Counseling parents on infant day care: How to do it effectively

August 1, 2004

Putting their baby in day care is an emotional occasion for parents, as well as a subject that often comes up during office visits. You're in an opportune position to provide advice and support on returning to work and finding the best child-care arrangement for the family.

Putting their baby in day care is an emotional occasion for parents, as well as a subject that often comes up during office visits. You're in an opportune position to provide advice and support on returning to work and finding the best child-care arrangement for the family.

The majority of women in the United States with children younger than 1 year are in the labor force.1 In fact, a recent multisite, prospective study of approximately 1,200 American infants and their families by the National Institute of Child Health and Human Development (NICHD) Early Child Care Network found that 825 of the infants experienced regular nonmaternal care during their first year.2 Most of the infants began nonmaternal care before 4 months of age and received such care for an average of almost 30 hours a week. By the time they were 1 year old, more than a third had been in three nonmaternal care arrangements, on average.

For parents, the topic of infant day care can be an exceedingly emotional one, and one that comes up often in the context of visits to the pediatrician. Parents want to make the best decisions about if and when to return to work, and the best type of care for their infant. They want to know what the short- and long-term effects of day care are and how to identify quality care. Pediatricians are in a unique situation to be able to help parents make informed decisions about the health and well-being of their children, including decisions about nonparental care. This article provides information that you can use when you talk with parents about infant day care. Specifically, we review in this article the following four areas that parents and pediatricians are likely to talk about:

• Should I go back to work? If so, when and for how many hours a week? If parents have any choice in the matter, are there more or less optimal infant ages at which to begin or resume work? Is any guidance available about how many hours per week in nonparental care are beneficial or detrimental?

• What effects will my working have on my child? Here, we consider cognitive development, social-emotional development, and communicable illnesses.

• What kind of care should I seek for my child? Because of liability issues, we do not recommend that pediatricians suggest any specific provider. We do, however, provide general information about different types of care that parents may want to consider for their child (nanny, day-care center, or family day care, for example).

• What signs of quality should I look for? This section provides information about aspects of quality of care that the pediatrician should highlight in conversations with parents. We also list several resources for parents and pediatricians.

"Should I return to work? When? And for how many hours a week?"

For many mothers, the decision about when to return to work is beyond their control. In the US, paid maternal leave is often based on delivery status and recovery of the mother. Maternal leave is typically six weeks for a normal delivery and eight weeks for a caesarean delivery. The Family Medical Leave Act passed by Congress in 1993 requires employers with more than 50 employees to grant unpaid leave with protected job security for as long as 12 weeks to care for a newborn or newly adopted child.

Mothers who have the job flexibility and financial resources to choose whether to work or stay at home are likely to wrestle with three questions: whether to return to work, when to return to work, and for how long to work (full- or part-time). Much of the decision about whether to return to work revolves around issues concerning the effects of day care on infants, which are discussed in the next section. Even more primal, however, are concerns about the nature of the infant-parent relationship and fears that the attachment between infant and parent will be compromised if the baby spends all day in alternate care.

In fact, since the 1980s, much of the research surrounding infant day care has focused on attachment differences between babies who are reared exclusively by their mothers and those who are in nonmaternal care. Many of these studies revealed no differences, but several found that mothers who were not employed or worked part-time were more likely to have securely attached infants than mothers who worked full-time.3 Some of the differences, however, can be attributed to stability and quality of care. In other words, if nonmaternal care is stable and of high quality, differences in attachment security between infants of employed and nonemployed mothers are much smaller.4

Research also has examined the impact on attachment of the timing of the mother's return to work, by contrasting the effects of returning to work during the first and second halves of the child's first year. Some of this research is guided by the hypothesis that a mother's return to work during the first six months is more harmful than a return later in the first year, whereas other studies are guided by the hypothesis that a return during the second six months is more problematic.5 According to attachment theory and research, however, initiating nonmaternal care before the child is 6 months old may be less stressful than starting later because the child is not able cognitively to form an attachment and experience normative separation anxiety until later in the first year. While leaving a very young infant in day care may be more difficult emotionally for the parent than leaving an older infant or toddler, the experience is likely to be less stressful for the infant if it occurs earlier, rather than later, in the first year.

For parents who have flexibility about how many hours a week to work, especially in terms of part-time vs. full-time employment, it should be noted that research findings are relatively unclear on this issue. Some argue that excessive work (more than 35 to 40 hours) during the child's first year is problematic,6 and others argue that anything more than part-time (10 to 20 hours or more a week) is detrimental.3 A recent report by the NICHD Early Child Care Network suggests that children whose mothers are employed more than 30 hours a week are at risk of acting out behavior problems such as aggression and noncompliance.7 In other analyses, the NICHD team has documented risk at more than 10 hours.8

Given the lack of clear guidelines, how should pediatricians advise parents about work hours? They should support parents in making the best decision that fits with the family's philosophy and needs in relation to income, career development, and desire to be at home or work. The experience will likely be good for both infant and parents to the extent that the child-care environment is safe, nurturing, and stable; the parents are content with their decision about work and day-care placement; and the time the child spends in day care is not routinely excessive. At the least, the experience will not be harmful if conditions concerning quality, stability, and satisfaction with work and family choices are met.

"What effects will day care have on my baby?"

Beyond very basic concerns about the possible impact of the day-care experience on the parent-child relationship, parents also want to know how day care may affect their child's development. Because of the complexity of the issue, the "outcomes" of day-care experience reported so far in the literature are mixed (Table 1). Moreover, the environment in which the child lives can substantially moderate the outcome. That is, the effects of day care on infants in single-parent homes or infants in lower socioeconomic conditions may differ considerably from the impact on infants in two-parent or more affluent homes. For this reason, we also consider the issue of environment as we discuss the findings.


Outcomes of early child-care experience

Cognitive developmentImproved language, IQ, and cognitive functioning scores for children from lower-income homes No net effects have been found for children from more advantaged homesNone identified
Social-emotional developmentSome studies show day-care children to be more autonomous, more empathic, and more socially skilled with peersSome studies show day-care children to be more aggressive and disobedient, and less likely to have a secure attachment to parents. These findings are mainly qualified by quality and stability of the care: The negative effects are not often seen in high quality and stable care
Common communicable illnessesSome evidence that early exposure to common communicable illnesses is associated with later resistance to illnessMore bouts of common illnesses, such as gastrointestinal illness, upper respiratory illness, and otitis media


Cognitive development. The clearest "effects" of day care have been seen for cognitive development. Much of the data in this area come from studies on the effects of early enrichment programs for disadvantaged children. Participation in such programs has been found consistently to predict higher IQ scores and better cognitive functioning for poor and minority children during infancy and the toddler and preschool years.9,10

The socioeconomic status of the child also appears to be an important moderator of the influence of child care on cognitive development. In general, it is thought that, for children from impoverished families, high-quality child care provides stimulation and learning opportunities superior to those available at home, thus improving cognitive functioning. Research has generally borne out this assumption, finding better cognitive scores for low-income children in alternate day care than those cared for at home, especially for children who begin alternate care early (during infancy and toddlerhood) and those in center-based care.11 For children from more advantaged home environments, however, early maternal employment does not appear to affect cognitive outcome.12,13 In general, parents can be assured that high-quality day care does not harm the cognitive development of infants and children and, in many circumstances, can provide learning opportunities that supplement what is provided at home.

Social-emotional development. Research related to social-emotional development is more controversial and has provided grist for contentious public debate. Some studies show deleterious effects on children of early maternal employment, including increases in infant-parent attachment insecurity and toddler aggression and noncompliance,3 as well as long-term effects on school-age children's aggressive behavior.4 Other analyses, however, document few negative effects of early employment14 and even suggest social and emotional benefits from early entry into quality day care.15,16 Still other studies show that family characteristics are more strongly related to social-emotional development than are child-care experiences17 and question the extent to which any perceptible negative effects last beyond early childhood.18

Based on this evidence, the argument has been made that day-care babies are more experienced in peer-group interactions than children reared at home, who have few competitors for toys and attention. As a result, they have a larger behavioral repertoire than children who did not have early experience of both negative and positive peer behavior and may be more socially skilled than home-reared children.19 On the other hand, given the large number of children in alternate care situations, the epidemiologic consequences are also worth considering: Subtle increases in individual children's aggressive and disobedient behavior may not by themselves be cause for concern, but small effects that affect a lot of people may in the end have greater societal consequences than large effects that impact only a few.

Communicable illness. Children who attend day care, especially those enrolled in child-care centers, are exposed more often to common communicable illnesses and experience more bouts of respiratory illness, otitis media, and diarrhea than children reared exclusively at home.20 The most vulnerable time for acquiring infections appears to be immediately after entry into a new child-care arrangement.21 Few prospective data are available, but findings from the longitudinal NICHD Early Child Care Study show that, although children in child care have more bouts of illness in the first two years of life than those who are home-reared, differences between the two groups become negligible by 3 years of age.

After this point, the size of the day-care group seems to play a role—children between 37 and 54 months of age in larger groups have more bouts of upper respiratory illness than children of the same age in smaller groups or who are home-reared.22 The number of hours spent in day care, however, appears to be unrelated to likelihood of illness. The risk of illness thus appears to be primarily a function of exposure to a sufficient number of other children.

To what extent does early exposure to illness in child care provide an immunologic benefit? It has been suggested that spending time in nonmaternal care may accelerate the immune response to the pathogens that cause common illnesses and that children in day care may become ill less often after they enter kindergarten and elementary school than exclusively home-reared children. To date, research findings are equivocal, but they do suggest that experience in large-group day care before 3 years of age is associated with a diminished likelihood of upper respiratory illness during the late preschool and early school years.22,23 Whether this is a short-term benefit or the beginning of long-term immunity remains unclear.

Parents have two issues to think about: the health of the child and the pragmatic concern that when children are sick, someone needs to take care of them. Most day-care providers will not accept ill children for fear of infecting other children in the day-care group. Some centers have sick rooms supervised by nurses for children who are mildly ill—but these centers are few and often costly. In other circumstances—when the child is cared for by a nanny or relative, for example—the day-care provider will care for a mildly ill child. Parents should inquire about the provider's policies with regard to sick children and make sure they have plans for occasions when their child is ill.

"Where should my child go for day care?"

A wide range of experiences are considered "day care." Nonmaternal care can range from large day-care centers to in-home family care to care provided by a nanny or a relative. Where do infants in the US go? Data from the multisite national study of day care funded by NICHD shows that, when mothers return to work initially, infants are cared for by the father or the mother's partner (24%), grandparent (18%), other relatives (8%), child-care homes (24%), child-care centers (13%), or a nonrelative babysitter or nanny (13%).2

Other data indicate that the use of professional day-care centers tends to increase with age, whereas reliance on child-care homes and care by relatives decreases. The National Child Care Survey found that the percentage of children of employed mothers cared for in a day-care center doubled from 20% in infancy to 43% in the preschool years.24 Table 2 lists the most common types of nonparental child-care experiences along with their pros and cons.


Types of nonparental child care: Pros and cons

Type of carePotential prosPotential cons
Child-care centerTraining and supervision of staff Resources and equipment Care is available during staff absences More likely to be licensed and subject to state regulationLarger groups of children Greater staff turnover Staff background can vary greatly Higher costs Greater likelihood of exposure to common illnesses
Family day careSmaller number of children than larger centers Home atmosphere Possibility of more flexible scheduling Children of different ages Less expensive than some centersMany family day-care providers are unlicensed and unregulated Supervision and background checks are often up to parent Resources and equipment can vary, depending on what is available in family day-care home
Babysitter or nannyOne-on-one care Care can be provided in infant’s own home Possibility of flexible scheduling Possibility of care when infant is illTends to be the most expensive type of care Burden of background checks and ongoing supervision is on parent Lack of care when nanny is sick or on vacation
Care provided by relativeOne-on-one care Care can be provided in infant’s own home Possibility of flexible scheduling Possibility of care when infant is ill May be low- or no-cost, especially if spouse is caregiverBurden of background checks and ongoing supervision is on parent Lack of care when relative is sick or on vacation


"What signs should I look for that indicate good quality care?"

High-quality care has been shown repeatedly to have a positive effect on children's social, emotional, and cognitive development, in both the short and long term.25,26 What does "high quality" mean? What should parents look for? Researchers have identified four elements that seem essential:

Adequate attention to and supervision of each infant. Two criteria can be used to evaluate this element. The first is the caregiver-infant ratio. An ideal size might be two steady caregivers for a group of five infants but no more than four infants for one caregiver. The second criterion is group size. In general, the smaller the group, the more attention can be paid to each infant. A good rule of thumb is that the group should be no larger than twice the number of children a single caregiver is responsible for—the maximum size for an infant group, therefore, would be eight infants with two caregivers.

It should be noted that states regulate both the size of the group and the caregiver-to-infant ratio in licensed day-care centers and licensed family day-care homes. However, state regulations vary with regard to acceptable group size and the caregiver-infant ratio. Regulations for any given state are available from the state's department of health and human services.

Encouragement of sensorimotor exploration and incipient language development. Infants should have access to and be encouraged to use a variety of easily manipulated toys. They should also have abundant exposure to games, songs, and conversation to foster language exposure.

Attention to health and safety. Day-care providers should have established cleanliness routines, such as hand washing after diaper changes and before meals, and the facility should be clean. Safety procedures should include accident prevention measures (safe toys, no small objects that can be swallowed, no toxic substances or medicines within children's reach), access to first aid and cardiopulmonary resuscitation (all employees should have training), reasonable security precautions and background checks of all employees, and safe areas for exploration, such as carpeted areas for crawling. Meals and snacks should be nutritionally sound.

Well-trained, professional caregivers. Parents should inquire about the training and experience of each of the caregivers and explore staff morale and turnover. Good signs are caregivers who are knowledgeable about infant development, low staff turnover, high morale, and evident enthusiasm.

The National Association for the Education of Young Children (NAEYC) has formalized recommendations that child-care providers should meet to ensure optimal child development.27 Table 3 lists the recommendations, also available in brochures from NAEYC, that physicians can make available to families (see "Resources for parents and physicians").


NAEYC recommendations for quality day care

Aspect of careRecommendations
Adult caregiversShould enjoy and understand how infants and young children grow Should provide adequate attention to each child Should observe and record each child’s progress and development No more than 4 infants for each caregiver No more than 8 infants per group
Activities and equipmentEnvironment should foster children’s growth and development Appropriate, sufficient, accessible equipment and play materials Language skills should be encouraged
Relation of staff to families and communityProgram should support the needs of the entire family Parents should be welcome to observe, make suggestions, discuss policies, andparticipate in the activities of the center Program should be aware of and make use of community resources such as social services, health services, and educational services (libraries) Staff should share information about community opportunities with families
Facility and programHealth of children, staff, and parents should be protected and promoted Facility should be safe for children and adults Environment should be spacious enough to accommodate activities and equipment Minimum of 35 square feet of usable playroom floor space indoors per child Minimum of 75 square feet of play space outside per child


A note about stability of care

Parents often have strong intuitive ideas about quality of care and know that they should look for high-quality child care. Less talked about, however, is stability of care. It is important to recognize that quality and stability are two independent dimensions of child care. Although research has repeatedly shown a positive correlation between quality of care and children's social, emotional, and cognitive development, in both the short term and the long term, the association between stability of care and outcomes has received little research attention.4 This is unfortunate, because as many as 30% to 40% of very young children change care arrangements at least once a year.28

Infants and toddlers who are cared for by many temporary caregivers or who experience a series of losses related to significant caregivers may be at risk of problems later; children in a stable care arrangement, on the other hand, are more likely to benefit from child care.4 Research has found, for example, that stability of care is particularly important in promoting secure attachment patterns in children under 30 months of age.29,30 Unstable child-care arrangements, on the other hand—especially when coupled with maternal insensitivity (parenting that is not particularly responsive to infant cues)—have been shown to increase the risk of infant-parent attachment insecurity.8 Some evidence suggests that boys may be especially vulnerable. In one study, boys who had multiple concurrent care arrangements were more defiant than girls or boys who were in the exclusive care of their mothers.31

In light of these findings, you should highlight the importance of stable child-care arrangements in your conversations with parents. If the quality of care is poor or the environment unsafe, parents should, of course, be encouraged to change providers. Our point is that, given good care, stability is also important.

Resources for parents and pediatricians

One of the best resources for parents is other parents. Encourage parents to talk to neighbors, friends, relatives, and coworkers about their day care experiences and ask for their recommendations. Pediatricians can also refer parents to local parenting groups, such as Zero To Three groups and community play groups. Two national organizations, the NAEYC and Zero To Three National Center for Infants, Toddlers, and Families, provide helpful resources for parents and physicians, including Web sites and low-cost materials for display and distribution (see "Resources for parents and physicians").

The NAEYC Academy for Early Childhood Program Accreditation administers a national, voluntary, professionally sponsored accreditation system to help raise the quality of all types of preschools, kindergartens, child-care centers, and child-care programs for school-age children. Parents can search for accredited centers on the NAEYC Web site and also look at the criteria by which centers are accredited. The criteria can help parents make their own determinations about the quality of a particular child-care environment.

Empowering parents to make good choices

Pediatricians are in a special position to empower families to make the best child-care decisions. They can assure parents that children thrive and develop in a variety of nonmaternal care arrangements, as long as, first, the child-care situation is safe, stable, warm, stimulating, and of high quality and, second, the child does not spend excessive hours in care. For children from a disadvantaged background, good day care can be a powerful and positive intervention.32 All parents should be encouraged to talk with other parents, learn as much as possible about whatever day-care arrangement they are considering, and be vigilant in monitoring their infant's daily experiences in child care. Table 4 provides a checklist for talking to parents about infant day care.


Discussing child care with parents A checklist for physicians



1. Bureau of Labor Statistics, US Department of Labor, Washington, D.C., 2000

2. NICHD Early Child Care Research Network: Childcare in the first year of life. Merrill-Palmer Quarterly 1997; 43:340

3. Belsky J: Developmental risks (still) associated with early child care. J Child Psychol Psychiatry 2001;42:845

4. Youngblade LM: Peer and teacher ratings of 3rd and 4th grade children's social behavior as a function of early maternal employment. J Child Psychol Psychiatry 2003;44:477

5. Hoffman LW, Youngblade LM: Mothers at Work: Effects on Children's Well Being. Cambridge, UK, Cambridge University Press, 1999

6. Hoffman LW: Effects of maternal employment in the two-parent family: A review of the recent research. American Psychologist 1989;44:283

7. NICHD Early Child Care Research Network: Early childcare and children's development prior to school entry. Symposium presented at the biennial meetings of the Society for Research in Child Development, Minneapolis, April 2001

8. NICHD Early Child Care Research Network: The effects of infant child care on infant-mother attachment security: Results of the NICHD Study of Early Child Care. Child Dev 1997;68:860

9. Zigler EF, Lang ME: Child Care Choices: Balancing the Needs of Children, Families, and Society. New York, The Free Press, 1991

10. Ramey CT, Ramey SL: Effective early intervention. Ment Retard 1992;30:337

11. Caughy MO, DiPietro JA, Strobino DM: Day-care participation as a protective factor in the cognitive development of low-income children. Child Dev 1994;65:457

12. Greenstein TN: Are the "most advantaged" children truly disadvantaged by early maternal employment? Journal of Family Issues 1995;16:149

13. NICHD Early Child Care Research Network: Mother-child interaction and cognitive outcomes associated with early child care: Results of the NICHD study. Poster presented at the biennial meetings of the Society for Research on Child Development, Washington, D.C., April 1997

14. Harvey E: Short-term and long-term effects of early parental employment on children of the National Longitudinal Survey of Youth. Dev Psychol 1999; 35:445

15. Field T: Quality infant day care and grade school behavior and performance. Child Dev 1991;62:863

16. Prodromidis M, Lamb M, Sternberg K, et al: Aggression and noncompliance among Swedish children in center-based care, family day care, and home care. International Journal of Behavioral Development 1995;18:43

17. NICHD Early Child Care Research Network: Early child care and self-control, compliance, and problem behavior at 24 and 36 months. Child Dev 1998;69:1145

18. Egeland B, Heister M: The long-term consequences of infant day-care and mother-infant attachment. Child Dev 1995;66:474

19. Clarke-Stewart KA, Gruber C, Fitzgerald L: Children at Home and in Day Care. Hillsdale, N.J., Erlbaum, 1994

20. NICHD Early Child Care Research Network: Child care and common communicable illnesses: Results from the NICHD study of early child care. Arch Pediatr Adolesc Med 2001;155:481

21. Churchill R., Pickering L: Health issues in the context of out-of-home child care: Diarrheal disease in infants and toddlers. Paper presented at the First Synthesis Conference of the National Center for Early Development and Learning, Chapel Hill, N.C., 1997

22. NICHD Early Child Care Research Network: Child care and common communicable illnesses in children aged 37 to 54 months. Arch Pediatr Adolesc Med 2003;157:196

23. Ball T, Holber C, Aldous M, et al: Influence of attendance at day care on the common cold from birth through 13 years of age. Arch Pediatr Adolesc Med 2002; 156:1221

24. Willer B, Hofferth SL, Kisker EE, et al: The Demand and Supply of Child Care in 1990. Washington, D.C., National Association for the Education of Young Children, 1991

25. NICHD Early Child Care Research Network: Nonmaternal care and family factors in early development: An overview of the NICHD Study of Early Child Care. Journal of Applied Developmental Psychology 2001;22:457

26. Phillips D, McCartney K, Scarr S: Child-care quality and children's social development. Dev Psychol 1987; 23:537

27. National Association for the Education of Young Children: Accreditation Criteria and Procedures of the National Association for the Education of Young Children. Washington, D.C., NAEYC, 1998

28. Moss P, Brannen J: Discontinuity in daycare arrangements for very young children. Early Child Development and Care 1987;29:435

29. Barnas MV, Cummings EM: Caregiver stability and toddlers' attachment-related behavior towards caregivers in day care. Infant Behavior and Development 1994;17:141

30. Howes C, Hamilton CE: The changing experience of child care: Changes in teachers and in teacher-child relationships and children's social competence with peers. Early Childhood Research Quarterly 1993;8:15

31. Crockenberg S, Litman D: Effects of maternal employment on maternal and two-year-old child behavior. Child Dev 1991;62:930

32. Scarr S: Families and day care: Both matter for children. Child Dev 1996;40:330

DR. YOUNGBLADE is associate director, Institute for Child Health Policy, and assistant professor, departments of pediatrics and health policy and epidemiology, University of Florida, Gainesville.
DR. CARTER is assistant professor, department of pediatrics, University of Florida, Gainesville.
The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

Resources for parents and physicians

National Association for the Education of Young Children
1509 16th Street, NW
Washington, DC 20036-1426
www.naeyc.orgBrochures available from NAEYC:Choosing a Good Early Childhood Program (#525)
Finding the Best Care for Your Infant or Toddler (#518)
A Caring Place for Your Infant (#548)
Keeping Healthy: Parents, Teachers and Children (#577)
So Many Goodbyes: Ways to Ease the Transition Between Home and Groups for Young Children (#573)

Zero To Three National Center for Infants, Toddlers, and Families

734 15th Street, NW Suite 1000
Washington, DC 20005-1013
MagazinesParent's Magazine
(provides information on children and families for parents)
www.parents.comWorking Mother (provides information for working parents on a variety of topics)