PEDIATRICS recent issues

COVID-19 Transmission in US Child Care Programs


Central to the debate over school and child care reopening is whether children are efficient coronavirus disease 2019 (COVID-19) transmitters and are likely to increase community spread when programs reopen. We compared COVID-19 outcomes in child care providers who continued to provide direct in-person child care during the first 3 months of the US COVID-19 pandemic with outcomes in those who did not.


Data were obtained from US child care providers (N = 57 335) reporting whether they had ever tested positive or been hospitalized for COVID-19 (n = 427 cases) along with their degree of exposure to child care. Background transmission rates were controlled statistically, and other demographic, programmatic, and community variables were explored as potential confounders. Logistic regression analysis was used in both unmatched and propensity score–matched case-control analyses.


No association was found between exposure to child care and COVID-19 in both unmatched (odds ratio [OR], 1.06; 95% confidence interval [CI], 0.82–1.38) and matched (OR, 0.94; 95% CI, 0.73–1.21) analyses. In matched analysis, being a home-based provider (as opposed to a center-based provider) was associated with COVID-19 (OR, 1.59; 95% CI, 1.14–2.23) but revealed no interaction with exposure.


Within the context of considerable infection mitigation efforts in US child care programs, exposure to child care during the early months of the US pandemic was not associated with an elevated risk for COVID-19 transmission to providers. These findings must be interpreted only within the context of background transmission rates and the considerable infection mitigation efforts implemented in child care programs.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user’s adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

Child Life Services

Child life programs are an important component of pediatric hospital-based care; they address the psychosocial concerns that accompany hospitalization and other health care experiences. Child life specialists focus on the optimal development and well-being of infants, children, adolescents, and young adults while promoting coping skills and minimizing the adverse effects of hospitalization, health care encounters, and/or other potentially stressful experiences. In collaboration with the entire health care team and family, child life specialists provide interventions that include therapeutic play, expressive modalities, and psychological preparation to facilitate coping and normalization at times and under circumstances that might otherwise prove overwhelming for the child. Play and developmentally appropriate communication are used to (1) promote optimal development, (2) educate children and families about health conditions, (3) prepare children and partner with families for medical events or procedures, (4) plan and rehearse useful coping and pain-management strategies with patients and families, (5) help children work through feelings about past or impending experiences, and (6) partner with families to establish therapeutic relationships between patients, siblings, and caregivers. Child life specialists collaborate with the entire interdisciplinary team to promote coping and enhance the overall health care experience for patients and families.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

Antibiotic Stewardship in Pediatrics

Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy, duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs; essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient antibiotic stewardship programs are provided.