When it comes to fostering the well-being of their children, most American parents seem eager to take advantage of every advance of science and medicine. Few parents are content simply to let nature take its course when a serious malady threatens. Most American parents take their children to see a pediatrician regularly, while spending billions on the vaccines, antibiotics, and drugs physicians recommend. Nor do American parents generally ignore their children’s psychological problems: pediatric psychiatry has emerged as a flourishing specialty, and more and more American parents are demanding that its insights be brought into the classroom in new programs to curb suicidal depression and violence.

Still, observers may wonder about the depth and sincerity of all the concern American parents express for their children’s well-being. If American parents genuinely do care about the physical and psychological health of their children, why do so many of them choose not to care for them themselves in their own homes, but rather to place them–often in infancy–in day care centers? No doubt some American parents use the day care center only with great reluctance and only because of adverse economic and family circumstances, but many reasonably well-off American parents who could care for their children at home choose to put them in a day care center because they regard it–like the vaccination clinic or the pediatrician’s office–as yet another institution affording the advantages of modern professionalism. Many contemporary parents see in the day care center a wonderful convenience that–like the latest wonder drug–allows them to escape from a merely natural pattern of life.

But this sanguine parental view of day care stirs troubling reflections on the trajectory of American society. In the past, parents have used the marvels of modern medicine–the vaccinations, analgesics, and therapies–to avoid natural threats, but also to secure natural benefits. That is, in using modern medical expedients to protect their children, parents have availed themselves of tools that are more-than-natural, but their objectives and motives have themselves remained recognizably instinctive and natural. Ancient and medieval parents, who knew nothing of modern science, wanted–just like modern suburbanites–to shield their children from suffering, distress, and illness by whatever means were available to them. When parents willingly and even gladly place their children in a day care center, however, they are acting in a way that would have mystified, even horrified, pre-modern parents.

For when they freely elect to place their children in day care, American parents are acting on a deeply problematic and entirely unnatural impulse, one radically unlike that which has traditionally motivated parents to seek out a doctor for their child or to purchase a medicine. For among those who now rely upon day care, we see the ascendance of a novel desire: not the perennial desire of parents to keep their children away from harm but the alarmingly novel desire of parents wanting simply to keep children away from them, particularly from mothers, so they can pursue their careers unencumbered. Parents animated by this desire use day care not to ward off the baleful aspects of nature, but to avoid the very best nature has to offer: namely, the familial role of parenthood, especially the role of motherhood. Tragically, in using the day care center for these deeply unnatural purposes, parents are exposing their children not only to natural afflictions that medieval parents would recognize only too well, but also to terribly unnatural and distinctly new psychological strains and epidemiological risks, including potentially lethal new strains of pathogens incubated and let loose within the perverse dynamic of day care.

Pediatricians and epidemiologists have understood for some time that taking young children out of maternal care in their own homes and putting them into professional care in a day care center exposes them to a considerably elevated risk of contracting many diseases, including some very serious ones. Researchers at the International Conference on Child Day Care Health, convened in 1994, frankly acknowledged the sobering truth: "Outbreaks of infectious diseases occur frequently within the day care setting."[1] The frequency with which such outbreaks occur should disturb parents even when the diseases spread are not especially severe. Mothers who place their infants in day care are, for example, putting those infants at slightly higher risk of recurrent risk of recurrent ear infections (otitis media) than mothers who care for their children at home, but expose them to the passive smoke of 20 cigarettes a day (Relative Risk of 1.78 vs. 1.76 respectively, compared to infants cared for at home by a non-smoking mother).[2] Similarly, mothers who put their children in day care are going to see an incidence of respiratory illness much higher than that found among children cared for at home, over 100 percent higher for infants, and 25 to 50 percent higher for older preschoolers.[3] For one particular childhood respiratory disease–pneumococcal disease–the relative risk of infection runs an astounding 36 times higher among children under two in day care centers than it does among similar-age children cared for at home.[4]

Day care placement of young children has a similarly dramatic effect on risk rates for a number of other diseases, also. Researchers report that the incidence of Hemophilus influenza type B (HiB) (commonly considered a type of flu) runs over twelve times higher among children in day care than among children cared for at home.[5] Similarly, the infection rate for giardiasis (a type of diarrhea) is a remarkable fifteen to twenty times higher than it is among children cared for at home.[6]

While the diseases most commonly spread in day-care centers are not especially serious, some day-care-linked illnesses are quite serious. The American Academy of Pediatrics has, for example, identified bacterial meningitis and hepatitis A as diseases with a worrisome connection to day care centers,[7] and public health officials have even suggested that "day care centers may represent the major source of hepatitis A cases of uncertain origin" (a source of infection can be identified in less than 40 percent of all cases of this disease).[8] Immeasurably worse than hepatitis A, the tragedy of Sudden Infant Death Syndrome (SIDS) has occurred in day care settings at a rate which experts regard as "disproportionately high," especially since the day care SIDS victims typically share "demographic characteristics...(white, born to older, more educated parents, and without a history of smoke exposure) [that] would typically place these infants in the lowest risk category."[9]

Even some of the more innocuous day care spread diseases pose the risk of dangerous complications. Ear infections contracted in a day care center often require the placement of drainage tubes (tympanostomy tubes) in the inner ear.[10] Ear infection results can also result in mild hearing loss with consequent difficulties in psychological and social development.[11] The Hemophilus influenza type B virus often spread in the day care center usually causes relatively little harm, but in some cases it leads to epliglottitis or childhood meningitis.[12] And although the cytomegalovirus (CMV) poses no risk to the day care children who pick it up at significantly higher rates than do home-reared children, pregnant mothers with day care children are exposing their unborn children to an elevated risk of CMV-related birth defects affecting vision, brain development, hearing, and neuromuscular functioning.[13]

Researchers offer a good overall measure of the overall severity of day care-transmitted disease when they report that the hospitalization rate for day care children stands at four-and-one-half times that seen among home-reared children.[14] It is hardly to be wondered at that when Pediatric Annals devoted a special issue to day care-related sicknesses, the editors sounded an urgent alarm in the title of the lead editorial: "Day Care, Day Care: Mayday! Mayday!"[15]

To be sure, day care is not the first social institution in which physicians have seen frequent outbreaks of disease, but the social institution to which physicians now find themselves turning for epidemiological parallels to what they see in the day care center is deeply troubling. In a 2000 study of Streptococcus pneumoniae, French scholars perceive a fundamental similarity between the way disease spreads in a day care center and the way it spreads in an orphanage.[16] This medically derived parallel receives unexpected confirmation from the distinguished cultural historian Jacques Barzun when he puzzles over the curious social developments that have given the modern world "two novelties: the day care center and the semi-orphan."[17]

Though it is hard to quarrel with Barzun when he identifies the day care center as a locus of disturbing novelty, in some ways day care is taking society back, to an unanticipated degree, to some of the darker episodes of our collective past. When, for instance, Barzun joins leading epidemiologists in perceiving the orphan-like character of today’s day care children, he forces us to recognize how recent social trends have unexpectedly plunged us back into the kind of world once surveyed by Charles Dickens and Victor Hugo. For all of its contemporary cachet as a distinctively modern institution, the day care center may have pushed us back to times even earlier than those of Dickens and Hugo: a prominent medical researcher blames day care for "outbreaks of enteric illness–diarrhea, dysentery, giardiasis, and epidemic jaundice–reminiscent of the pre-sanitation days of the seventeenth century."[18]

Of course, parents with children in day care do see the illnesses, and wanting to do something to prevent them, they appeal to day care providers and to medical authorities. The trouble is that neither day care providers nor medical authorities can do very much that will help. One medical authority resignedly concludes that the spread of disease is inevitable in any context that brings together large numbers of diapered, toy-sucking, drooling, messy-eating children. This authority sees no way to prevent germs from being transmitted in an environment in which the typical day care child puts "a hand or object in the mouth every three minutes," and so he counsels his colleagues simply to recognize that with respect to most day care diseases, "there seem to be few specific actions to be taken."[19]

Unfortunately, parents often demand that doctors speedily cure the diseases that neither they nor day care providers can stop from spreading. Day care-reliant parents want a quick cure so that they can get their child back into the day care center without delay. Of course, it was likely the day care center that brought the child in contact with the illness-carrying pathogen in the first place, but this center will not care for him once the symptoms are fully evident (although by then the child has probably passed the germs on to several other children). So long as the day care center refuses to take their sick child, employed mothers must actually shoulder the unwelcome task of being an at-home parent–or the equally unwelcome task of locating some other surrogate. Desperate to avoid both of these unwelcome tasks, many parents badger their pediatricians to do something, anything, to make their child well. The something pediatricians dealing with day care children do all too often is to prescribe an antibiotic.

Now so rampant that in 2001 a team of pediatric researchers called it "one of the most important public health issues of the decade,"[20] the unwarranted prescribing of antibiotics is a medical problem heavily influenced by the movement of mothers into paid employment and the concurrent rise of day care. The scope of the problem may be gauged from the phenomenal 194% rise between 1980 and 1992 in the number of prescriptions written for amoxicillin, an antibiotic commonly used to treat otitis media. Pediatric authorities studying this sharp rise in amoxicillin prescriptions conclude that it must be "due in part to widespread day care attendance, improved access to care, and overprescription of antimicrobial agents."[21] A careful observer will note, however, that the first and third items on this short list of the causes of the dramatic increase in antibiotic use are, in fact, closely linked. For it is parents with children in day care who are responsible for many of the unjustified prescriptions for antibiotics.

The problem is not simply that day care spreads infection–though that is in itself a serious and sobering problem. The problem is also that many employed mothers are now so dependent upon day care that when a child falls ill (an event that the epidemiology of day care yields with distressing frequency), they and their husbands will often make it difficult for the child’s pediatrician to make the proper professional decision about treatment. A 1999 survey of pediatricians found that fully 96 percent "had parents request antibiotics during the past month when they were not indicated," while 48 percent said "parents pressure them to prescribe antibiotics when their children are ill, but antibiotics are not indicated." One third of the pediatricians surveyed admitted to "complying with these requests."[22] A leading researcher on the issue and a professor of pediatrics and public health at Boston University School of Medicine, Howard Bauchner declares flatly: "Parental pressure is the most common cause for the overuse of antibiotics."[23]

Why all this parental pressure for antibiotics that are not medically indicated? No candid investigator will claim that this pressure usually springs from genuine parental concern for their children’s health. Rather, it is employed mothers’ perceived need to get back to their jobs and to get their children back into day care which is creating this pressure. Speaking to the issue of why parents demand unnecessary antibiotics, a pediatrician involved in a 1998 study spoke with rare frankness: "My patients’ parents...want to be able to get the child back to day care quickly."[24] Another commentator explains parental insistence on their children’s receiving antibiotics by remarking on how employed "parents" (i.e., mothers) "worry about using a limited number of available sick days and/or favors from their supervisors for a few hours off to take their child to the physician, especially if this might be avoided with a preemptive antibiotic prescription."[25] In more typically oblique professional language, researchers refer to "the reliance on out-of-home child care" as "a reason for overprescribing."[26] And in yet more opaque language, an editorial in Pediatrics refers to "sociocultural and economic pressures" affecting "antibiotic overuse" in a situation in which "children are in day care centers that must develop policies for the general protection of the group with regard to infection control. Unfortunately, this usually translates into practice as the exclusion of [sick] children...unless they are on antibiotics."[27]

The fact that day care does in fact spread diseases and that some of these diseases are amenable to treatment with antibiotics would predict higher levels of antibiotic use among day care children. However, only unjustified pressure from employed mothers eager to get their children back in day care can account for antibiotic use which is over three-and-a-half times higher among day care children than among home-care children.[28] Medical authorities, who predictably enough want to stop the massive misuse of antibiotics, speak of the need to "educate physicians, parents, the public, and day care center staff about appropriate antibiotic use."[29] Some prominent researchers go so far as to say that "efforts to reduce antibiotic use in children should be particularly directed toward young children in day care centers."[30]

The appropriate pediatric and public-health organizations have, in fact launched educational campaigns aimed at curtailing the overuse of antibiotics. Investigating the effectiveness of such a recent initiative in Wisconsin, researchers were able to document real and heartening declines in the number of physician prescriptions for both solid (capsule/tablet) and liquid antibiotics, with an overall decline of 19 percent for such prescriptions for solid antibiotics and of 11 percent for liquid antibiotics. Unfortunately, however, the researchers also noted that "in child-care facilities, there was no apparent impact on judicious antibiotic use." For all of the progress they found elsewhere within the intervention area, the researchers were compelled to admit that they were "unable to demonstrate a reduction in inappropriate antibiotic prescribing among children who attended day care."[31] Likewise discouraging are the results of a recent attempt to use an instructional video to educate parents about the medical risks of pediatric overuse of antibiotics. The video effected only a "modest" shift in parental attitude toward the use of antibiotics, a result researchers called "disappointing."[32]

No one should expect much better from future attempts by doctors and health officials to deal with the problem of antibiotic misuse in the day care setting. Because the misuse of antibiotics in day care derives from an unhealthy and unnatural social dynamic and not from a failure of medical science or technique, no attempt to solve it through improved medical education or expertise holds much promise. The problem is that medicine (in this case, antibiotic medicine) has been enlisted into the service of an untenably unnatural social ideal–namely, the absolute equality in the labor market of men and women, an equality which can last only as long as an institution such as the day care center takes over the tasks of motherhood. So long as this feminist ideal of absolute gender equality remains unchallenged, the medical problems in day care–which do not spring from a medical cause–will remain, intractable and insoluble.

Pediatricians are misusing antibiotics within day care children because they are captive to a social agenda in which antibiotics are no longer being used principally for their legitimate medical purpose, that of fighting off disease. Rather, reliance upon day care is causing employed mothers to hector pediatricians into using antibiotics to protect them from motherhood. That is, employed mothers are now using antibiotics not to keep pathogens away, but rather to keep their own children away. It is this distortion of medicine that is frustrating the medical profession’s attempt to curtail overuse of antibiotics. In a way, antibiotics have joined contraceptives in modern pharmacology’s cornucopia of chemical armaments against motherhood.

This misuse of antibiotics might indeed have been predicted in a contraceptive culture, but in some ways, this new medical safeguard against motherhood is even stranger and more problematic than that of contraceptives. For while the use of contraceptives poses serious ethical questions, the relationship between means and ends in the use of contraceptives is reasonably straightforward. Those who use them avoid what they wish to avoid (namely conception) in a way that their makers fully intended. But in relying on antibiotics in order to keep children in day care (and out of the home), mothers are using a type of medicine intended to fight disease for a purpose entirely unanticipated and unintended by their makers. The creatures these mothers are really trying to keep away are not the pathogens these medicines were made to destroy, but their own children, the patients these medicines are supposed to protect. These mothers are at least as concerned with preventing full-blown motherhood as they are with preventing full-blown disease. It is this fundamental confusion about means and ends which is fueling the overuse of antibiotics in the day care center.

Unfortunately, the misuse of antibiotics in day care carries dangerous consequences for the children involved, for their families, and for the general public. For as any evolutionary biologist could have predicted, heavy use of antibiotics creates an environment favoring the emergence of antibiotic-resistant pathogens. In recent years, doctors have seen an alarmingly high incidence of such antibiotic-resistant germs in hospitals, where physicians have–as might well be expected–relied heavily upon antibiotics to treat their patients. But as Boston Globe science correspondent Richard Saltus noted in a 1994 analysis, hospitals are "not solely to blame for today’s worrisome increase in antibiotic-resistant bacteria. Experts also point to day care centers as prime ‘clearinghouses’ for spreading antibiotic-resistant infections."[33]

A 1999 study of Streptococcus pneumoniae infections found that "the risk of invasive Streptococcus pneumoniae infections is greatly increased in children attending care centers" compared to children cared for at home, and that 17 percent of the strains of the pathogen carried by these day care children were resistant to penicillin, while 14 percent were resistant to multiple antibiotics.[34] In another 1997 study of invasive pneumococcal disease, researchers concluded that day care children ages 2 to 59 months were almost four times as likely as children cared for at home to contract an infection caused by a penicillin-resistant strain of the disease.[35] The problem is growing worse, and when population geneticists at Emory University looked at how antibiotic-resistant germs were evolving in the day care environment, they limned a "road to no return." That is, their test results dashed hopes that "bacteria that have become resistant to overused antibiotics would ‘evolve backward,’ losing their resistance...once drugs were removed." "The best we can do," admitted one of the Emory researchers, "is slow the pace at which resistance evolves."[36]

Unfortunately, it is even harder to keep the antibiotic germs that evolve in the day care center confined to the day care center than it is to keep those that evolve in the hospital confined to the hospital. For, unlike hospital patients, day care children go home every evening, often as carriers of newly virulent strains of pathogens. Pediatricians worry about how "children congregating in day care centers pass on resistant bugs to each other and later to their families and society at large."[37] In part because of the remarkable way day care has helped to spread superbugs, many health officials now fear that "medicine’s purported triumph over infectious disease has become an illusion."[38] The alarming increase in the number of cases in which antibiotics fail is causing many unfavorable treatment outcomes, and in some cases, even death, prompting the National Foundation for Infectious Diseases to label "antimicrobial resistance and emerging infections as the most crucial problem in infectious disease control."[39] Some authorities now even gloomily predict "the end of antibiotics."[40]

Of course, the problem of antibiotic resistance would confront physicians–especially in hospitals–even if all day care centers closed their doors and all young children were cared for at home by their mothers. However, epidemiologists have adduced considerable evidence that day care has profoundly enlarged the scope and severity of the problem. As pediatricians continue to prescribe antibiotics, not primarily so children can get well, but rather so that their mothers can pursue their employment unencumbered, as more and more children contract infections of new and dangerous germs untouched by such antibiotics, we see only too clearly the consequences of this terrible perversion of medicine. We see the result of using medicine not to ward off the natural evil of disease, but rather to avoid the natural good which once was motherhood. Is it any wonder that this repudiation of nature is incubating little monsters of more than natural strength and lethality? Unnatural patterns of living create unnatural types of sickness. Tragically, the prey for the microbial monsters born in day care are children who have had no choice in their care–and then their families, who have.

Indeed, by putting their children in day care centers, mothers are not only exposing them to diseases–of natural and now more-than-natural virulence–they are also denying them the natural benefits of the most natural and most healthy form of nutrition and of disease prevention: breast feeding. Because breastfeeding confers so many nutritional and immunological advantages, it greatly alarms pediatricians that the movement of women into paid labor that has created the demand for day care has been accompanied by a "steep, steady decline in the likelihood of breastfeeding...particularly prolonged breastfeeding."[41] Physicians plausibly theorize, in fact, that one of the reasons for the sharply elevated incidence of disease in day care is that placement in such a setting generally means "reducing the likelihood that a child...will be protected by the effect of breastfeeding."[42] Mothers, too, benefit from breastfeeding: psychologists find a "decrease in negative mood" among mothers who breastfeed and a contrasting "decrease in positive mood" among mothers who bottle feed.[43] Because they typically do not breastfeed, mothers putting their infants in day care are thus more likely to experience negative mood and less likely to experience positive mood.

Though it is quite understandable that the sharp declines in breastfeeding trouble health authorities, breast milk is probably not what day care children lack most. Child psychologist Burton White regards increasing use of day care as "a disaster," because children in such settings do not receive the "large doses of custom-made love" a mother can give them at home.[44] Herself an employed mother who quit her job to be at home, Elizabeth Fallows recognizes that "there’s something special that only parents can give their children, a nuance that they’re someone most special."[45] Children in day care are not receiving that nuance. In an environment one child psychologist has characterized as "dangerously different," day care children learn to hit, to kick, to swear, to tease, and to argue more than children cared for at home.[46] Predictably, in a landmark 2001 study, researchers at the National Institute of Child Health found that unnaturally "negative/aggressive behavior" was strongly correlated with hours in non-maternal child care.[47] Other recent studies have documented unnaturally elevated levels of cortisol–symptomatic of a physiological reaction to stress–in blood samples taken from day care children[48] and have linked day care to an unnaturally high incidence of "insecure ambivalent" child-mother bonds.[49]

That day care brings with it an ugly load of unnatural troubles–unnatural diseases, unnatural misuse of medicine, unnatural aggression, unnatural stress, and unnatural child-mother attachment–would have surprised few Americans a generation ago. Until the feminist movement made female employment the sine qua non of women’s liberation, Americans understood that motherhood naturally meant caring for children, not simply dropping them off at a day care center and paying the bill. As social historian Margaret Steinfels points out, Americans traditionally accepted placement of children in day care only in emergency situations and only "until the mother could be restored to her rightful place in the home....Day care was not a service for the normal."[50]

In their tireless efforts to normalize day care, feminist activists have enjoyed the cooperation of a pliant media–predictably enough, since many of the writers, editors, and broadcast journalists are themselves now dependent upon day care. Consequently, relatively few of the medical and psychological risks of day care have received much media attention. Journalist Sherri Eisenberg complains that the media have typically tried to gloss research on day care "with a great big smiley face of a lead" and have "buried" negative findings "if they mentioned them at all."[51] When an occasional negative report about day care does make it into the media, prominent national commentators like Ellen Goodman minimize their import, counseling employed mothers to "take your dose of research with a large chaser of skepticism" in order to avoid "a case of gut wrench and guilt sweats."[52] Further, on the rare occasions when bad news about day care slips through the feminist censorship, the offending researchers can expect to be scolded by editorialists characterizing them as "trigger-happy scientists leap[ing] to the podium."[53] As one who has been subjected to a good deal of such scolding, day care researcher Jay Belsky asserts that "there are a lot of people out there who don’t open their mouths [about day care risks] because they know how vehement the reaction can be."[54]

Perhaps when it comes to the adverse psychological effects of day care, the media conspiracy of silence can be maintained for some years yet. Already well-credentialed sophists are explaining away these psychological effects as the overly negative interpretations of inadequate data.[55] But somewhere in some day care child’s diaper or on some other child’s saliva-covered toy lurk the tiny but increasingly lethal pathogens that guarantee that ugly truths about day care will eventually break through. No sophistry is shrewd enough, no media bias is broad enough, to hide the kind of epidemics day care is now incubating. Maybe some parents can talk themselves into accepting the unnatural behaviors and unnatural psychological perspectives their children are picking up in the day care center, but what parents will quietly reconcile themselves to their children’s hospitalization–and perhaps even death–because of an unnaturally noxious infection acquired in the day care center? Which journalists will ignore massive outbreaks of day care-bred supergerms? And once day care has let loose upon the nation’s children–and their families–plagues that the weapons in the physician’s armory of antibiotics can no longer defeat, then pundits and commentators will find it hard to deny that the unnatural repudiation of motherhood has exposed the nation to a worse-than-natural retribution.

Then, perhaps, it will be time to rediscover that most wonderful of all natural patterns, cherished by all previous generations–that of motherhood. With that rediscovery will come the promise of real health for American children.

Endnotes: