Some of our children’s food choices are made at home – but as they grow, many are made in childcare or at school. We need our schools and daycare centers to be working with us, not against us in teaching children to enjoy healthy amounts of good food, cultivating Nutritional Intelligence.

About half of all middle schools and high schools in the US permit advertising of candy, fast-food restaurants, and/or sodas at school! This practice is most common in Ohio (nearly 70 percent of schools) and least common in New York (24 percent).

Does advertising affect our kids’ food choices? Of course it does! And in more ways that you might think. The Institute of Medicine has found that advertising to children affects their preferences, purchases, and consumption – changing their habits for different food and beverage categories, in addition to specific product brands.

Some estimate that each year, nationwide, for every dollar spent on promoting junk food to our children only about 1/10 of a penny is spent promoting healthy food. Schools are one place where the opposite should be true. At least.

CDC (Centers for Disease Control and Prevention) Children’s Food Environment State Indicator Report, 2011.

IOM (Institute of Medicine). 2005. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: The National Academies Press.

Yale Rudd Center for Food Policy and Obesity. “Fast Food FACTS: Evaluating Fast Food Nutrition and Marketing to Youth.” November, 2010

As parents, we consider many factors when selecting a childcare situation for our children – among them cost, convenience, philosophy, hours and the ratio of caregivers to kids. But how many of us give a thought to environmental health? We should, because young children’s developing bodies are very susceptible to chemical exposures.

To make it a little easier, Environmental Working Group put together these tips on how to create a green childcare environment, with an emphasis on the steps that matter most. We’re all about strategic changes that make the biggest difference to kids’ health. Parents can use these tips to assess childcare facilities – and share the downloadable tip sheet with staff to help them create a greener space. Remember, a few simple actions can reduce many exposures to toxic chemicals. Why not start today with this great list?

Most important for infants:

Mix formula with fluoride-free water, as the American Dental Association recommends. If your tap water has fluoride, buy non-fluoridated water.

Don’t serve ready-to-eat formula – it contains more BPA (from the can lining).

Never microwave food or heat milk in plastic. Use glass or ceramic instead.

Use glass or BPA-free baby bottles. Discard older plastic ones, especially if scratched.

Use fragrance-free wipes, diapers & diaper cream.

Create a healthy space

Seal or remove arsenic-treated wood decks & play structures. Those built before 2003 likely contain arsenic. Don’t allow children to eat at older picnic tables (or cover them with a cloth).

Have kids wash hands after playing near these surfaces, or avoid them altogether.

Watch for lead paint. Older paint may contain lead. Kids face health risks from loose chips and lead in dust. If your building was built before 1978, use a certified lead-safe contractor for any repairs.

Don’t use bug spray or weed killer inside or out.

Clean greener & disinfect when kids aren’t around. Choose certified green cleaning supplies, dust & vacuum often (with a HEPA filter), use fragrance-free laundry detergent and skip air fresheners & dryer sheets. Disinfectants can be toxic. Where necessary, disinfect with safer peroxide-based products or bleach. Always follow product directions.

Remove or repair furniture & mattresses with exposed foam. Before 2005, most foam was treated with toxic fire retardants.

Take care with compact fluorescent light bulbs. Don’t put them in lamps that can fall, releasing mercury. If a bulb breaks, clear the room, air it out, put on gloves, safety glasses and a dust mask, seal the waste, wash up. Replace mercury thermometers & thermostats with mercury-free options.

Eating & drinking

Offer healthy snacks. Choose fruits & veggies from EWG’s Clean 15 list or buy organic – and always wash them. Don’t microwave food in plastic. Microwave popcorn bags contain toxic chemicals – try air-popping instead. Choose organic dairy and meat when possible; buy rBGH/hormone-free milk. Use BPA-free dishware.

Wash little hands before eating – with plain soap & water. Skip anti-bacterial soaps – they’re no better than plain soap and contain toxic triclosan. If you use alcohol-based hand sanitizers, choose fragrance-free.

Drink safer water. Filter tap water as needed to remove contaminants. Check EWG’s Tap Water Database to find an effective filter. Test water fountains for lead.

Playtime!

Avoid soft plastic toys & metal jewelry. Many plastic softeners are toxic. Choose items labeled PVC- and phthalate-free. Avoid metal trinkets and play jewelry, which can contain heavy metals. Skip face paint unless you know it’s free of lead and other contaminants. Natural, unpainted wood toys are a good choice.

Use safer art supplies. Don’t use rubber cement, permanent or dry-erase markers or materials meant for adults. Stick with paper/cardboard, yarn, wood & homemade play dough. If you don’t know what’s in something, skip it.

Apply safer sunscreen. Use EWG’s Sunscreen Guide to find ones with SPF 30+ and zinc or titanium. Skip oxybenzone, retinyl palmitate, sprays, added bug repellent. Wear hats & avoid mid-day sun.

Adjust outdoor play based on local air quality using AIRNow.gov. On high pollution days, limit high-energy outdoor play for kids, especially those with asthma.

Another resource for parents and care providers is the national eco-healthy childcare program, which helps childcare facilities shift to safer practices through a self-certification system.

MRSA infections now kill more Americans than does HIV/AIDS, according to a CDC report in the October 17, 2007 Journal of the American Medical Association. Most of these infections are in adults over age 65, but infections with resistant bacteria are on the rise, even among healthy children. The important bacteria for parents to know about are called Staph. Aureus,  often called just “staph”.

These bacteria are very common on the skin and in the noses of healthy kids. Sometimes they slip through a break in the skin and cause infections. In fact, they are among the most common causes of skin infections – usually just little pimples or boils.  In hospitals, though, the infections were sometimes lethal, because the bacteria became resistant to major antibiotics. Now resistant staph is showing up in schools. When the bacteria become resistant to antibiotics, they can spread rapidly through communities. In some places in the US, MRSA infections (methicillin-resistant Staph. aureus) now account for 75 percent of staph infections in otherwise totally normal children. These infections are more common where kids are in close skin contact, such as in daycare centers and in contact sports (perhaps daycare is a contact sport!). On average, they are more common in kids under 2 than they are in teens.

Most of these infections can be successfully treated, especially if caught early, but occasionally they progress to serious or even fatal infections.  This week, another previously healthy high school student died from MRSA. How do you know if your child might be infected? MRSA infections usually begin as infected bumps on the skin, or what people might think are just infected “insect bites” or “spider bites”. They usually start at a place with a scrape, bite, or cut – or a place on the body covered with hair. The American Academy of Pediatrics says in their 2007 MRSA management alert that any suspected insect bite or spider bite should now be considered MRSA until proven otherwise. And how do you prove otherwise? Have a doctor drain some of the pus from the middle of the lesion and send it for culture. In a previously healthy child, if the infection is small it can usually be treated with drainage (possibly adding a MRSA- appropriate oral antibiotic – TMP/SXT, clindamycin, or doxycycline for kids over age 8 – but NOT one of the typical antibiotics used to treat skin infections). If the wounds are large, though, or the children are very sick, they may need to be hospitalized for emergency treatment.

How do you help prevent MRSA? Keep scrapes and cuts clean and covered. Keep the hands clean with soap and water or instant hand sanitizers. Take a soapy shower after sports. Minimize sharing towels, razors, or other objects that rub the skin (and clean shared toys often).  But perhaps the most important take home message is just to be on the lookout for superbugs at school. Be sure your doctor knows about any red, swollen, or painful bumps that may be filled with, or draining, pus. Early treatment usually does the trick.

Healthy kids 3 to 5 years old thrive best with at least 120 minutes a day of moderate-to-vigorous physical activity (MVPA). Most people think of preschoolers as high-activity kids, but the current obesity epidemic prompted researchers to measure preschool physical activity levels, just to be sure. This generation of school-age kids is the most sedentary in history.

What’s the story during preschool? Researchers fitted children from 9 different preschools with accelerometers, which they wore for an average of 4.4 hours on an average of 6.6 days, to measure how much they really move about. The results were published in the November 2004 Pediatrics. The children averaged about 30 minutes a day of the recommended level of activity at preschool, and it was unlikely that they made up the difference at home.

Perhaps the most striking finding of the study was the major differences in activity levels from preschool to preschool. A full day at one preschool might provide more than 80 minutes of exercise, at another only 30. More than half of the kids in the United States attend a formal preschool. I wish that all preschools provided 2 hours a day for kids to dance the hokey-pokey, play ga-ga ball, or romp in some other fun way. In the meantime, I recommend that parents consider physical activity opportunities when selecting a preschool for their children.

On average, kids in day care during the first three years of their lives get about twice as many colds as their peers during those years. But each time a child fights off a cold, she develops immunity to that virus.

A study in the February 2002 issue of the Archives of Pediatrics and Adolescent Medicine followed a large group of these children for 13 years. At ages 6 to 11, the children who had gone to day care had only about 1/3 as many colds as their peers who didn’t. Kids who attended day care are spared throughout the elementary school years, when being home sick might make a bigger difference.

Each year in the US there are about 23 million days of school absence from the common cold.

“I’m sorry, but your child can’t come back to daycare until she starts antibiotics.” Statements like this led to a study that was published in the February 2000 issue of Archives of Pediatric and Adolescent Medicine. The report concluded that directors of child care centers, in their wonderful efforts to protect children, often exclude sick children unnecessarily, refer children to physicians inappropriately and request antibiotic therapy for children who would be better off without them.

The great majority of daycare directors, for instance, believe that antibiotics should be given to children with bronchitis, and that excluding kids with cough and green nasal discharge will decrease the spread of colds. Childcare workers deserve better education about the basics of dealing with children who have common respiratory infections.

Dr. Greene’s Answer:

This is a very complex and important question. It concerns the care of millions of kids in the United States alone — over 50 percent of preschool-age children are in group day care settings. Day care can be a wonderful experience for children. It can provide freedom for parents to pursue their goals. But it can also provide a setting where germs spread easily.

Most kids who are in day care are there because the adults they live with work outside the home. These parents sign contracts with you agreeing that while they are at their workplaces, you will care for their children in exchange for monetary payment. You agree to take the best possible care of these growing, learning, energetic tots. So far, so good. But what happens when (not if, but when) one of the children in your care gets sick? Let’s look at it from a few different angles.

Child Care Provider — You get to be with these wonderful (sometimes challenging) kids during their most productive hours five days out of every week. You learn to read their moods. Often, you are there to see those precious “firsts.” You grow attached to the children. You want the best for each child in your care.

When one child gets sick, you are not only concerned for that child, but for all the others who are being exposed to the illness while that child is in your care. You are not equipped to care for sick children, you don’t have time to give special attention to a sick child, and you are responsible for protecting the other children.

Employer — In order for a business to run, it must generate enough money to pay all the bills. Of course most employers would like to actually show a profit, but even if they can’t, they must at least cover expenses. So whether a business is doing well or barely making it, employers want and need to keep productivity up.

All other things being equal, parents with young children can be less productive than those who do not have such responsibilities. Nine to five just isn’t enough in most jobs. It is not unusual for employees, especially those in management, to come in early and leave late. Yet parents often come in late and rush out in time to pick their children up before 6 p.m., when child care is no longer available.

When one of the workers needs to leave suddenly to take care of a sick child, the employers are usually less than thrilled. If the worker plays a vital role, other workers will need to shuffle responsibilities to cover. If the worker is involved in a project with a deadline, his or her absence could throw everything off. Regardless of the specific job, the employer wouldn’t be paying the employee unless he or she was needed.

Parent — Most parents I know feel stress over leaving their children to go back to work. Often I walk into a 2-month physical to find a mom (still post-partum) in tears because her maternity leave is ending. These parents shop for a wonderful place to entrust their precious children. They want what is best for their child. For many, this means group child care. It is an honor to be chosen to play this vital role.

As time goes by, many parents become comfortable with the arrangement, yet they still feel torn. They are parents first, but they feel pressure from their jobs to work more. The parents’ employers have specific expectations of them. These employers often provide some vacation time, a few paid holidays, and a limited number of sick days. Those parents who are self-employed often find themselves in even tougher circumstances.

When parents get a call that they need to leave work, and quite likely not come back for several days, they are put in a tough spot. They don’t want to use their vacation to stay home with a miserable child (that’s no vacation!), they have limited sick leave, and they don’t have anyone else to care for the child. At the same time, they care about their child’s health. Their best hope is that you, the child care provider, are overreacting.

Child — Learning to leave mom and dad is hard for most kids. The adjustment period can be tough on everyone, but the kids learn to be happy with you. They are stimulated in your care. They make friends. These friends carry germs. These friends share germs. These kids get sick. And no matter how much they grow attached to you, there is no one like mom and dad when you don’t feel well!

On the other hand, there are times when a child is contagious, but he or she doesn’t feel particularly bad. Recently, my youngest son had a post-vaccine case of chicken pox. He had a total of four very small pox and he appeared to feel fine. In fact he had lots of energy!

There are several things that can be done to make this situation as easy on everyone as possible:

As the child care provider, you should provide a brief, written outline stating your objective criteria for determining when a child is sick. Here are some issues to consider including:

• Fever – While a high fever is worrisome, a child may have a slightly elevated temperature due to teething or a recent vaccine. In these situations you will want to inform the parent at the end of the day, but you do not need to require that the child be immediately taken home.
• Rash — Common, non-communicable rashes, such as baby acne or eczema , do not require children to be separated from each other. On the other hand, rash associated with a fever would be a reason to send a child home. Chicken pox for example, is highly contagious.
• Vomiting — One episode following active play may not be a problem. One episode a day for several days needs to be looked into. Multiple episodes on the same day or vomiting accompanied by general discomfort would necessitate calling parents to take the child home.
• Diarrhea – Children who have diarrhea especially associated with fever should be kept at home. Children with diarrhea containing blood or mucous should be seen by their doctor before returning to school.
• Pink eye – A child with a red, irritated eye associated with fever or with an eye discharge, should be sent home and seen by a doctor before returning to school.
• Lice & Scabies – There’s no way around this one! When kids are infested they need to be removed from the group setting as quickly as possible.

New research comes out frequently that changes how childhood diseases are handled. The condition you asked about, Fifth Disease, is a case in point. Until recently, it was routine practice to confine children with the Fifth Disease (also known as Slapped Cheek ) rash. Now we understand that this is not necessary. As with Roseola, when the rash appears, the child is no longer contagious! By keeping up with the latest infection-control guidelines you can prevent unnecessary hardship on parents.

You are wise to require parents to sign a contract that requires them to take care of their children when they are sick. Even better, have them sign a plan describing how they are going to do so.

• Perhaps there is a grandparent or close family friend with a more flexible schedule than either of the parents’. Arrangements can often be made to call upon them to step in when the child gets sick. It’s almost always easier to follow up on a plan than to improvise on the spot.
• New child care companies are being developed in many communities that are on-call specifically to take care of sick children. They are typically very expensive, but they can be cheaper than losing a day at the office or, worse yet, jeopardizing a job.
• If mom or dad (or a combination of both) are going to be personally responsible, instruct them to talk with their employers when they sign the child up for day care. This can make a big difference when the time comes for mom or dad to leave work suddenly.

Parents are often the ones who lose the most when their children are sick — they may face angry employers, they spend valuable time off nurturing children who aren’t very fun to be with, they may have their paychecks docked for missed work, and they still have to pay you to take care of their children. From a parent’s point of view, this just doesn’t seem fair. Of course your fixed expenses must be paid even when a child is out, but most parents feel like this is adding insult to injury — especially when they don’t agree with your assessment of the child’s need to stay away from the group.

The question of requiring full payment for sick days does not have an easy solution, but alternative payment plans can be explored. Consider raising your monthly fees in exchange for a discount for days missed. The bookkeeping on this would be bothersome, but some parents would feel better if their fees were reduced when their child is sick, even if it meant paying more on a regular basis. Even if this approach doesn’t work in your setting, you can get a lot of valuable information by asking parents for input. In the process, they might begin to understand your point of view.

C.E., I believe the keys to a successful relationship are mutual respect, open communication , and a willingness to try new solutions. As you treat each other with respect, talk with each other about the difficulties having a sick child can cause, and look for new ways to solve the problem. I believe you will become even stronger allies in the process of caring for the greatest treasures in the world.