Provider-reported illness and absence due to illness among children attending child-care homes and centers in San Diego, Calif

Using the MCRISP Network for Surveillance of Pediatric Exanthema in Child Care Centers

Background:

Systematic monitoring of exanthema is largely absent from public health surveillance despite emerging diseases and threats of bioterrorism. Michigan Child Care Related Infections Surveillance Program (MCRISP) is the first online program in child care centers to report pediatric exanthema.

Methods:

MCRISP aggregated daily counts of children sick, absent, or reported ill by parents. We extracted all MCRISP exanthema cases from October 1, 2014 through June 30, 2019. Cases were assessed with descriptive statistics and counts were used to construct epidemic curves.

Results:

360 exanthema cases were reported from 12,233 illnesses over 4.5 seasons. Children ages 13-35 months had the highest rash occurrence (45%, n = 162), followed by 36-59 months (41.7%, n = 150), 0-12 months (12.5%, n = 45), and kindergarten (0.8%, n = 3). Centers reported rashes of hand-foot-mouth disease (50%, n = 180), nonspecific rash without fever (15.3%, n = 55), hives (8.1%, n = 29), fever with nonspecific rash (6.9%, n = 25), roseola (3.3%, n = 12), scabies (2.5%, n = 9), scarlet fever (2.5%, n = 9), impetigo (2.2%, n = 8), abscess (1.95, n = 7), viral exanthema without fever (1.7%, n = 6), varicella (1.7%, n = 6), pinworms (0.8%, n = 3), molluscum (0.6%, n = 2), cellulitis (0.6%, n = 2), ringworm (0.6%, n = 2), and shingles (0.2%, n = 1).

Conclusion:

Child care surveillance networks have the potential to act as sentinel public health tools for surveillance of pediatric exanthema outbreaks.

Ophthalmic antibiotic use for acute infectious conjunctivitis in children

BACKGROUND

Infectious conjunctivitis is among the most common pediatric infections worldwide; antibiotics are often not indicated. We aimed to determine factors associated with ophthalmic antibiotic prescribing and changes in prescribing prior to and during the COVID-19 pandemic at a single center.

METHODS

Encounters for children with infectious conjunctivitis from 2017 to 2020 at Denver Health and Hospital Authority clinics were analyzed retrospectively. Factors associated with prescribing were evaluated using multivariable logistic regression modeling. Encounter numbers and prescribing patterns for telephone versus in-person visits before and during the pandemic were compared and stratified.

RESULTS

Of 5,283 patients encounters for conjunctivitis, 3,841 (72.7%) resulted in an ophthalmic antibiotic prescription. Concurrent diagnosis with acute otitis media (adjusted odds ratio [aOR] 0.20 (95% CI, 0.16-0.25) and later study year (2018-aOR = 0.76 [95% CI, 0.65-0.89]; 2019- aOR = 0.57 [95% CI, 0.48-0.67]) were associated with reduced odds of prescribing. Compared with those evaluated in pediatric clinics, patients evaluated in family medicine (aOR = 0.69 [95% CI, 0.58-0.83]) or optometry/ophthalmology clinics (aOR = 0.06 [95% CI, 0.02-0.14]) were less likely to have antibiotics prescribed, whereas, patients evaluated via telephone had a 5.43 (95% CI, 3.97-7.42) greater odds of being prescribed ophthalmic antibiotics. Antibiotic prescribing increased from 67.8% prior to the COVID-19 pandemic to 81.9% during the pandemic (P < 0.0001).

CONCLUSIONS

Discordant with national guideline recommendations, ophthalmic antibiotic use for conjunctivitis was high. Telephone visits were associated with higher rates of prescribing. Rates of prescribing increased significantly during the COVID-19 pandemic.

The Statewide Economic Impact of Child Care-Associated Viral Acute Gastroenteritis Infections

INTRODUCTION

More than 65% of children aged ≤5 years in the United States require out-of-home child care. Child care attendance has been associated with an elevated risk of respiratory illness and acute gastroenteritis (AGE). While child care-associated respiratory disease cases are more numerous, AGE is associated with more severe symptoms and more than double the number of absences from child care. In addition, viral pathogens such as norovirus, rotavirus, and adenovirus are highly infectious and may be spread to parents and other household members. As a result, child care-associated viral AGE may incur substantial economic costs due to healthcare service usage and lost productivity.

METHODS

We used surveillance data from a network of child care centers in Washtenaw County, Michigan, as well as a household transmission model to estimate the annual cost of child care-associated viral AGE in the state of Michigan.

RESULTS

We estimated that child care-associated viral AGE in Michigan costs between $15 million and $31 million annually, primarily due to lost productivity.

CONCLUSIONS

The economic burden of child care-associated infections is considerable. Effective targeted interventions are needed to mitigate this impact.

Gastrointestinal and respiratory illness in children that do and do not attend child day care centers: a cost-of-illness study

Background

Gastrointestinal and respiratory diseases are major causes of morbidity for young children, particularly for those children attending child day care centers (DCCs). Although both diseases are presumed to cause considerable societal costs for care and treatment of illness, the extent of these costs, and the difference of these costs between children that do and do not attend such centers, is largely unknown.

Objective

Estimate the societal costs for care and treatment of episodes of gastroenteritis (GE) and influenza-like illness (ILI) experienced by Dutch children that attend a DCC, compared to children that do not attend a DCC.

Methods

A web-based monthly survey was conducted among households with children aged 0–48 months from October 2012 to October 2013. Households filled-in a questionnaire on the incidence of GE and ILI episodes experienced by their child during the past 4 weeks, on the costs related to care and treatment of these episodes, and on DCC arrangements. Costs and incidence were adjusted for socioeconomic characteristics including education level, nationality and monthly income of parents, number of children in the household, gender and age of the child and month of survey conduct.

Results

Children attending a DCC experienced higher rates of GE (aIRR 1.4 [95%CI: 1.2–1.9]) and ILI (aIRR: 1.4 [95%CI: 1.2–1.6]) compared to children not attending a DCC. The societal costs for care and treatment of an episode of GE and ILI experienced by a DCC-attending child were estimated at €215.45 [€115.69–€315.02] and €196.32 [€161.58–€232.74] respectively, twice as high as for a non-DCC-attending child. The DCC-attributable economic burden of GE and ILI for the Netherlands was estimated at €25 million and €72 million per year.

Conclusions

Although children attending a DCC experience only slightly higher rates of GE and ILI compared to children not attending a DCC, the costs involved per episode are substantially higher.

Emergency department and urgent care for children excluded from child care

BACKGROUND

Children in child care are frequently unnecessarily excluded for illness. We investigated parental use of urgent medical evaluation for sick children unable to attend child care.

METHODS

In May 2012, authors conducted a nationally representative survey of parents, who completed online questions regarding child illness causing absence from child care and their medical care-seeking behavior. Main outcome was parents' use of emergency department or urgent care (ED/UC).

RESULTS

Overall survey participation rate was 62%. Of participating parent cohort with children 0 to 5 years old, 57% (n = 357) required child care, of which 84% (n = 303) required out-of-home child care. Over 88% of parents sought acute medical care for their sick children unable to attend child care. Approximately one-third of parents needed a doctor's note for employers and/or child care. Parents sought medical evaluation (>1 option possible) from primary care (81%), UC (26%), or ED (25%). ED/UC use was most common for rash (21%) and fever (15%). Logistic regression indicated ED/UC use was significantly higher among single/divorced parents (odds ratio [OR] = 4.3; 95% confidence interval [CI]: 2.5-13.5); African American parents (OR = 4.2; 95% CI: 1.2-14.6); parents needing a doctor's note (OR = 4.2; 95% CI: 1.5-11.7); and those with job concerns (OR = 3.4; 95% CI: 1.2-9.7).

CONCLUSIONS

A substantial proportion of parents whose sick children cannot attend child care seek care in ED/UC. Training child care professionals regarding appropriate illness exclusions may decrease ED/UC visits by lowering child care exclusions.

Health and safety of child care centers: an analysis of licensing specialists' reports of routine, unannounced inspections

OBJECTIVES

We assessed the prevalence of regulatory noncompliance of licensed child care centers and identified factors associated with improved compliance.

METHODS

We analyzed 676 routine, unannounced reports of child care centers collected by the Connecticut Department of Public Health licensing specialists over a 2-year time period, included characteristics of centers, and created categories of regulations.

RESULTS

The sample included 41% of licensed child care centers. Of the 13 categories of regulations in the analyses, 7 categories (outdoor safety, indoor safety, indoor health, child and staff documentation, emergency preparedness, infant-toddler indoor health, and infant-toddler indoor safety) had regulations with center noncompliance greater than 10%. Playground hazard-free was the regulation with the highest frequency (48.4%) of noncompliance. Compliance with the regulation for 20 hours of continuing education per year for child care providers was the characteristic most frequently associated with regulations compliance.

CONCLUSIONS

Efforts to support continuing education of child care providers are essential to improve and sustain healthy and safe early-care and education programs. Analyses of state child care licensing inspection reports provide valuable data and findings for strategic planning efforts.

Self-Report of Child Care Directors Regarding Return-to-Care

BACKGROUND

The American Academy of Pediatrics (AAP) introduced revised return-to-care recommendations for mildly ill children in 2009 that were added to national standards in 2011. Child care directors' practices in a state without clear emphasis on return-to-care guidelines are unknown. We investigated director return-to-care practices just before the release of recently revised AAP guidelines.

METHODS

A telephone survey with 5 vignettes of mild illness (cold symptoms, conjunctivitis, vomiting/diarrhea, fever, and ringworm) was administered to randomly sampled directors in metropolitan Milwaukee, Wisconsin. Directors were asked about return-to-care criteria for each illness. Questions for return-to-care criteria were open-ended; multiple responses were allowed. Answers were compared with AAP return-to-care recommendations.

RESULTS

A total of 305 directors participated. Based on director responses to vignettes, the percentage of correct responses regarding return-to-child care management compared with AAP return-to-care recommendations was low: fever (0%); conjunctivitis (0%); diarrhea (1.6%); cold symptoms (12%); ringworm (21%); and vomiting (80%). Two illnesses (conjunctivitis and cold symptoms) would require the child to have an urgent medical evaluation or treatment not recommended by the AAP, as follows: Conjunctivitis-antibiotics for 24 hours (62%), physician visit (49%), any antibiotic treatment (6%), and symptom resolution (4%); and Cold Symptoms-physician visit (45.6%), antibiotics (10%), and symptom resolution (25%).

CONCLUSIONS

Directors' self-reported return-to-child care practices differed substantially before the release of revised AAP return-to-care recommendations. Active adoption of AAP return-to-child care guidelines would decrease the need for unnecessary urgent medical evaluation and treatment as well as unnecessary exclusion of a child from child care.

Unnecessary child care exclusions in a state that endorses national exclusion guidelines

OBJECTIVE

No study has evaluated the association between state endorsement of American Academy of Pediatrics (AAP) and American Public Health Association (APHA) national guidelines and unnecessary exclusion decisions. We sought to determine the rate of unnecessary exclusion decisions by child care directors in a state that endorses AAP/APHA guidelines and to identify factors that are associated with higher unnecessary exclusion decisions.

METHODS

A telephone survey was administered to directors in metropolitan Milwaukee, Wisconsin. Directors were randomly sampled from a list of 971 registered centers. Director, center, and neighborhood characteristics were obtained. Directors reported whether immediate exclusion was indicated for 5 vignettes that featured children with mild illness that do not require exclusion by AAP/APHA guidelines. Weighted data were summarized by using descriptive statistics. Regression analysis was used to identify factors that were associated with directors' exclusion decisions.

RESULTS

A total of 305 directors completed the survey. Overall, directors would unnecessarily exclude 57% of children. More than 62% had never heard of the AAP/APHA guidelines. Regression analysis showed fewer exclusions among more experienced compared with less experienced directors, among larger centers compared with smaller centers, and among centers that were located in areas with a higher percentage of female heads of household. Centers with < or =10% children on state-assisted tuition excluded more.

CONCLUSIONS

High rates of inappropriate exclusion persist despite state endorsement of AAP/APHA guidelines. Focused initial and ongoing training of directors regarding AAP/APHA guidelines may help to reduce high rates of unnecessary exclusions.

Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers

OBJECTIVE

The objective of this study was to determine whether the installation of equipment for diaper-changing, hand-washing, and food preparation that is specifically designed to reduce the transmission of infectious agents would result in a decrease in the rate of diarrheal illness among children and their teachers in child care centers.

METHODS

Twenty-three pairs of child care centers were matched on size and star-rated license level. One member of each pair was randomly assigned to an intervention group and the other to a control group. Intervention centers received new diaper-changing, hand-washing, and food-preparation equipment, and both intervention and control centers received hygiene and sanitation training with reinforcement and follow-up as needed. Families with children in participating classrooms were called biweekly to ascertain the frequency and severity of any diarrheal illness episodes. Staff attendance was monitored, and staff hygiene and sanitation behaviors were observed and recorded monthly.

RESULTS

Although hygiene and sanitation behaviors improved in both intervention and control centers, there was a significant difference favoring the intervention centers with respect to frequency of diarrheal illness (0.90 vs 1.58 illnesses per 100 child-days in control centers) and proportion of days ill as a result of diarrhea (4.0% vs 5.0% in control centers) among the children. Staff in those same classrooms were reported to have a significantly lower proportion of days absent as a result of any illness (0.77% in treatment centers versus 1.73% in control centers).

CONCLUSION

Diapering, hand-washing, and food-preparation equipment that is specifically designed to reduce the spread of infectious agents significantly reduced diarrheal illness among the children and absence as a result of illness among staff in out-of-home child care centers.

Compliance with American Academy of Pediatrics and American Public Health Association illness exclusion guidelines for child care centers in Maryland: who follows them and when?

BACKGROUND

In 1992, the American Academy of Pediatrics and the American Public Health Association jointly published guidelines for temporary exclusion of sick children from child care. However, little is known about key stakeholders' compliance with these guidelines.

OBJECTIVES

The purpose of this work was to compare pediatricians', parents', and child care providers' compliance with American Academy of Pediatrics guidelines and determine predictors for higher rates of compliance.

METHODS

We conducted a cross-sectional survey of 215 randomly selected Maryland pediatricians, 223 parents, and 192 child care providers from 22 Baltimore, Maryland, child care centers from January to July 2004. Questionnaires contained the following 6 case vignettes depicting common child care illnesses: upper respiratory infection, conjunctivitis, gastroenteritis, mild febrile illness, tinea capitis, and atopic dermatitis. The instrument measured the correctness of exclusion and inclusion decisions (using American Academy of Pediatrics/American Public Health Association guidelines as gold standard) according to varying levels of fever, disease severity (eg, clear versus yellow eye discharge), familiarity with the child, and parent work schedule flexibility.

RESULTS

Response rates were 71% for pediatricians, 56% for parents, and 85% for child care providers. Guideline compliance was higher for pediatricians (74%) than for child care providers (60%) and parents (61%). Only 23% of pediatricians and parents and 29% of child care providers reported familiarity with American Academy of Pediatrics/American Public Health Association guidelines by name. In general, child care providers and parents had lower false-negative rates (allowed fewer children to attend who met criteria for exclusion) than pediatricians, suggesting that pediatricians may underexclude. Child care providers and parents correctly excluded in 65%-98% of cases requiring exclusion, whereas pediatricians correctly excluded 31%-86% of cases requiring exclusion, depending on the vignette. Yet pediatricians were much more specific about which children met criteria (pediatricians correctly included 61%-93% of cases requiring inclusion versus child care providers and parents who correctly included 20%-75% of such cases), suggesting that child care providers and parents may overexclude. Compliance rates varied significantly by stakeholder, vignette (disease), level of fever, and disease severity but did not vary with the stakeholder's familiarity with the child or the flexibility of the parent's work schedule.

CONCLUSIONS

Pediatricians, parents, and child care providers were unfamiliar with American Academy of Pediatrics/American Public Health Association illness exclusion guidelines by name but moderately compliant with them. When noncompliant, child care providers and parents generally overexcluded, and pediatricians underexcluded. Stakeholder- and disease-specific predictors for noncompliance gleaned from this study suggest how educational interventions aiming to increase guideline compliance could be individually tailored to child care providers, parents, and pediatricians.

Pediatrician attitudes to exclusion of ill children from child-care centers in Israel: pressure on ambulatory practices

BACKGROUND

The exclusion of ill children from child-care centers may be associated with high social, economic and medical costs.

OBJECTIVE

To assess the opinions of pediatricians working in an outpatient setting in Israel on the exclusion/return of children in child-care centers.

METHODS

A questionnaire on practices of exclusion/return of children in child-care centers, in general and according to specific signs and symptoms, was administered to a random computer-selected cross-sectional sample of 192 primary care community pediatricians in Israel.

RESULTS

One hundred and seventy-three pediatricians completed the questionnaires, for a response rate of 90%; 147 were board-certified and 26 were not. About half the pediatricians felt pressured by parents requesting antibiotic therapy to accelerate the return of their sick child to the child-care center. The majority also believed their practice was overloaded by often unnecessary demands for medical notes by the child-care centers before children could return. More than half based their decision to exclude children on "common sense" and the remainder, on accepted guidelines. Except for scabies and lice, there were no significant correlations between the physicians' stipulation for a note on return of the child and the specific illness guidelines.

CONCLUSIONS

This study shows that a high proportion of pediatricians based their exclusion practices on "common sense" and personal understanding instead of established guidelines, and that the guidelines did not affect their opinion on the duration of illness that warrant a note. Furthermore, half were subjected to parental pressure to employ inappropriate practices. These findings, combined with our earlier survey of child-care centers staff, indicate that better education of parents and day-care staff about ill child-care-center-exclusion policy in Israel would increase their common understanding with pediatricians.

Knowledge and Beliefs About Guidelines for Exclusion of Ill Children From Child Care

BACKGROUND

The American Academy of Pediatrics published national child care illness exclusion guidelines in 1992 and 2002. To our knowledge, no published studies have examined child care providers', parents', and pediatricians' knowledge or beliefs about these guidelines.

OBJECTIVE

To compare parents', pediatricians', and center-based child care providers' (CCPs) knowledge and beliefs about exclusion guidelines.

DESIGN

Cross-sectional survey conducted in 2000 of 80 CCPs, 142 parents, and 36 pediatricians in Baltimore City. Main outcome measures included familiarity with and knowledge of exclusion guidelines and beliefs about exclusion effectiveness among these groups.

RESULTS

Response rates were 58% for parents, 59% for pediatricians, 85% for CCPs. Sixteen percent of child care providers (CCPs), 39% of parents, and 53% of pediatricians had not seen any written exclusion guidelines. Compared with national guidelines for 12 common symptoms, responses from CCPs and parents indicated overexclusion, while pediatricians indicated underexclusion. The groups scored similarly in number of correct answers on knowledge items (CCPs 63%, parents 64%, pediatricians 61%, P = .44). More CCPs and parents than pediatricians believed that exclusion effectively controlled infection spread and that sick children should be excluded because they spread disease, would be more comfortable, and recover faster at home (P < .001).

CONCLUSIONS

This survey found CCPs, parents, and pediatricians all failed to recognize how national guidelines recommended managing 4 out of 10 common conditions on average. CCPs were more likely than pediatricians to believe that exclusion was warranted to control infection or for the child's personal needs.

Dynamics of pneumococcal carriage among healthy Icelandic children attending day-care centres

Invasive pneumococcal disease and antimicrobial (AM) resistance in pneumococci are important public health concerns. With the advent of new pneumococcal vaccines, information on serotype prevalence and their temporal fluctuations is important. Information on AM use and consent for participation was obtained by a questionnaire to parents of children at 5 day-care centres in Reykjavik from 1992 to 1999, and nasopharyngeal swabs were cultured selectively for pneumococci. The pneumococci were serotyped and pulsed field gel electrophoresis used to determine clonality. Of 1228 nasopharyngeal swabs, 640 (52.1%) yielded pneumococci of which 89 (13.9%) had decreased susceptibility to penicillin and 1 was resistant. Children receiving AMs during the month preceding nasopharyngeal sampling and children attending a day-care centre where AM use was high were significantly more likely to carry penicillin non-susceptible isolates. Serotypes 6A, 6B and 23F were most common (48%), and 74% of serotyped isolates belonged to 1 of the 7 most common serotypes. Almost all penicillin non-susceptible isolates were of serotype 6B or 19A. Serotype prevalence fluctuated markedly between y. In conclusion, there was significant variation in serotype prevalence between y, and only 51% of the pneumococci belonged to serotypes covered by the current 7-valent conjugated vaccine.

Exclusion of ill children from child-care centers in Israel

The aim of the study was to examine criteria for ill children in child-care centers. A questionnaire on practices of exclusion/return of children according to specific signs and symptoms was mailed to the directors of care centers in central Israel. Thirty-six of the 60 questionnaires (60%) were returned by mail and the reminded were completed in personal visits to the CCCs achieving a response rate of 100%. About half (51.7%) used "common sense" and "personal feelings" to exclude children and to allow their return, and 29 (48.3%) used the guidelines of the Ministries of Education and Health or other authorities. The percentage of centers excluding children by signs/symptoms was as follows: high fever (>38 degrees C), 100%; low-grade fever, 76.7%; asthma exacerbation, 80.0%; heavy cough, 75.0%; eye discharge or conjunctivitis, 83.3%; diarrhea and vomiting more than twice per day, 100%; rash, 72.3%; otalgia, 46.7%; and infected skin lesion, 66.7%. Only four centers excluded children with head lice. Most centers required a physician's note on return of a child after high fever (76.7%), eye discharge or conjunctivitis (48.3%), and from 75 to 80%, respectively, for frequent vomiting and bloody or mucinous diarrhea. The results show that exclusion practices among child-care centers (CCCs) vary widely, suggesting the need for the establishment of a uniform exclusion and return policy in Israel, with distribution of clear, up-to-date guidelines on the prevention and control of communicable diseases to all day-care centers. In a simple way, this study identified attitudes concerning the exclusion/return of sick children in CCCs and was useful for the discussion of the related policy with CCCs responsible and national health and educational authorities.

Effect of total attending period on infection episode rate in a child-care center

BACKGROUND

Attendance to a child-care facility is known to be associated with increased rate of episodes of infectious diseases in children. This retrospective cohort study investigates the infection episode rate and the effect of total attending period on infection episode rates in a child-care center (Gulveren Child-Care Center, Ankara, Turkey), at a stable environmental condition, over a 7-year follow-up period.

METHODS

During the study period, 288 children attended the center and enrolled. Sex, total duration of breastfeeding, starting age at the center, total duration of attendance, and the type and frequency of infections diseases were recorded. Episode rates were calculated for each child.

RESULTS

The mean starting age at the child care center was 4.1 +/- 0.7 years (range: 2.5-5.8 years); the mean total duration of attendance at the center was 20.4 +/- 9.9 months. Over the study period, 1000 infection episodes were detected. The general infection episode rate was calculated as 2.04/child per year. In bivariate analysis, children with longer attendance period (> or =12 months), and a younger starting age at the center (<4 years of age) had lower 'moderate general infection' (> or =3 episode/child per year) episode rates than those of other groups. In multiple logistic regression analysis, only total attending period in the center was significantly associated with 'moderate' level general infection episode rate. The presence of asthma slightly increased the lower respiratory tract infections episode rate in bivariate analysis, and was the only significant predictor of LRTI episode rate in multivariate analysis.

CONCLUSIONS

The results of the present study show that among children attending a single facility, longer periods of attendance at the facility was associated with a decreased risk of general infection episode, regardless of starting age at the center. Additional cohort studies are needed to determine whether this reduction in general infection episode rate extends into school-age years and whether children moving between different centers affects the incidence of infectious episodes.

Respiratory illness in children attending daycare

Daycare attendance has been associated with an increased occurrence of respiratory illness, but little is known about which children are at particular risk. Our objectives were to determine the association between the incidence of respiratory illness and attendance in daycare, and to determine if the risk is modified by selected sociodemographic factors. Using a prospective study design, 185 newborns in Prince Edward Island, Canada, were recruited between January 1997-March 2000. They were followed for 2 years or until the end-date of the study in September 2000. Information on daycare attendance and respiratory illness was collected twice monthly by telephone interviews of the parent. Comparing those who were ever in daycare more than 1 day per week (daycare group) to those who were not, the association between daycare and illness was stronger among children 15 months of age compared to those less than 3 months of age (P < 0.001), and stronger among those without siblings than those with siblings (P < 0.001). Among those not in daycare, family income was inversely related to the proportion of days with an illness episode: 9.8% (CI, 6.0, 13.6) if family income was < $30,000 vs. 5.2% (CI, 4.1, 6.3) if > or = $30,000 (P = 0.003). However, in the daycare group, income did not influence illness, with respective values of 14.6% (CI, 12.4, 16.8) vs. 13.2% (CI, 12.1, 14.3) (P = 0.21). In conclusion, younger children and those with siblings may be less susceptible to illness associated with daycare, and daycare attendance may negate a protective effect of higher income on respiratory illness.