Day care, grandparent, pod or nanny? How to manage the risks of pandemic child care

Pre-pandemic, about half of U.S. families reported having trouble finding care for a young child. That number jumped to nearly two-thirds this spring, as day cares closed and other caretakers, such as grandparents and nannies, were told to stay home.

And with many schools operating remotely, in a hybrid model or abruptly changing course this fall, many more parents, including those with kids in elementary school and beyond, are grappling with a child care crisis.

This shakeup of an already-fragile child care puzzle is no longer just a matter of logistics ("Who can watch the preschooler when I work?") or finances ("Can I afford to share a nanny with two other families?"). The pandemic makes these questions even more complicated and anxiety-provoking.

"Everything is about risk mitigation right now," says Dr. Anne Rimoin, a UCLA Fielding School of Public Health epidemiologist who specializes in emerging infectious diseases. "So you have to think carefully about where you're putting your kids and who's taking care of them and make the best decision that you can based on the options available to you."

How should families go about making these difficult decisions — and make any child care setup as safe as possible for kids, families and care providers?

Emerging data about the virus and thoughtful public health tactics can help.

First, one small bit of consolation is that children, especially those between the ages of 1 and 9, are less likely than adolescents and adults to get very sick from this coronavirus (although some still do get very ill).

The very youngest, however, are more vulnerable than their slightly older counterparts, accumulating evidence suggests. Infants younger than 12 months have been much more likely to be hospitalized for COVID-19 infection than any other pediatric age group. And, rarely, children — even those who had mild or no symptoms — have developed a severe inflammatory syndrome.

Kids also seem less likely than adults to spread the virus to others. The information is still flowing in about this new-to-humans virus however, and the latest studies indicate the virus might be much more common in young kids than previously thought; children under the age of 5 might carry even higher amounts of the virus than adults or older kids.

So, if you're trying to make new child care decisions, one key is to pay attention to how severe community spread is in your area, says Kumi Smith, an epidemiologist at the University of Minnesota School of Public Health who focuses on community health.

"We now find ourselves in a position where each family has to balance what their resources are and what they can bear," Smith says. But it's clear that "any time we're mixing different people from different households together, that's how the virus spreads."

We asked Smith, Rimoin and other experts to help walk us through their thinking and the latest science on the particular risks and considerations for four common child care arrangements.

1) Daycare, preschool, and other child care centers

Key questions: Is the center checking kids for symptoms, cleaning rigorously and restricting kids and staff to the same small groups each day?

Child care centers have fairly detailed guidance from the U.S. Centers for Disease Control and Prevention on steps to take to reduce the spread of COVID-19. Those CDC suggestions are "a good starting point," says Dr. Tina Tan, a pediatrician at Northwestern Feinberg School of Medicine and Lurie Children's Hospital of Chicago who specializes in infectious diseases.

To distill the lengthy recommendations, Tan tells NPR, the key things parents should look for at a child care center are: intensive cleaning and disinfection procedures and a protocol that assigns children to groups that consistently stay together (ideally with the same adult) each day, to reduce the number of people they come into contact with. It's also important, she says, that the procedures for drop-off and pick-up avoid crowding.

Dr. Stan Spinner, chief medical officer at Texas Children's Pediatrics and Texas Children's Urgent Care, adds to that list. All day care workers should wear masks, he says, and day cares should routinely screen children (and parents) for fever, COVID-19 symptoms and exposure to people who have tested positive for the virus. These steps "are a must," he says. Facilities should also be able to quickly pinpoint and isolate any child or worker who has symptoms, he adds, limit the sharing of toys and do their best to keep children physically distanced "when feasible and age appropriate."

Many recommendations from health officials, however, can tax already-strained facilities. One of the CDC's guidelines, for example, suggests adults wearing gloves use a five-step process to clean any toy that has been put in a baby's or toddler's mouth.

"I have strong doubts that many daycares have the ability to strictly adhere to these guidelines," Spinner says.

Risk depends, too, on how widely the virus is circulating in the community. "If there is a surge of COVID-19 cases or a very high rate of infection in the community, it probably would not be a good idea for child care facilities to open," Tan says. As of early August, after cases had surged during the summer in Texas, more than 1,000 children attending day care in the state (and more than 2,000 staff members) had tested positive for the virus.

And Smith cautions against hanging too much importance on temperature screenings or other symptom checks for catching infections. In fact, people tend to be at their most infectious right before they get any symptoms the latest evidence suggests. And "many infections are asymptomatic," Smith notes. She suggests regular testing should be part of any day care center's strategy for avoiding an outbreak.

If families have a choice among child care options, Tan recommends taking a close look at any facility and asking questions about what preventative steps they are taking. "The riskiest child care option," she says, "would be a large day care center that has not implemented the basic strategies to prevent exposure and spread of COVID-19."

2) Grandparent or other COVID-vulnerable family member

Key question: Can everyone — kids included — commit to sticking exclusively to a very small 'bubble' of close contacts?

Older people are at a drastically higher risk of getting severely ill and dying from COVID-19. And many common underlying conditions, such as hypertension and diabetes can increase that risk for any age group.

So for many grandparents, the safest choice is to not be the grandkids' caregiver. "This has been one of the most challenging aspects," Smith says, "because it's painful."

But there are some things families can do to lower the risks in these situations. For example, they can go on a strict regime of physical distancing outside the family (no play dates, no in-person schooling for young kids, always wearing masks and distancing when in public, etc.) for two weeks and then go into an even smaller, closed "bubble" with the older caregiver. Then ensure everyone continues to uphold these practices.

"If you're essentially 'bubbling' with these grandparents and relatives, and you're all staying safe, and not seeing other people, and not going out, then that's an option," Rimoin says. "You just have to remember that even if the risk is low of children transmitting the virus to adults, the risk is not zero, and you just have to think about that with caution." One report, for example, found high levels of the virus in children (including in a few newborns), which means even they could be capable of passing it on.

With in-person schooling canceled, postponed or part time in many places for the fall, some parents are considering older relatives as backup child care. If this is the case, the families should plan on that two-week isolation before enlisting this help if possible. Spinner notes that the family should take every step they can to limit that child's exposure to others in the community before contact with their higher-risk relative.

To help everyone involved decide if they feel comfortable with that sort of setup, Smith suggests having some tough conversations. "It might seem morbid," she says, but ask the relative what their plan is if they or someone else in the family starts feeling sick and where they would want to be taken to the hospital. "I've had this conversation," she says; "it helps make the situation more real to everyone involved."

3) Nanny

Key Questions: Do parents and the nanny have open communication about everyone's level of caution when outside the home? Is everyone able to practice good hygiene and risk mitigation when in the home?

Professional in-home child care has appeared, for many, to be a relatively safe option. And data from Care.com, one of the largest online clearinghouses for this service, bears that out. "We're seeing a triple-digit percent increase in demand for in-home care on our platform," Tim Allen, the company's CEO noted in an email to NPR. A survey his organization carried out in late May found that more than 63 percent of parents weren't comfortable at the time sending children to day care. Virus cases have only increased since then.

But there are still risks to consider — and ways to minimize them.

"A nanny will pose as much of an exposure risk as his or her personal daily activities dictate," Spinner notes. "Is the nanny spending time around other people, going out in public areas, such as the grocery store, restaurant, hairdresser? Is the nanny wearing a mask routinely?"

It's important to have transparency and open communication in these discussions, Smith says, "for all parties to be honest with each other about how many contacts they are having outside the home." Families and caregivers should also discuss plans and protocols for testing and isolation should any of them or their close contacts develop symptoms or test positive for the coronavirus. Allen also stresses the importance of paying nannies above board — that provides caregivers better access to sick leave and unemployment benefits, which could help minimize virus spread.

Tan recommends that a paid in-home caregiver have coronavirus screenings the same way a day care center employee would, with temperature and symptom checks before starting work, for example. And they should maintain other best hygiene practices, such as washing their hands frequently, removing their shoes in the home, and maintaining physical distance — especially from adult members in the household — when possible. And family members should do these things as well, to protect the caregiver's health.

"Even a conscientious nanny can be a risk to your family's health," Rimoin says. "On the other hand, [by] having a nanny you're exposing your family to one caregiver, but a day care might introduce more teachers and aides into the equation."

The details of the care arrangement also play a large role in the level of risk. For example, an au pair who lives with the family (and who is also following best practices when outside the home) is probably the safest nanny option.

But if you're considering sharing a care provider with another family — or families — (a setup that has recently surged in popularity, Allen says), that brings additional layers of risk.

"If the nanny takes care of multiple children from different families and lives in the community, group-based care in which you have cohorting of children and staff may be safer," Tan says.

4) 'Podding' or care-sharing with another family

Key questions: Is everyone in the pod committed to mask-wearing, physical distancing and protecting all pod members? Do you have a plan if someone gets COVID-19 or tests positive for the virus?

During the pandemic many families have created small pods, with one other family or even a few others to share in child care duties. Collaborating with friends or neighbors that way might seem safe, but it is not risk-free. In fact, "If you had asked me back in March, I would have said 'absolutely not.' " Smith says. But now, she acknowledges, in many cases in which people don't have other options, "that does seem like a necessary risk that would make this a more bearable situation" — and more sustainable.

Any group of people is only as safe as its least-safe member. For example, notes Spinner, "I would be reluctant to co-mingle with a family whose members choose to go to a gym or eat inside at a restaurant at this point in time." To be safest, each person in these closed pods should be taking every precaution when outside the group, for example, always wearing a mask when out in public and not having close contact with anyone who isn't a member of the bubble.

As in the other care arrangements, it is important for everyone to have open communication about their behaviors, health and plans in case of potential illness.

Another consideration is the number of people involved in the pod — especially the number of adults. Fewer is safer. "In general, the more people who are working in the community, the more chance there is for exposure to COVID-19," notes Tan.

A national child care strategy: 'Our only way forward'

Even before the pandemic, child care was something not every family had access to, financially or logistically. As of last year, Care.com found that about half of American families were spending 15 percent or more of their income on child care expenses. And at various times this year, many states have taken the safety precaution of limiting the number of children in any room of a child care center. That has also had the effect of lowering the number of day care spots available to families and has put a financial strain on centers that remain open.

The pandemic has made any form of child care feel even more precious — and also oftentimes risky. "At the end of the day, everyone's going to have to balance feasibility with safety," Rimoin says. And for many families these days, if they can get child care at all, they don't have the option of choosing its form.

As Rimoin sees it, though, these shaky decisions parents are having to make are not the right solution — for them or for the economy more broadly. "Our only way forward is to have a national strategy to be able to reduce the spread of this virus," she says.

That is exactly what other countries that have been able to return young children to more regular child care have done. Denmark reopened day care centers in April, and kept the country's numbers of new cases of coronavirus infection low — often to just a few dozen per day. And France, which also managed to blunt viral spread to steadily low numbers in April, was able to remove physician distancing measures from its day cares.

"Why this whole country is not coming together to bring this virus under control for the sake of our children is just beyond me," Rimoin says of the United States.

In the meantime, she says, "everybody is suffering because of it. Everybody."

Katherine Harmon Courage is a freelance science and health journalist and editor, contributor for Scientific American and Vox, and author of “Cultured” and “Octopus!” You can find her on Twitter at @KHCourage.

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