2004 Job Lewis Smith Acceptance Address
http://www.100md.com
《小儿科》
the Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
Abbreviations: AAP, American Academy of Pediatrics ECELS, Early Childhood Education Linkage System TLC, The Learning Center
The late Fred Rogers taught me that, when someone thanks you for your work, gracious acceptance is a reciprocal gift. Many of you know Fred from his television program, Mr. Rogers' Neighborhood. So, with humility, I thank you for giving me the Job Lewis Smith Award. You have validated my work in community pediatrics. This award not only honors me but hopefully encourages others to pursue the goals that have guided my career as well.
The award is named for Job Lewis Smith. Dr Smith was a 19th-century pediatrician and clinical professor of diseases of children at Bellevue Medical School in New York City. He was a community pediatrician who focused on reducing adverse child health outcomes that were the result of poverty and poor living conditions among working class families. In 1880, he helped form the American Medical Association Section on Pediatrics and, in 1888, was a founder of the American Pediatric Society.
Like Dr Smith, I am a start-up person who has focused on preventive health needs for children and on engaging others in these efforts. Although I often used traditional approaches, my work with early education and child care has provided many more opportunities. When I was a young mother, I noted that many infants, toddlers, and preschool-aged children spend much of their time in the care of someone other than their parents. Every day, tired young parents grab one last hug as they drop off their young children with bags of diapers, spare clothing, food, favorite toys, and nap blankets in early education and child care arrangements. Many of these young adults are stressed and needy. They are simultaneously learning the basics of parenting, keeping a foothold in the workplace, maintaining caring relationships with life partners and other family members, and searching for time to care for themselves.
As a primary pediatric clinician, community pediatrician, and academician, I found my early childhood activities the most rewarding. Research repeatedly confirms that early childhood is a period of rapid growth and plasticity that offers unique opportunities for effective interventions that can have lifetime socioemotional and physical health benefits.1
My first big project was to start an innovative early education and child care center at the Medical College of Pennsylvania, on the edge of the poorest section of Philadelphia. This program was called the Learning Center (TLC). It served children from families in the community and those affiliated with the medical school. The children were enrolled in heterogeneous groupings by age and socioeconomic status. Each classroom had male and female teachers. Studies of the developmental outcome of children at TLC matched the positive results reported for Head Start and middle-class nursery schools, which typically had more homogeneous arrangements.
As designer and executive director of the center, I worked collaboratively for a decade with early education colleagues. This experience increased my understanding of child development, gave me a valuable foundation for subsequent work with early childhood educators, and taught me how to be an effective leader and administrator in a community setting. The center's success was the result of commonly held goals and objectives among all those involved, ie, early educators, parents, community members, and health professionals. TLC closed 2 years after my departure, because of staffing and budget problems. This event taught another lesson: that effective leaders must ensure the sustainability of successful programs before moving on.
My involvement with the American Academy of Pediatrics (AAP) began at the chapter level. When I became a Fellow of the AAP, I joined the Pennsylvania chapter. In the early 1970s, the chapter was thriving under Bill Mebane's able leadership. Over the following years, the previously productive organization became less so. In the 1980s, as an appointed committee chair and then as an elected leader of the chapter, I engaged others in reestablishing the Pennsylvania AAP as a voice for children. By accepting grants and state contracts, the chapter began to be known as a provider of innovative and effective community service programs in the state. The successful model involved identifying pediatricians willing to champion a child health initiative, finding funding, and developing and advising a program that a few competent staff members then manage day-to-day. Together, these individuals mobilize a large corps of public and private professionals to work on solutions to child health problems in communities across the state. Many other chapters have adopted this model.
Two of the Pennsylvania AAP's ongoing projects developed directly from my work. The first is the federal and state-funded Traffic Injury Prevention Project that uses state-directed, federal funds to establish car seat loaner programs and to provide education on passenger and pedestrian issues, school bus safety, and safe teen driving for children. Although I launched this program, its leadership over more than 2 decades of operation has been in the able hands of my husband, Jerry. The result is improved child safety through the actions of parents, police officers, judges, school principals, teachers, health professionals, and the general public.
The second Pennsylvania AAP project I started is the Early Childhood Education Linkage System (ECELS), also known as Healthy Child Care Pennsylvania. ECELS uses federal, state, and private funds to improve health and safety in early education settings. ECELS was a model for the federally funded initiative that established Healthy Child Care America programs in every state. By linking the work of health professionals with that of early educators, ECELS brings prevention and health promotion into the daily lives of young children and their families. I will say more about this later.
Sustaining good work requires mentoring others. For a few years, I have been meeting with all second-year residents from the Children's Hospital of Philadelphia, teaching a seminar on advocacy tools to small groups of them at a time. From my vantage as a senior citizen, I teach the residents that work and personal life cannot be balanced as if they are opposites. We multitask and navigate our roles, setting priorities that shift from one period of life to another. I am a woman, wife, mother, grandmother, primary/community/academic pediatrician, and social activist simultaneously. At any one moment, I allocate my time based on what I think I will have wished I had done when reflecting 20 years from now. My "20-year rule" has served me well. All of my roles are part of my persona.
None of my successes are mine alone. Learning how to help groups of people work together productively is a set of essential skills. Over the years, my employers and the AAP gave me formal and informal training in organizational development. I learned that success is more likely if you can help people stop blaming and complaining and focus on problem solving. Problem solving is more likely to achieve desirable outcomes when those who are affected, those with authority to implement change, and those with expertise are involved. Although these approaches are common tools taught in business schools, success requires more than strategy. Achievements come more easily by combining serendipity with strategy. Remaining alert and ready to exploit unforeseen opportunities makes it possible to sustain an endless stream of good outcomes, even in times of lean funding.
Although stressful, disagreements with collaborators are welcome when they provide fruit for even better plans. My mentors taught me how to negotiate by clarifying differences to find common ground. Often, positive outcomes can come from by having members of a group agree to hang irresolvable differences outside the door, while working on mutual goals. Celebrating even small accomplishments helps too. As my grandmother often quoted from some unknown source, "There is no limit to the good you can do if you share the credit."
Plato was right; the essence of truth does not change; we keep rediscovering it. The present and future roles of primary pediatricians will evolve from ageless principles. We must continually assess and mobilize resources to respond to the needs of children and families, using approaches that are properly seasoned with what families and society want us to provide. Parents want pediatricians to talk about certain topics because of what they have seen or heard from others and what they think will make them seem like good parents to the pediatrician and to others. What parents want to know or ask is not always the same as what they need to know. Wants are based on currently perceived need, whereas needs are objectively measured deficits. We survey wants; we objectively measure needs.
My work in early education requires continuous integration of wants and needs of families. Parents of young children want to think their children are safe and able to thrive in the arrangements they choose. In some cases, one or both parents provide most of their children's education and care themselves, but it is very difficult to do so without participation by competent members of the extended family. More commonly, parents use some services provided by nonrelatives, choosing among home-based and center-based services that they find in their communities. Parents sometimes use a combination of more than one type of care on any day or during any given week. They may have some of their children in one set of arrangements while others use services elsewhere.
The types of arrangements vary by the age of the child as well as the needs of parents. Regulatory requirements for these services vary widely by state. National standards for infants and toddlers are for ratios of at least 1 teacher per 3 infants and 1 teacher per 4 toddlers and 2-year-olds (children between 13 and 30 months of age). The group size should be no more than 6 children for infants and 8 for toddlers and 2-year-olds. Some states permit teachers to care for many more children and much larger groups. Regulatory requirements set the floor for legal operation. Typically, most programs in the community function close to regulatory requirements. Because many parents choose cost and convenience over quality, competition for enrollment drives quality downward.
Nationally, two thirds to three fourths of children younger than 6 years of age regularly attend some type of early education and child care, with the proportion in nonparental care increasing from infancy to 3 to 4 years of age.2,3 In my home state of Pennsylvania and elsewhere, infants and toddlers are more likely to be in home-based rather than center-based care. These services are often neighborhood businesses or services provided by relatives. Many of these services are legally unregulated or operated without the required registration with authorities.
The situation is different for preschool-aged children. Use of center-based care is more common for this age group. For 3- and 4-year-old children, only one quarter of children receive parent-only care, another one quarter use family child care homes, and 44% are in some type of center-based educational program. The services may include programs that operate before and after school, for full or part days and full or part weeks. Two teachers should be responsible for groups of no more than 14 children who are 3 years of age and up to 16 children who are 4 years of age. Pennsylvania has nearly 4000 legally operating (licensed) centers, about 4000 regulated family child care homes, and approximately 1000 Head Start facilities and 700 nursery schools.
In the United States, only a small proportion of available early education and child care services (14%) are of good quality and nearly three fourths are mediocre. For infants and toddlers, approximately 40% of early education and child care services are below minimum standards. Home-based care tends to be of poorer quality than center-based care.4–7
Cost and quality are closely tied. Financially starved early education providers do not receive enough income to attract and retain well-educated staff members for this physically and intellectually demanding work. Nationally, on average, teachers/caregivers in early education settings receive $8 to $10 per hour, around the hourly wage of parking lot attendants and less than bellhops, service station attendants, and bicycle repairers. Tree trimmers and animal trainers make more; kindergarten teachers make twice as much per hour.8 The result is that staff turnover in early education programs is high, 30% per year for teaching staff.
Although not universal, quality nonparental early education is recognized as a beneficial foundation for later learning. Early education is the norm in the United States. Ironically, unlike the situation in other developed countries, early education receives less public subsidy than elementary, secondary, higher, and remedial education. Parents need to know how to choose and to use early education and child care, as well as how to work with others in their communities to advocate for better choices than are generally available.
Whatever they are called and whoever funds them, early education programs generally involve caring adults who are trying to do the best they can with insufficient resources. Many early education and child care providers seek accreditation that requires commitment to meet rigorous criteria for staff credentials, curriculum, teaching, relationships, health and safety, physical environment, leadership/management, assessment, family, and community relationships. Early educators recognize that staff training and program accreditation make a difference and seek these within their operational constraints. They know that health and safety are essential elements and that they need help from health professionals to achieve quality.9
Early education and child care offers rich opportunities for collaboration of health professionals and early educators to prevent harm and promote health. For infectious disease, research shows that the increased burden of illness associated with group care can be controlled with immunization, hygiene, and sanitation.10–12
For injuries, on the basis of hours of contact, fewer and less serious injuries occur in child care settings than in children's own homes.13–15 Still, those that occur are preventable. The most common and most severe injuries are attributable to falls from climbing structures. Many of these injuries can be prevented with developmentally appropriate equipment and properly cushioned surfaces under and around climbing structures. Injury prevention education is a largely underutilized and effective opportunity for health promotion in early education programs. One example of such a curriculum is Risk Watch, a nationally available injury prevention intervention that has achieved increases in desired knowledge and injury prevention behaviors.16
On-site visits by health professionals to early education facilities help improve health and safety by enabling direct observations and building interdisciplinary relationships. Health consultations that involve both telephone contacts and site visits by health professionals have been shown to improve health and safety practices and to reduce days absent for illness, improve immunization rates, and increase utilization of a medical home as recorded in the children’s on-site medical records in these programs. Effective health consultations do not require large amounts of professional time (J. Kotch, MD, MPH, written communication, 2003).
In the past decade, federal funding through the Child Care and Development Block Fund has been available to states to subsidize and to improve quality in early education and child care programs. The military child care system, a worldwide early education network, requires all of its centers to be accredited by the National Association for the Education of Young Children. Other federally supported national quality improvement initiatives include the Healthy Child Care America Campaign based at the AAP, the National Resource Center for Health and Safety in Child Care based at the University of Colorado Health Sciences Center, and the National Training Institute for Child Care Health Consultants at the University of North Carolina at Chapel Hill.
The AAP has excellent references that describe what constitutes health and safety in early education and child care programs and a variety of ways in which primary care clinicians and pediatric subspecialists can become involved.17,18 In 2002, the AAP and the American Public Health Association published Caring for Our Children: The National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care. Preparation of this publication was funded by the Maternal and Child Health Bureau. It is considered the key reference for training, regulation setting, accreditation, and practice of health and safety in early education and child care. In addition to Caring for Our Children, many other helpful publications to improve health and safety in early education are available. One of the newest of these is a spin-off of Caring for Our Children and the AAP Red Book, Managing Infectious Diseases in Child Care and Schools, a Quick Reference Guide. Another product stimulated by the standards in Caring for Our Children is the new AAP pediatric first aid course for teachers and caregivers called PedFACTS. Other useful tools to improve health and safety in child care are available from the AAP, the Pennsylvania AAP, and the National Association for the Education of Young Children.19–22 An extensive set of references is listed on the ECELS-Healthy Child Care PA Web site (www.ecels-healthychildcarepa.org).
All pediatric health professionals can and should contribute to improving the quality of early education and child care for their patients. Ask, "Who cares for your child when you aren't available" and "Do you care for children of other parents in your home" The answers to these questions provide opportunities to discuss prevention and health promotion where children spend their time. When young infants are involved, be sure to emphasize the messages about how to prevent sudden infant death syndrome, ie, "Back to Sleep," with no covering of the face or bed sharing, avoiding soft bedding and toys, not overheating, protecting against exposure to environmental smoke, and of course encouraging breastfeeding. Although >85% of parents were putting infants on their backs to sleep by 1999, other caregivers are not following this practice as consistently. A higher rate of sudden infant death syndrome per hour of exposure occurs in family child care than in child care centers or in parent care.23–25 We should focus on this issue especially carefully when family child care arrangements are used for young infants.
The results of a recent periodic survey conducted by the AAP suggest that pediatricians are more aware of what constitutes quality early education and child care but are reluctant to get involved because of their time constraints and lack of knowledge about how to incorporate this information into routine anticipatory guidance.26 The approaches are simple and not necessarily very time-consuming. Discuss early education and child care arrangements. Visit local early education programs that are mentioned by more than a few families in the practice, to learn about the reality of that service. Offer medical consultation or advice, or consider other ways to advocate for quality child care at the community or state level. Use Caring for Our Children as a primary reference; it contains not only standards for quality programs but also the rationale and references that support each standard.
Those bothersome forms parents bring to children's clinicians are valuable means of communication with educators. Early educators can be armed with appropriate tools such as the Immunization Dose Counter, available on request from the AAP, or the Internet application software that tracks preventive health services, called WellCareTracker, that is available from the Pennsylvania AAP at www.wellcaretracker.org. With these tools, educators can check the records they have on hand to identify children who have gaps in immunization and screening services and who therefore need referral to their medical homes. WellCareTracker software was developed and rigorously tested by pediatricians as part of the work of ECELS-Healthy Child Care Pennsylvania at the Pennsylvania AAP.
At the least, all clinicians should provide advice to families about health and safety issues in group care settings and should communicate special health care instructions directly to the teachers/caregivers who care for their patients on a regular basis. Direct communication through written notes carried by parents or oral communication authorized by parents ensures that early educators/caregivers have accurate information to care properly for the children. Whisper-down-the-lane communication from health professionals to parents to teachers/caregivers is rarely effective. Educators welcome pediatric health professionals who offer their advice about individual children or about the group of children or become advocates for better quality of early education in the community. A pediatrician who advocates for better services can make a difference in public policy decisions about early education.
The AAP offers many opportunities to pursue advocacy for improved health and safety in early education settings. Within the Section on Community Pediatrics, a special interest group on Early Education and Child Care unites >200 health professionals.
Progress is being made but much more remains to be done. To make progress, (1) do your best by providing good care and caring about what you do, (2) help others achieve success while you strive to do your part, (3) base decision-making on needs and wants, (4) use opportunities and good ideas wherever you find them, (5) collaborate to leverage personal efforts, and (6) pace yourself and navigate your life roles realistically.
For me, a combination of strategy and serendipity has brought much success. I am passionate about using early education programs as opportunities for prevention and health promotion. My efforts have been magnified many times by the work of others. If I have a legacy, I hope it will be to have increased the ongoing commitment of others to this work. The folks I'm counting on are colleagues, friends, children, grandchildren, and you.
FOOTNOTES
Accepted Sep 22, 2004.
No conflict of interest declared.
REFERENCES
Shonkoff JP, Phillips DA, eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: National Academy Press; 2000
US Department of Labor, Women's Bureau. 20 Facts on Women Workers. Washington, DC: US Department of Labor; 2000
Ehrle J, Adams G, Tout K. Who's Caring for Our Youngest Children Child Care Patterns of Infants and Toddlers. Washington, DC: Urban Institute; 2001
Helburn S, ed. Cost, Quality, and Child Outcomes in Child Care Centers: Technical Report. Denver, CO: Economics Department, University of Colorado; 1995
Kontos S, Howes C, Shinn M, Galinsky E. Quality in Family Child Care and Relative Care. New York, NY: Teachers College Press; 1995
Hofferth SL. Child care in the United States today. Future Child. 1996;6 :41 –61
Larner MB. Caring for infants and toddlers. Future Child. 2001;11 :7 –18, 35–53
Cordell RL, MacDonald JK, Solomon SL, Jackson LA, Boase J. Illnesses and absence due to illness among children attending child care facilities in Seattle-King County, Washington. Pediatrics. 1997;100 :850 –855
Roberts L, Smith W, Jorm L, et al. Effect of infection control measures on the frequency of upper respiratory infection in child care: a randomized, controlled trial. Pediatrics. 2000;105 :738 –742
Roberts L, Jorm L, Patel M, et al. Effect of infection control measures on the frequency of diarrheal episodes in child care: a randomized, controlled trial. Pediatrics. 2000;105 :743 –746
Kotch JB, Dufort VM, Stewart P, et al. Injuries among children in home and out-of-home care. Inj Prev. 1997;3 :267 –271
Rivera F, DiGuiseppi C, Thompson R, et al. Risk of injury to children less than 5 years of age in day care versus home care settings. Pediatrics. 1989;84 :1011 –1016
Gunn W, Pinsky P, Sacks J, et al. Injuries and poisonings in out-of-home child care and home care. Am J Dis Child. 1991;145 :779 –781
Aronson S, ed. Model Child Care Health Policies. Media, PA: Pennsylvania Chapter of the American Academy of Pediatrics; 2002
Aronson S, ed. Immunization Dose Counter. Media, PA: Pennsylvania Chapter of the American Academy of Pediatrics; 2004
Aronson S, ed. Healthy Young Children. Washington, DC: National Association for the Education of Young Children; 2002
Moon R, Patel K, McDermott-Shaefer S. Sudden infant death syndrome in child care settings. Pediatrics. 2000;106 :295 –300
Gershon NB, Moon RY. Infant sleep position in licensed child care centers. Pediatrics. 1997;100 :75 –78
Moon RY, Weese-Mayer DE, Silvestri JM. Nighttime child care: inadequate sudden infant death syndrome risk factor knowledge, practice, and policies. Pediatrics. 2003;111 :795 –799
Olson, L, Inkelas M, Halfon N, et al. Overview of the content of health supervision for young children: reports from parents and pediatricians. Pediatrics. 2004;113 :1907 –1916(Susan S. Aronson, MD, FAA)
Abbreviations: AAP, American Academy of Pediatrics ECELS, Early Childhood Education Linkage System TLC, The Learning Center
The late Fred Rogers taught me that, when someone thanks you for your work, gracious acceptance is a reciprocal gift. Many of you know Fred from his television program, Mr. Rogers' Neighborhood. So, with humility, I thank you for giving me the Job Lewis Smith Award. You have validated my work in community pediatrics. This award not only honors me but hopefully encourages others to pursue the goals that have guided my career as well.
The award is named for Job Lewis Smith. Dr Smith was a 19th-century pediatrician and clinical professor of diseases of children at Bellevue Medical School in New York City. He was a community pediatrician who focused on reducing adverse child health outcomes that were the result of poverty and poor living conditions among working class families. In 1880, he helped form the American Medical Association Section on Pediatrics and, in 1888, was a founder of the American Pediatric Society.
Like Dr Smith, I am a start-up person who has focused on preventive health needs for children and on engaging others in these efforts. Although I often used traditional approaches, my work with early education and child care has provided many more opportunities. When I was a young mother, I noted that many infants, toddlers, and preschool-aged children spend much of their time in the care of someone other than their parents. Every day, tired young parents grab one last hug as they drop off their young children with bags of diapers, spare clothing, food, favorite toys, and nap blankets in early education and child care arrangements. Many of these young adults are stressed and needy. They are simultaneously learning the basics of parenting, keeping a foothold in the workplace, maintaining caring relationships with life partners and other family members, and searching for time to care for themselves.
As a primary pediatric clinician, community pediatrician, and academician, I found my early childhood activities the most rewarding. Research repeatedly confirms that early childhood is a period of rapid growth and plasticity that offers unique opportunities for effective interventions that can have lifetime socioemotional and physical health benefits.1
My first big project was to start an innovative early education and child care center at the Medical College of Pennsylvania, on the edge of the poorest section of Philadelphia. This program was called the Learning Center (TLC). It served children from families in the community and those affiliated with the medical school. The children were enrolled in heterogeneous groupings by age and socioeconomic status. Each classroom had male and female teachers. Studies of the developmental outcome of children at TLC matched the positive results reported for Head Start and middle-class nursery schools, which typically had more homogeneous arrangements.
As designer and executive director of the center, I worked collaboratively for a decade with early education colleagues. This experience increased my understanding of child development, gave me a valuable foundation for subsequent work with early childhood educators, and taught me how to be an effective leader and administrator in a community setting. The center's success was the result of commonly held goals and objectives among all those involved, ie, early educators, parents, community members, and health professionals. TLC closed 2 years after my departure, because of staffing and budget problems. This event taught another lesson: that effective leaders must ensure the sustainability of successful programs before moving on.
My involvement with the American Academy of Pediatrics (AAP) began at the chapter level. When I became a Fellow of the AAP, I joined the Pennsylvania chapter. In the early 1970s, the chapter was thriving under Bill Mebane's able leadership. Over the following years, the previously productive organization became less so. In the 1980s, as an appointed committee chair and then as an elected leader of the chapter, I engaged others in reestablishing the Pennsylvania AAP as a voice for children. By accepting grants and state contracts, the chapter began to be known as a provider of innovative and effective community service programs in the state. The successful model involved identifying pediatricians willing to champion a child health initiative, finding funding, and developing and advising a program that a few competent staff members then manage day-to-day. Together, these individuals mobilize a large corps of public and private professionals to work on solutions to child health problems in communities across the state. Many other chapters have adopted this model.
Two of the Pennsylvania AAP's ongoing projects developed directly from my work. The first is the federal and state-funded Traffic Injury Prevention Project that uses state-directed, federal funds to establish car seat loaner programs and to provide education on passenger and pedestrian issues, school bus safety, and safe teen driving for children. Although I launched this program, its leadership over more than 2 decades of operation has been in the able hands of my husband, Jerry. The result is improved child safety through the actions of parents, police officers, judges, school principals, teachers, health professionals, and the general public.
The second Pennsylvania AAP project I started is the Early Childhood Education Linkage System (ECELS), also known as Healthy Child Care Pennsylvania. ECELS uses federal, state, and private funds to improve health and safety in early education settings. ECELS was a model for the federally funded initiative that established Healthy Child Care America programs in every state. By linking the work of health professionals with that of early educators, ECELS brings prevention and health promotion into the daily lives of young children and their families. I will say more about this later.
Sustaining good work requires mentoring others. For a few years, I have been meeting with all second-year residents from the Children's Hospital of Philadelphia, teaching a seminar on advocacy tools to small groups of them at a time. From my vantage as a senior citizen, I teach the residents that work and personal life cannot be balanced as if they are opposites. We multitask and navigate our roles, setting priorities that shift from one period of life to another. I am a woman, wife, mother, grandmother, primary/community/academic pediatrician, and social activist simultaneously. At any one moment, I allocate my time based on what I think I will have wished I had done when reflecting 20 years from now. My "20-year rule" has served me well. All of my roles are part of my persona.
None of my successes are mine alone. Learning how to help groups of people work together productively is a set of essential skills. Over the years, my employers and the AAP gave me formal and informal training in organizational development. I learned that success is more likely if you can help people stop blaming and complaining and focus on problem solving. Problem solving is more likely to achieve desirable outcomes when those who are affected, those with authority to implement change, and those with expertise are involved. Although these approaches are common tools taught in business schools, success requires more than strategy. Achievements come more easily by combining serendipity with strategy. Remaining alert and ready to exploit unforeseen opportunities makes it possible to sustain an endless stream of good outcomes, even in times of lean funding.
Although stressful, disagreements with collaborators are welcome when they provide fruit for even better plans. My mentors taught me how to negotiate by clarifying differences to find common ground. Often, positive outcomes can come from by having members of a group agree to hang irresolvable differences outside the door, while working on mutual goals. Celebrating even small accomplishments helps too. As my grandmother often quoted from some unknown source, "There is no limit to the good you can do if you share the credit."
Plato was right; the essence of truth does not change; we keep rediscovering it. The present and future roles of primary pediatricians will evolve from ageless principles. We must continually assess and mobilize resources to respond to the needs of children and families, using approaches that are properly seasoned with what families and society want us to provide. Parents want pediatricians to talk about certain topics because of what they have seen or heard from others and what they think will make them seem like good parents to the pediatrician and to others. What parents want to know or ask is not always the same as what they need to know. Wants are based on currently perceived need, whereas needs are objectively measured deficits. We survey wants; we objectively measure needs.
My work in early education requires continuous integration of wants and needs of families. Parents of young children want to think their children are safe and able to thrive in the arrangements they choose. In some cases, one or both parents provide most of their children's education and care themselves, but it is very difficult to do so without participation by competent members of the extended family. More commonly, parents use some services provided by nonrelatives, choosing among home-based and center-based services that they find in their communities. Parents sometimes use a combination of more than one type of care on any day or during any given week. They may have some of their children in one set of arrangements while others use services elsewhere.
The types of arrangements vary by the age of the child as well as the needs of parents. Regulatory requirements for these services vary widely by state. National standards for infants and toddlers are for ratios of at least 1 teacher per 3 infants and 1 teacher per 4 toddlers and 2-year-olds (children between 13 and 30 months of age). The group size should be no more than 6 children for infants and 8 for toddlers and 2-year-olds. Some states permit teachers to care for many more children and much larger groups. Regulatory requirements set the floor for legal operation. Typically, most programs in the community function close to regulatory requirements. Because many parents choose cost and convenience over quality, competition for enrollment drives quality downward.
Nationally, two thirds to three fourths of children younger than 6 years of age regularly attend some type of early education and child care, with the proportion in nonparental care increasing from infancy to 3 to 4 years of age.2,3 In my home state of Pennsylvania and elsewhere, infants and toddlers are more likely to be in home-based rather than center-based care. These services are often neighborhood businesses or services provided by relatives. Many of these services are legally unregulated or operated without the required registration with authorities.
The situation is different for preschool-aged children. Use of center-based care is more common for this age group. For 3- and 4-year-old children, only one quarter of children receive parent-only care, another one quarter use family child care homes, and 44% are in some type of center-based educational program. The services may include programs that operate before and after school, for full or part days and full or part weeks. Two teachers should be responsible for groups of no more than 14 children who are 3 years of age and up to 16 children who are 4 years of age. Pennsylvania has nearly 4000 legally operating (licensed) centers, about 4000 regulated family child care homes, and approximately 1000 Head Start facilities and 700 nursery schools.
In the United States, only a small proportion of available early education and child care services (14%) are of good quality and nearly three fourths are mediocre. For infants and toddlers, approximately 40% of early education and child care services are below minimum standards. Home-based care tends to be of poorer quality than center-based care.4–7
Cost and quality are closely tied. Financially starved early education providers do not receive enough income to attract and retain well-educated staff members for this physically and intellectually demanding work. Nationally, on average, teachers/caregivers in early education settings receive $8 to $10 per hour, around the hourly wage of parking lot attendants and less than bellhops, service station attendants, and bicycle repairers. Tree trimmers and animal trainers make more; kindergarten teachers make twice as much per hour.8 The result is that staff turnover in early education programs is high, 30% per year for teaching staff.
Although not universal, quality nonparental early education is recognized as a beneficial foundation for later learning. Early education is the norm in the United States. Ironically, unlike the situation in other developed countries, early education receives less public subsidy than elementary, secondary, higher, and remedial education. Parents need to know how to choose and to use early education and child care, as well as how to work with others in their communities to advocate for better choices than are generally available.
Whatever they are called and whoever funds them, early education programs generally involve caring adults who are trying to do the best they can with insufficient resources. Many early education and child care providers seek accreditation that requires commitment to meet rigorous criteria for staff credentials, curriculum, teaching, relationships, health and safety, physical environment, leadership/management, assessment, family, and community relationships. Early educators recognize that staff training and program accreditation make a difference and seek these within their operational constraints. They know that health and safety are essential elements and that they need help from health professionals to achieve quality.9
Early education and child care offers rich opportunities for collaboration of health professionals and early educators to prevent harm and promote health. For infectious disease, research shows that the increased burden of illness associated with group care can be controlled with immunization, hygiene, and sanitation.10–12
For injuries, on the basis of hours of contact, fewer and less serious injuries occur in child care settings than in children's own homes.13–15 Still, those that occur are preventable. The most common and most severe injuries are attributable to falls from climbing structures. Many of these injuries can be prevented with developmentally appropriate equipment and properly cushioned surfaces under and around climbing structures. Injury prevention education is a largely underutilized and effective opportunity for health promotion in early education programs. One example of such a curriculum is Risk Watch, a nationally available injury prevention intervention that has achieved increases in desired knowledge and injury prevention behaviors.16
On-site visits by health professionals to early education facilities help improve health and safety by enabling direct observations and building interdisciplinary relationships. Health consultations that involve both telephone contacts and site visits by health professionals have been shown to improve health and safety practices and to reduce days absent for illness, improve immunization rates, and increase utilization of a medical home as recorded in the children’s on-site medical records in these programs. Effective health consultations do not require large amounts of professional time (J. Kotch, MD, MPH, written communication, 2003).
In the past decade, federal funding through the Child Care and Development Block Fund has been available to states to subsidize and to improve quality in early education and child care programs. The military child care system, a worldwide early education network, requires all of its centers to be accredited by the National Association for the Education of Young Children. Other federally supported national quality improvement initiatives include the Healthy Child Care America Campaign based at the AAP, the National Resource Center for Health and Safety in Child Care based at the University of Colorado Health Sciences Center, and the National Training Institute for Child Care Health Consultants at the University of North Carolina at Chapel Hill.
The AAP has excellent references that describe what constitutes health and safety in early education and child care programs and a variety of ways in which primary care clinicians and pediatric subspecialists can become involved.17,18 In 2002, the AAP and the American Public Health Association published Caring for Our Children: The National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care. Preparation of this publication was funded by the Maternal and Child Health Bureau. It is considered the key reference for training, regulation setting, accreditation, and practice of health and safety in early education and child care. In addition to Caring for Our Children, many other helpful publications to improve health and safety in early education are available. One of the newest of these is a spin-off of Caring for Our Children and the AAP Red Book, Managing Infectious Diseases in Child Care and Schools, a Quick Reference Guide. Another product stimulated by the standards in Caring for Our Children is the new AAP pediatric first aid course for teachers and caregivers called PedFACTS. Other useful tools to improve health and safety in child care are available from the AAP, the Pennsylvania AAP, and the National Association for the Education of Young Children.19–22 An extensive set of references is listed on the ECELS-Healthy Child Care PA Web site (www.ecels-healthychildcarepa.org).
All pediatric health professionals can and should contribute to improving the quality of early education and child care for their patients. Ask, "Who cares for your child when you aren't available" and "Do you care for children of other parents in your home" The answers to these questions provide opportunities to discuss prevention and health promotion where children spend their time. When young infants are involved, be sure to emphasize the messages about how to prevent sudden infant death syndrome, ie, "Back to Sleep," with no covering of the face or bed sharing, avoiding soft bedding and toys, not overheating, protecting against exposure to environmental smoke, and of course encouraging breastfeeding. Although >85% of parents were putting infants on their backs to sleep by 1999, other caregivers are not following this practice as consistently. A higher rate of sudden infant death syndrome per hour of exposure occurs in family child care than in child care centers or in parent care.23–25 We should focus on this issue especially carefully when family child care arrangements are used for young infants.
The results of a recent periodic survey conducted by the AAP suggest that pediatricians are more aware of what constitutes quality early education and child care but are reluctant to get involved because of their time constraints and lack of knowledge about how to incorporate this information into routine anticipatory guidance.26 The approaches are simple and not necessarily very time-consuming. Discuss early education and child care arrangements. Visit local early education programs that are mentioned by more than a few families in the practice, to learn about the reality of that service. Offer medical consultation or advice, or consider other ways to advocate for quality child care at the community or state level. Use Caring for Our Children as a primary reference; it contains not only standards for quality programs but also the rationale and references that support each standard.
Those bothersome forms parents bring to children's clinicians are valuable means of communication with educators. Early educators can be armed with appropriate tools such as the Immunization Dose Counter, available on request from the AAP, or the Internet application software that tracks preventive health services, called WellCareTracker, that is available from the Pennsylvania AAP at www.wellcaretracker.org. With these tools, educators can check the records they have on hand to identify children who have gaps in immunization and screening services and who therefore need referral to their medical homes. WellCareTracker software was developed and rigorously tested by pediatricians as part of the work of ECELS-Healthy Child Care Pennsylvania at the Pennsylvania AAP.
At the least, all clinicians should provide advice to families about health and safety issues in group care settings and should communicate special health care instructions directly to the teachers/caregivers who care for their patients on a regular basis. Direct communication through written notes carried by parents or oral communication authorized by parents ensures that early educators/caregivers have accurate information to care properly for the children. Whisper-down-the-lane communication from health professionals to parents to teachers/caregivers is rarely effective. Educators welcome pediatric health professionals who offer their advice about individual children or about the group of children or become advocates for better quality of early education in the community. A pediatrician who advocates for better services can make a difference in public policy decisions about early education.
The AAP offers many opportunities to pursue advocacy for improved health and safety in early education settings. Within the Section on Community Pediatrics, a special interest group on Early Education and Child Care unites >200 health professionals.
Progress is being made but much more remains to be done. To make progress, (1) do your best by providing good care and caring about what you do, (2) help others achieve success while you strive to do your part, (3) base decision-making on needs and wants, (4) use opportunities and good ideas wherever you find them, (5) collaborate to leverage personal efforts, and (6) pace yourself and navigate your life roles realistically.
For me, a combination of strategy and serendipity has brought much success. I am passionate about using early education programs as opportunities for prevention and health promotion. My efforts have been magnified many times by the work of others. If I have a legacy, I hope it will be to have increased the ongoing commitment of others to this work. The folks I'm counting on are colleagues, friends, children, grandchildren, and you.
FOOTNOTES
Accepted Sep 22, 2004.
No conflict of interest declared.
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