Association of Child Masking With COVID-19-Related Closures in US Childcare Programs.

Importance: It is not known how effective child masking is in childcare settings in preventing the transmission of SARS-CoV-2. This question is critical to inform health policy and safe childcare practices. Objective: To assess the association between masking children 2 years and older and subsequent childcare closure because of COVID-19. Design, Setting, and Participants: A prospective, 1-year, longitudinal electronic survey study of 6654 childcare professionals at home- and center-based childcare programs in all 50 states was conducted at baseline (May 22 to June 8, 2020) and follow-up (May 26 to June 23, 2021). Using a generalized linear model (log-binomial model) with robust SEs, this study evaluated the association between childcare program closure because of a confirmed or suspected COVID-19 case in either children or staff during the study period and child masking in both early adoption (endorsed at baseline) and continued masking (endorsed at baseline and follow-up), while controlling for physical distancing, other risk mitigation strategies, and program and community characteristics. Exposures: Child masking in childcare programs as reported by childcare professionals at baseline and both baseline and follow-up. Main Outcomes and Measures: Childcare program closure because of a suspected or confirmed COVID-19 case in either children or staff as reported in the May 26 to June 23, 2021, end survey. Results: This survey study of 6654 childcare professionals (mean [SD] age, 46.9 [11.3] years; 750 [11.3%] were African American, 57 [0.9%] American Indian/Alaska Native, 158 [2.4%] Asian, 860 [12.9%] Hispanic, 135 [2.0%] multiracial [anyone who selected >1 race on the survey], 18 [0.3%] Native Hawaiian/Pacific Islander, and 5020 [75.4%] White) found that early adoption (baseline) of child masking was associated with a 13% lower risk of childcare program closure because of a COVID-19 case (adjusted relative risk, 0.87; 95% CI, 0.77-0.99), and continued masking for 1 year was associated with a 14% lower risk (adjusted relative risk, 0.86; 95% CI, 0.74-1.00). Conclusions and Relevance: This survey study of childcare professionals suggests that masking young children is associated with fewer childcare program closures, enabling in-person education. This finding has important public health policy implications for families that rely on childcare to sustain employment.

Connecting Families to Food Resources amid the COVID-19 Pandemic: A Cross-Sectional Survey of Early Care and Education Providers in Two U.S. States.

Early care and education (ECE) settings are important avenues for reaching young children and their families with food and nutrition resources, including through the U.S. federally funded Child and Adult Care Food Program (CACFP). Researchers conducted a cross-sectional survey of ECE providers in two U.S. states in November 2020 to identify approaches used to connect families with food and nutrition resources amid the COVID-19 pandemic. Logistic regression models were used to estimate odds of sites reporting no approaches and adjusted Poisson models were used to estimate the incidence rate ratio of the mean number of approaches, comparing sites that participate in CACFP to those that did not. A total of 589 ECE sites provided responses. Of those, 43% (n = 255) participated in CACFP. CACFP participating sites were more likely to report using any approaches to connecting families to food resources and significantly more likely to report offering "grab and go" meals, providing meal delivery, distributing food boxes to families, and recommending community food resources than non-CACFP sites. This study suggests that CACFP sites may have greater capacity to connect families to food resources amid emergencies than non-CACFP participating sites.

Surveillance of SARS-CoV-2 transmission in educational institutions, August to December 2020, Germany.

This study aims at providing estimates on the transmission risk of SARS-CoV-2 in schools and day-care centres. We calculated secondary attack rates (SARs) using individual-level data from state-wide mandatory notification of index cases in educational institutions, followed by contact tracing and PCR-testing of high-risk contacts. From August to December 2020, every sixth of overall 784 independent index cases was associated with secondary cases in educational institutions. Monitoring of 14 594 institutional high-risk contacts (89% PCR-tested) of 441 index cases during quarantine revealed 196 secondary cases (SAR 1.34%, 0.99-1.78). SARS-CoV-2 infection among high-risk contacts was more likely around teacher-indexes compared to student-/child-indexes (incidence rate ratio (IRR) 3.17, 1.79-5.59), and in day-care centres compared to secondary schools (IRR 3.23, 1.76-5.91), mainly due to clusters around teacher-indexes in day-care containing a higher mean number of secondary cases per index case (142/113 = 1.26) than clusters around student-indexes in schools (82/474 = 0.17). In 2020, SARS-CoV-2 transmission risk in educational settings was low overall, but varied strongly between setting and role of the index case, indicating the chance for targeted intervention. Surveillance of SARS-CoV-2 transmission in educational institutions can powerfully inform public health policy and improve educational justice during the pandemic.

Prevalence and Transmission of Severe Acute Respiratory Syndrome Coronavirus Type 2 in Childcare Facilities: A Longitudinal Study.

OBJECTIVE: To evaluate the role of childcare facilities in the transmission of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) in a longitudinal study to gain further knowledge of SARS-CoV-2 prevalence, transmission, and spread among preschool children, their parents, and their caregivers. STUDY DESIGN: Children aged 1-6 years, their parents, and their caregivers in 14 childcare facilities in Dresden, Saxony/Germany were invited to participate in the KiTaCoviDD19-study between July 2020 and January 2021. Seroprevalence of SARS-CoV-2 antibodies was assessed up to 4 times during the study period in all participating adults, and demographic characteristics, as well as epidemiologic information on personal SARS-CoV-2 history were obtained. Samples for stool virus shedding of SARS-CoV-2 were analyzed by polymerase chain reaction every 2-4 weeks in all participating children. RESULTS: In total, 318 children, 299 parents and 233 childcare workers were enrolled. By January 2021, 11% of the participating adults were found to be seropositive, whereas the percentage of children shedding SARS-CoV-2 was 6.8%. Overall, we detected 17 children with SARS-CoV-2 virus shedding in 8 different childcare facilities. In 4 facilities, there were a maximum of 3 connected cases in children. Approximately 50% of SARS-CoV-2 infections in the children could not be connected to a secondary case in our study population. CONCLUSIONS: This study does not provide evidence of relevant asymptomatic ("silent") spread of SARS-CoV-2 in childcare facilities in both low- and high-prevalence settings. Our findings add to the evidence that childcare and educational settings do not have a crucial role in driving the SARS-CoV-2 pandemic.

Childcare Attendance and Academic Achievement at Age 16 Years.

Importance: Low school preparedness is linked to high school dropout, poor employment, and negative outcomes. Childcare attendance may increase school readiness and foster academic achievement. Objective: To explore whether childcare attendance was associated with academic achievement at the end of compulsory schooling (age 16 years in the UK), whether maternal education level was a moderator, and the benefit-cost ratio of childcare regarding productivity returns of academic achievement. Design, Setting, and Participants: In this cohort study, data were included from the Avon Longitudinal Study of Parents and Children (ALSPAC) born from April 1991 to December 1992 and the UK National Pupil Database for examination results. Data on academic achievement at age 16 years were available for 11 843 participants. Data were collected from June 2006 to June 2008, and data were analyzed from September 2019 to May 2020. Exposures: On average, 3.7%, 5.9%, and 90.4% attended childcare full time, part time, and less than 10 hours per week, respectively. Maternal education was assessed by questionnaire during pregnancy. Analyses included weights for population representativeness and propensity score weights to account for parental selection into childcare. Main Outcomes and Measures: Academic achievement was defined as no certificate, Level 1 General Certificate of Secondary Education (GCSE; limited training), or Level 2 GCSE (qualification for academic post-16 education; high school diploma equivalent). Lifetime productivity return estimates were withdrawn from previous economic analysis based on pupil's qualifications. Results: Of 14 541 children in the ALSPAC study, 8936 children had complete data on childcare attendance, academic achievement, and maternal education levels. Of these, 4499 (50.3%) were male. Attending childcare was associated with higher probabilities of obtaining a Level 1 or 2 GCSE qualification (Level 1: relative risk, 1.41; 95% CI, 1.16-1.73; Level 2: relative risk, 1.62; 95% CI, 1.30-2.01); however, this association was moderated by the child's maternal education level. When children of mothers with low education attended childcare, their probability of no GCSE qualification went from 28.9% (95% CI, 26.8-31.0) to 20.3% (95% CI, 18.0-22.8), whereas children of mothers with higher education had a probability of no qualification of less than 10% regardless of childcare attendance. The benefit-cost ratio for each £1 (US $1.40) invested in full-time childcare attendance for children of mothers with low education was £1.71 (95% CI, 1.03-2.45; US $2.39; 95% CI, 1.44-3.43) for those who reached a Level 2 GCSE qualification. Conclusions and Relevance: Promoting universal childcare with facilitated access for children of lower socioeconomic backgrounds deserves to be considered as a way to reduce the intergenerational transmission of low academic achievement.

Characteristics of COVID-19 Cases and Outbreaks at Child Care Facilities - District of Columbia, July-December 2020.

The occurrence of cases of COVID-19 reported by child care facilities among children, teachers, and staff members is correlated with the level of community spread (1,2). To describe characteristics of COVID-19 cases at child care facilities and facility adherence to guidance and recommendations, the District of Columbia (DC) Department of Health (DC Health) and CDC reviewed COVID-19 case reports associated with child care facilities submitted to DC Health and publicly available data from the DC Office of the State Superintendent of Education (OSSE) during July 1-December 31, 2020. Among 469 licensed child care facilities, 112 (23.9%) submitted 269 reports documenting 316 laboratory-confirmed cases and three additional cases identified through DC Health's contact tracers. Outbreaks associated with child care facilities,† defined as two or more laboratory-confirmed and epidemiologically linked cases at a facility within a 14-day period (3), occurred in 27 (5.8%) facilities and accounted for nearly one half (156; 48.9%) of total cases. Among the 319 total cases, 180 (56.4%) were among teachers or staff members. The majority (56.4%) of facilities reported cases to DC Health on the same day that they were notified of a positive test result for SARS-CoV-2, the virus that causes COVID-19, by staff members or parents.§ Facilities were at increased risk for an outbreak if they had been operating for <3 years, if symptomatic persons sought testing ≥3 days after symptom onset, or if persons with asymptomatic COVID-19 were at the facility. The number of outbreaks associated with child care facilities was limited. Continued implementation and maintenance of multiple prevention strategies, including vaccination, masking, physical distancing, cohorting, screening, and reporting, are important to reduce transmission of SARS-CoV-2 in child care facilities and to facilitate a timely public health response to prevent outbreaks.¶.

The relationship between educators' and children's physical activity and sedentary behaviour in early childhood education and care.

OBJECTIVES: The early childhood education and care (ECEC) environment has a significant role to play in the promotion of physical activity and reduction of sedentary behaviour in young children. Educators may be an important social factor influencing children's physical activity and sedentary behaviour, however limited evidence exists on this relationship. The primary aim was to examine the relationships between educators' and children's physical activity and sedentary behaviours within ECEC settings. DESIGN: A cross sectional study. METHODS: The study involved 11 ECEC centres from NSW, Australia (n=110 educators; n=490 children). Data for each centre were collected over five consecutive days. Objectively measured physical activity and sedentary behaviour were collected from children using Actigraph accelerometers and were analysed using STATA 13c. Linear regression was used to examine relationships between children and educators, adjusted for centre clustering. RESULTS: A significant association was reported between educators' sedentary behaviour and children's sedentary behaviour (p=0.047). Educators spent 61% of their work day in sedentary behaviour. No significant associations were reported between educators' physical activity and children's physical activity, for any intensity of physical activity. CONCLUSIONS: The positive relationship between educators' sedentary behaviours and children's sedentary behaviour in this study highlights a novel area to target in future interventions. Improving physical activity and sedentary behaviours of educators will likely improve children's physical activity levels and thus health and wellbeing outcomes.

Model-based projections for COVID-19 outbreak size and student-days lost to closure in Ontario childcare centres and primary schools.

There is a pressing need for evidence-based scrutiny of plans to re-open childcare centres during the COVID-19 pandemic. Here we developed an agent-based model of SARS-CoV-2 transmission within a childcare centre and households. Scenarios varied the student-to-educator ratio (15:2, 8:2, 7:3), family clustering (siblings together versus random assignment) and time spent in class. We also evaluated a primary school setting (with student-educator ratios 30:1, 15:1 and 8:1), including cohorts that alternate weekly. In the childcare centre setting, grouping siblings significantly reduced outbreak size and student-days lost. We identify an intensification cascade specific to classroom outbreaks of respiratory viruses with presymptomatic infection. In both childcare and primary school settings, each doubling of class size from 8 to 15 to 30 more than doubled the outbreak size and student-days lost (increases by factors of 2-5, depending on the scenario. Proposals for childcare and primary school reopening could be enhanced for safety by switching to smaller class sizes and grouping siblings.

Hand-washing promotion for preventing diarrhoea.

BACKGROUND: Diarrhoea accounts for 1.8 million deaths in children in low- and middle-income countries (LMICs). One of the identified strategies to prevent diarrhoea is hand washing. OBJECTIVES: To assess the effects of hand-washing promotion interventions on diarrhoeal episodes in children and adults. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, nine other databases, the World Health Organization (WHO) International Clinical Trial Registry Platform (ICTRP), and metaRegister of Controlled Trials (mRCT) on 8 January 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: Individually-randomized controlled trials (RCTs) and cluster-RCTs that compared the effects of hand-washing interventions on diarrhoea episodes in children and adults with no intervention. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trial eligibility, extracted data, and assessed risks of bias. We stratified the analyses for child day-care centres or schools, community, and hospital-based settings. Where appropriate, we pooled incidence rate ratios (IRRs) using the generic inverse variance method and a random-effects model with a 95% confidence interval (CI). We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included 29 RCTs: 13 trials from child day-care centres or schools in mainly high-income countries (54,471 participants), 15 community-based trials in LMICs (29,347 participants), and one hospital-based trial among people with AIDS in a high-income country (148 participants). All the trials and follow-up assessments were of short-term duration. Hand-washing promotion (education activities, sometimes with provision of soap) at child day-care facilities or schools prevent around one-third of diarrhoea episodes in high-income countries (incidence rate ratio (IRR) 0.70, 95% CI 0.58 to 0.85; 9 trials, 4664 participants, high-certainty evidence) and may prevent a similar proportion in LMICs, but only two trials from urban Egypt and Kenya have evaluated this (IRR 0.66, 95% CI 0.43 to 0.99; 2 trials, 45,380 participants; low-certainty evidence). Only four trials reported measures of behaviour change, and the methods of data collection were susceptible to bias. In one trial from the USA hand-washing behaviour was reported to improve; and in the trial from Kenya that provided free soap, hand washing did not increase, but soap use did (data not pooled; 3 trials, 1845 participants; low-certainty evidence). Hand-washing promotion among communities in LMICs probably prevents around one-quarter of diarrhoea episodes (IRR 0.71, 95% CI 0.62 to 0.81; 9 trials, 15,950 participants; moderate-certainty evidence). However, six of these nine trials were from Asian settings, with only one trial from South America and two trials from sub-Saharan Africa. In seven trials, soap was provided free alongside hand-washing education, and the overall average effect size was larger than in the two trials which did not provide soap (soap provided: RR 0.66, 95% CI 0.58 to 0.75; 7 trials, 12,646 participants; education only: RR 0.84, 95% CI 0.67 to 1.05; 2 trials, 3304 participants). There was increased hand washing at major prompts (before eating or cooking, after visiting the toilet, or cleaning the baby's bottom) and increased compliance with hand-hygiene procedure (behavioural outcome) in the intervention groups compared with the control in community trials (data not pooled: 4 trials, 3591 participants; high-certainty evidence). Hand-washing promotion for the one trial conducted in a hospital among a high-risk population showed significant reduction in mean episodes of diarrhoea (1.68 fewer) in the intervention group (mean difference -1.68, 95% CI -1.93 to -1.43; 1 trial, 148 participants; moderate-certainty evidence). Hand-washing frequency increased to seven times a day in the intervention group versus three times a day in the control arm in this hospital trial (1 trial, 148 participants; moderate-certainty evidence). We found no trials evaluating the effects of hand-washing promotions on diarrhoea-related deaths or cost effectiveness. AUTHORS' CONCLUSIONS: Hand-washing promotion probably reduces diarrhoea episodes in both child day-care centres in high-income countries and among communities living in LMICs by about 30%. The included trials do not provide evidence about the long-term impact of the interventions.

ANTECEDENTES: La diarrea es responsable de 1 800 000 muertes de niños en los países de ingresos bajos y medios (PIBM). Una de las estrategias identificadas para prevenir la diarrea es el lavado de manos. OBJETIVOS: Evaluar los efectos de las intervenciones de promoción del lavado de manos sobre los episodios de diarrea en niños y adultos. MÉTODOS DE BÚSQUEDA: El 8 de enero de 2020 se realizaron búsquedas en CENTRAL, MEDLINE, Embase, en otras nueve bases de datos, la Plataforma de registros internacionales de ensayos clínicos (ICTRP) de la Organización Mundial de la Salud (OMS) y el metaRegister of Controlled Trials (mRCT), además de comprobación de referencias, búsqueda de citas y contacto con los autores de los estudios para identificar estudios adicionales. CRITERIOS DE SELECCIÓN: Ensayos controlados aleatorizados (ECA) individuales y por conglomerados que compararon los efectos de las intervenciones de lavado de manos sobre los episodios de diarrea en niños y adultos, con ninguna intervención. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos autores de la revisión, de forma independiente, evaluaron la elegibilidad de los ensayos, extrajeron los datos y evaluaron los riesgos de sesgo. Los análisis se estratificaron por guarderías infantiles o escuelas, comunidad y contextos hospitalarios. Cuando fue conveniente, se agruparon los cocientes de la tasa de incidencia (CTI) según el método de la varianza inversa genérica y un modelo de efectos aleatorios con un intervalo de confianza (IC) del 95%. Se utilizaron los criterios GRADE para evaluar la certeza de la evidencia. RESULTADOS PRINCIPALES: Se incluyeron 29 ECA: 13 ensayos de guarderías infantiles o escuelas en países principalmente de ingresos altos (54 471 participantes), 15 ensayos comunitarios en PIMB (29 347 participantes) y un ensayo hospitalario en pacientes con sida en países de ingresos altos (148 participantes). Todos los ensayos y evaluaciones de seguimiento fueron a corto plazo. La promoción del lavado de manos (actividades educativas, a veces con la provisión de jabón) en las guarderías infantiles o las escuelas previene alrededor de un tercio de los episodios de diarrea en los países de ingresos altos (cociente de tasa de incidencia [CTI] 0,70; IC del 95%: 0,58 a 0,85; nueve ensayos, 4664 participantes, evidencia de certeza alta), y podría prevenir una proporción similar en los PIMB, pero solo dos ensayos en zonas urbanas de Egipto y Kenya lo han evaluado (CTI 0,66; IC del 95%: 0,43 a 0,99; dos ensayos, 45 380 participantes, evidencia de certeza baja). Solo cuatro ensayos informaron sobre medidas de cambio en el comportamiento y los métodos de recopilación de datos fueron susceptibles de sesgo. En un ensayo de los EE.UU. se informó de que el comportamiento de lavado de manos mejoró; y en el ensayo de Kenya que proporcionó jabón gratuito, el lavado de manos no aumentó, pero sí el uso de jabón (datos no agrupados; tres ensayos, 1845 participantes, evidencia de certeza baja). La promoción del lavado de manos entre las comunidades en los PIMB probablemente previene alrededor de una cuarta parte de los episodios de diarrea (CTI 0,71; IC del 95%: 0,62 a 0,81; nueve ensayos, 15 950 participantes, evidencia de calidad moderada). Sin embargo, seis de estos nueve ensayos procedían de entornos asiáticos, y solo hubo un ensayo en América del Sur y dos en el África subsahariana. En siete ensayos, el jabón se suministró gratuitamente junto con la educación para el lavado de manos, y el tamaño del efecto medio general fue mayor que en los dos ensayos que no suministraron jabón (jabón suministrado: RR 0,66; IC del 95%: 0,58 a 0,75; siete ensayos, 12 646 participantes; solo educación: RR 0,84; IC del 95%: 0,67 a 1,05; dos ensayos, 3304 participantes). Hubo un aumento del lavado de manos en los momentos más importantes (antes de comer o cocinar, después de ir al baño o de limpiar el trasero del niño), y un aumento en el cumplimiento del procedimiento de higiene de las manos (resultado conductual) en los grupos de intervención, en comparación el control, en los ensayos comunitarios (datos no agrupados: cuatro ensayos, 3591 participantes; evidencia de certeza alta). La promoción del lavado de manos en el único ensayo realizado en un hospital en una población de alto riesgo mostró una reducción significativa de los episodios medios de diarrea (1,68 menos) en el grupo de intervención (diferencia de medias ­1,68; IC del 95%: ­1,93 a ­1,43; un ensayo, 148 participantes, evidencia de certeza moderada). En este ensayo hospitalario la frecuencia del lavado de manos aumentó hasta siete veces al día en el grupo de intervención versus tres veces al día en el grupo control (un ensayo, 148 participantes, evidencia de certeza moderada). No se encontraron ensayos que evaluaran los efectos de la promoción del lavado de manos sobre las muertes relacionadas con la diarrea ni el coste­efectividad. CONCLUSIONES DE LOS AUTORES: La promoción del lavado de manos probablemente reduce los episodios de diarrea en las guarderías infantiles de los países de altos ingresos y en las comunidades que viven en los PIMB, en aproximadamente el 30%. Los ensayos incluidos no aportan evidencia sobre el efecto a largo plazo de esta intervención.

No SARS-CoV-2 carriage observed in children attending daycare centers during the intial weeks of the epidemic in Belgium.

To gain knowledge about the role of young children attending daycare in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic, a random sample of children (n = 84) aged between 6 and 30 months attending daycare in Belgium was studied shortly after the start of the epidemic (February 29th) and before the lockdown (March 18th) by performing in-house SARS-CoV-2 real-time polymerase chain reaction. No asymptomatic carriage of SARS-CoV-2 was detected, whereas common cold symptoms were common (51.2%). Our study shows that in Belgium, there was no sign of early introduction into daycare centers at the moment children being not yet isolated at home, although the virus was clearly circulating. It is clear that more evidence is needed to understand the actual role of young children in the transmission of SARS-CoV-2 and their infection risk when attending daycare.

Association of environmental factors and high HFMD occurrence in northern Thailand.

BACKGROUND: The major population vulnerable to hand, foot and mouth disease (HFMD) is children aged less than 5 years, particularly those who are cared for at day care centers (DCCs). This study aimed to assess the associations of environmental and sanitation factors with high HFMD occurrence rates in DCCs of northern Thailand. METHODS: A case-control study was used to gather information from caregivers and local government administrative officers. DCCs in areas with high and low HFMD occurrence rates were the settings for this study. A validated questionnaire was used to collect environmental and sanitation information from the DCCs. In-depth interviews were used to collect information from selected participants who were working at DCCs and from local government administrative officers on the HFMD capacity and prevention and control strategies in DCCs. Logistic regression analysis was used to determine the associations between many environmental factors and HFMD at the α = 0.05 significance level while the content analysis was used to extract information from the interviews. RESULTS: Two variables were found to be associated with a high rate of HFMD occurrence: the number of sinks available in restrooms and the DCC size. Children attending DCCs that did not meet the standard in terms of the number of sinks in restrooms had a greater chance of contracting HFMD than children who were attending DCCs that met the standard (AOR = 4.21; 95% CI = 1.13-15.04). Children who were attending a large-sized DCC had a greater chance of contracting HFMD than those attending a small-sized DCC (AOR = 3.28; 95% CI = 1.21-5.18). The yearly budget allocation and the strategies for HFMD control and prevention, including collaborations among stakeholders for HFMD control and prevention in DCCs, were associated with the effectiveness of HFMD control and prevention. CONCLUSIONS: The number of sinks in restrooms and DCC size are major concerns for HFMD outbreaks. Sufficient budget allocation and good collaboration contribute to effective strategies for preventing and controlling HFMD in DCCs.

Use of a spatiotemporal approach for understanding preschoolers' playground activity.

This study used spatiotemporal hot-spot analysis to characterize physical activity on the childcare center playground. Preschool-aged children (N = 34) wore a GPS and accelerometer during 2-3 outdoor periods on one day. A spatiotemporal weights matrix was generated so that points within a specified distance in meters (space) and 3 min (time) were considered neighbors. The Getis-Ord G* statistic was calculated to detect locations of significant hot/cold spots in vector magnitude counts/15­sec. Hot/cold spots changed within a single outdoor period and between outdoor periods, highlighting the importance of time. This approach can be used to identify points of intervention during provided outdoor time.

Using a Respectful Approach to Child-centred Healthcare (ReACH) in a paediatric clinical trial: A feasibility study.

BACKGROUND: There is a growing momentum in paediatric ethics to develop respectful research and healthcare protocols. We developed, tested and refined our 'Respectful Approach to Child-centred Healthcare' (ReACH), to underpin respectful participant interactions in a clinical trial. OBJECTIVE: To determine whether a ReACH-based approach is acceptable to children and parents, and effective in obtaining compliance with common healthcare assessments in a clinical trial of healthy 4-6-year-old children. METHODS: ReACH-based child assessments were evaluated at two baseline clinics and one post-intervention, using mixed methods. Children (n = 49; 46.9% female; mean age = 5.24±0.88 years at baseline) and their parents provided independent evaluation, via customised 5-point Likert scales and qualitative feedback. A dedicated child researcher evaluated adherence to the study ReACH principles. RESULTS: Children achieved compliance rates of 95% for body composition (BodPod) assessments; 89% for blood pressure measurements, and 92% (baseline) and 87% (post-intervention) for blood draws. Adherence to ReACH principles during clinic visits was positively associated with child compliance, significantly for baseline BodPod (p = 0.002) and blood test (p = 0.009) clinics. Satisfaction with BodPod protocols was positively associated with compliance, for children at baseline (p = 0.029) and for parents post-intervention (p <0.001). Parents rated the study itself very highly, with 91.7% satisfied at baseline and 100% post-intervention. Qualitative feedback reflected an enjoyable study experience for both parents and children. CONCLUSIONS: Adherence to our emerging ReACH approach was associated with high child compliance rates for common healthcare assessments, although no causality can be inferred at this preliminary stage of development. Participants expressed satisfaction with all aspects of the study. Our use of child-centred methods throughout a research intervention appears feasible and acceptable to children and their parents.

Abusive Head Trauma in Day Care Centers.

BACKGROUND: Abusive head trauma (AHT) warrants particular attention in terms of prevention. One of the key questions asked is how often AHT occurs in infant day care centers compared with private parental or nonparental homes. To investigate this, we studied the caretaking arrangement and child's location at the time of injury in a cohort of cases involving AHT from the courts. METHODS: This multicenter retrospective study covering an 18-year period included all medical and court records of 323 children (2.5 months to 3 years) with AHT, confirmed by the authors acting as medical experts. All markers for abuse and forensic written reports were analyzed by using a standardized data collection tool. The usual child care arrangement and the child's location at the time of injury were noted. The percentage of day care centers found in the study was compared to the expected rate in the French population (19.5%) by using the χ2 test. RESULTS: In 317 AHT cases (98.5%), the assault occurred in a private home (4 in other indoor settings and 1 with missing data). In only 1 case, shaking occurred in a day care center when the nurse was alone with the infant for a few minutes. In 317 cases (98.5%), the usual child care arrangement was by a single adult in charge of 1 or more children. CONCLUSIONS: The fact that AHT is an unusual occurrence in day care centers could help social service agencies make decisions in terms of prevention. Recent government policies regarding stay-at-home orders during a pandemic have given this issue new relevance.

Australian childcare centres are too close to car parks exposing children with developing lungs to high levels of traffic pollution.

OBJECTIVE: To examine the co-location of childcare centres and their outdoor play spaces with car parks in Melbourne and Sydney, Australia. METHODS: The co-location of childcare centre outdoor play spaces and car parks was examined through measurement of horizontal and vertical distances using Google Earth Pro satellite imagery. RESULTS: One hundred and forty-two childcare centres were studied in Melbourne, with 133 accompanying car parks identified. Eighty-one (57.0%) centres had a significant size car park within 150 m and 43.7% had a car park within 100 m. Twenty car parks (15.0%) were found within 10 metres of childcare centres, of which 12 (9.0%) had more than 100 spaces. Twenty centres were examined in Sydney, with 31 associated car parks identified. Eighteen childcare centres (90.0%) had car parks within 150 m and 17 (85.0%) had car parks within 100 m. CONCLUSION: Australian childcare centres are located too close to car parks exposing children to pollution and likely impacting the development of chronic respiratory disease. Traffic pollution is an avoidable risk that must be considered when planning childcare centre location. Implications for public health: The co-location of childcare centres with large-scale car parks may have long-term impacts on the respiratory health of Australian children under the age of five.

Preschool environment and preschool teacher's physical activity and their association with children's activity levels at preschool.

OBJECTIVE: The aim of this study was to investigate the association between preschool playground size, formalized physical activity (PA) policies, time spent outdoors and preschool teacher's levels of PA and children's objectively assessed levels of PA and sedentary time (ST) during preschool hours. METHODS: In total, 369 children and 84 preschool teachers from 27 preschools in Södermalm municipally, Stockholm Sweden wore an Actigraph GT3X+ accelerometer during 7 consecutive days. Preschool environmental and structural characteristics were measured via the Environment and Policy Evaluation Self-Report (EPAO-SR) instrument and time in- and outdoors was recorded by preschool teachers during the PA measurements. Weight and height of children were measured via validated scales and parents filled out a questionnaire on demographical and descriptive variables. Linear mixed models, nested on preschool level, were used to assess the association between predictors and outcomes. RESULTS: The mean child age was 4.7 years (SD 0.8) and 45% were girls. We found that children were more active in preschools with a formalized PA policy, compared to preschools without such a policy, but not less sedentary. The association between policy and activity seemed to be more pronounced when accounting for other environmental factors. Similar associations were found in children spent most time outdoors (uppermost quartile) compared with children spent least time outdoors (Lowermost quartile). Preschool teachers' light PA (LPA) (ß = 0.25, P = 0.004) and steps (ß = 0.52, P<0.001) were associated with children's LPA and steps while the preschool playground size showed no association with PA in children, when accounting for other environmental factors. CONCLUSION: The current study showed that preschool structural characteristics such as formalized PA policies and more time spent outdoors were positively associated with children's PA. These findings suggest that formalized PA policies and time outdoors may be of importance for promoting children's PA during preschool hours.

Changes in Foods Served and Meal Costs in Boston Family Child Care Homes after One Year of Implementing the New Child and Adult Care Food Program Nutrition Standards.

This study aimed to determine the impact of 2017 revisions to the Child and Adult Care Food Program (CACFP) nutrition standards on foods and beverages served and meal costs in family child care homes (FCCHs). Our pre-post study utilized four weeks of menus and food receipts from 13 FCCH providers in Boston, MA prior to CACFP nutrition standards changes in 2017 and again one year later, resulting in n = 476 menu observation days. We compared daily servings of food and beverage items to the updated standards. Generalized estimating equation models tested for changes in adherence to the standards and meal costs. FCCHs offered more whole grains and less juice and refined grains from baseline to follow-up. FCCHs were more likely to meet the revised whole grain standard at follow-up (OR = 2.7, 95% CI: 1.4, 5.2, p = 0.002), but rarely met all selected standards together. Inflation-adjusted meal costs increased for lunch (+$0.27, p = 0.001) and afternoon snack (+$0.25, p = 0.048). FCCH providers may need assistance with meeting CACFP standards while ensuring that meal costs do not exceed reimbursement rates.

Changes in Child and Adult Care Food Program (CACFP) Practices at Participating Childcare and Education Centers in the United States Following Updated National Standards, 2017-2019.

The U.S. Department of Agriculture's (USDA) Child and Adult Care Food Program (CACFP) updated meal pattern standards took effect in October 2017. The aim of this quasi-experimental, pre-post study is to identify changes in food and beverage practices of CACFP-participating centers due to implementation of updated CACFP meal patterns over a 21-month period. Eight hundred and fifty-eight centers located in 47 states and the District of Columbia completed a survey (primarily electronic) at both time points (67.6% follow-up response rate). Multivariable logistic regressions with robust standard errors assessed changes over time, accounting for repeated observations within each site. From baseline to follow-up, centers reported the increased familiarity and implementation, albeit with time, money, and staffing-related challenges. Significant improvements were seen in not serving sugary cereals or flavored milk, in serving 100% whole grains, and serving processed meats less than once a week. While CACFP-participating centers reported making significant progress in meeting the updated meal pattern standards and suggested best practices within 15-19 months of their effective date, reported compliance and adherence to the standards and best practices was not universal. USDA, state agencies, and technical assistance providers should work to provide centers with additional guidance to help them with implementation.

Conceptualization of Major Stakeholders in Emergency Management of Childcare Facilities.

This study aims to conceptualize the key stakeholders in emergency management of childcare facilities for applicable nations by referring to the Korean case. Qualitative content analysis is the main methodology used. Unique features are gathered from the Korean literature on childcare facilities and then summarized; however, universal principles from the English language literature on international childcare facilities are emphasized. The analysis of five major stakeholders in Korean childcare facilities, namely, governments, community personnel, parents, childcare providers, and children, shows that their current efforts are directed only at general safety management. Multi-hazard management or an integrated approach in terms of social work is thus provided as an alternative for not only Korea but also other nations.