karen Thiel, lead quality initiatives navigator at the council.

Families as well as educators have expressed other concerns related to how new health and safety guidelines at centers might impact children and their development. Thiel has had families ask, “How are children going to learn to interact in socially appropriate ways if they are expected to stay 6 feet apart?”

Mullen Davis heard from another parent recently who was worried about her infant surrounded by masked staff for 40 hours a week. “She was concerned about how masks affect language and social emotional development if children cannot see their caregiver’s friendly or responsive face,” she says. “We just don’t have research on this.”

Covid-19 might put many child care centers out of business

With all of these changes, a large proportion of child care centers — like so many other small businesses — might not survive the pandemic.

In Colorado, “many center directors are worried that they will not have enough children to cover the costs of care if they reopen,” Mullen Davis says. Centers are also dealing with extreme fluctuations in staffing as well as attendance. And with many states capping group size at around 10, that takes a serious bite of tuition revenue, especially for preschool, where classrooms often average close to 17 children.

The CSCCE found in a recent survey that 14 percent of the more than 2,000 California child care programs polled that are currently closed will not be able to sustain a closure that runs past the end of May. And for those that have stayed open, they found that 63 percent would not be able to survive a closure of more than a month.

There is already a shortage of child care in the US. Some half of US families with young children have reported having trouble finding child care, according to the Center for American Progress, a progressive-leaning research and advocacy organization. (The group estimated that in 2016, 2 million US parents quit jobs or drastically changed their work due to issues with child care.)

“This crisis has revealed the central role child care teachers play in our society,” Austin says. “This is a moment to stabilize and invest in this critical component of our infrastructure so that it exists going forward and does so in a manner that protects the well-being of children, early educators, and communities.”

Some states are taking large steps to ensure child care centers can remain solvent for now. Vermont, for example, is using a combination of state and federal funds to provide any revenue centers have lost.

Others are reexamining earlier actions. “Gov. Mike DeWine in Ohio really stands out,” Javaid Siddiqi, president of the Hunt Institute, told Vox. “Just [last] week he pulled back and acknowledged that the reopening of child care was just too important to do haphazardly. He wants their plan to be based on science and safety. That’s a difficult stance to take in the face of pressure to reopen, but it’s clear that he really understands the gravity of the situation.” The state’s child care centers have been closed there since March 26 (with emergency care for health care workers), but there are now plans to reopen at the end of May with new measures in place.

But, as Bartlett notes, “As parents of young children know, even the day care centers with the most meticulous attention to hygiene have transmission of infections. There are measures that we can undertake to decrease the risk of transmission, but it will never be zero.”

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