Pediatricians have long recognized that social determinants (the circumstances in which children live, learn, and play) influence the health and well-being of children and their families.1  The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of this broader scope of health care, which encompasses more than simply addressing a child’s medical conditions. Although the vast majority of COVID-19 cases in children have been mild, the secondary effects on the health of children have been profound. Downstream effects of the virus on a family’s social circumstances, including increased food insecurity, housing instability, school closures, and lack of child care, have exacerbated preexisting socioeconomic and racial disparities.2  Although it has often been overlooked, the need for safe and enriching child care that allows parents to be able to work, particularly for the most vulnerable children in our society, has become more acute over the last several months and requires urgent action.

The pandemic has brought to light the lack of safe, reliable, and affordable child care options. Even before the closure of many facilities, child care was plagued by long waitlists, ballooning costs, and safety concerns. Child care costs for preschool-aged children can rival college tuition,3  making high-quality child care nearly inaccessible for many families, especially those experiencing material hardships. With recent school closures due to COVID-19, even older children now require supervision throughout the day. As such, parents have been forced to consider child care arrangements that may not best align with the needs of their family. This includes taking parents (predominantly women who face the disproportionate burden4 ) away from work or calling on family members and friends to oversee the care of their children, perhaps risking their health or the health of others. Simply put, safe and reliable child care is an essential for economic and social recovery and subsequent stability.

Securing child care is particularly challenging for low-resourced families, including those with children with chronic health conditions, those with parents who work nontraditional hours, and those in non–English-speaking households and in rural areas. At urban community health centers, one study found that nearly one-third of families had an unmet child care need, and this was before any coronavirus effects were present.1  Today, many essential workers are from lower socioeconomic strata and must continue reporting to work in person, lacking flexibility to arrange for the around-the-clock child care now needed. Unfortunately, it is these same communities in which child care facilities see decreased revenue because of community financial instability and therefore run the risk of closure.5 

Pediatrics as a field has moved to more formally screen and address specific social determinants of health, including food insecurity and housing instability.1,6  Thus far, however, child care has not been a focus of large-scale, practice-based interventions or public policies. Although policy solutions have emerged to combat housing instability, unemployment, and food insecurity worsened by this pandemic, child care has lagged behind. We believe child care is a social determinant of health that crucially impacts the health, development, and economic well-being of children and families and that, as pediatricians, we have a duty to help address this prevalent need. Surveys during the pandemic have revealed significant challenges in child care availability for both high- and low-income families, further emphasizing this gap.2  Given this context, we make the following recommendations.

Advocating for increased capacity of high-quality child care is crucial to helping families and children achieve adequate child care access. Most notably, the Child Care Development Fund assists families in finding and affording child care, and Head Start and Early Head Start provide early childhood education for children, from birth to age 5, from low-income backgrounds. These programs were highly used even before the crisis.3,7 

Given the dire situation of both child care workers and families, the Coronavirus Aid, Relief, and Economic Security Act was passed in March 2020. The act provided $3.5 billion for the Child Care and Development Block Grant to pay child care worker salaries, keep child care centers open for essential workers, and waive child care costs for families. A total $750 million was allocated to Head Start, and the Community Development Fund and Small Business Specific Supports provided additional funding that could be used to support child care facilities.7 

Despite the successes of these programs, both before and during COVID-19, demand far outpaces supply. In Massachusetts, the waitlist for Child Care Development Fund vouchers was >25 000 families, and some families that were able to secure vouchers could not find available child care.3 

Economic analyses have shown that with increased access to child care, parents participate in the labor force in larger numbers and are able to improve the economic position of their families. For example, in 2009, Washington, District of Columbia, began offering 2 additional years of free full-day preschool. As a result, maternal employment increased from 65% before 2009 to 76.4% afterward. More than 40% of mothers earn the majority of their household income, and yet difficulty obtaining child care nearly unilaterally decreases maternal employment.5  Pediatricians must therefore work with legislators both at the local and national levels to prioritize and augment continued government focus on increasing child care accessibility.

The American Academy of Pediatrics has recommended social determinants of health screening at routine health care visits since 2016. However, many validated screening tools, including the Institute of Medicine and Centers for Medicaid & Medicare Services, do not include child care in their prioritized screenings.6  Although time with individual patients is limited, the act of inquiring about child care arrangements and offering information about local care centers, child care subsidies, and other resources reinforces the importance that child care has on a family’s life. Screening and referring for child care and Head Start at visits have been shown to increase enrollment.1 

Collaboration with other specialties can allow medical providers to comprehensively address the need for child care. It is impractical to expect clinicians to independently forge links with local facilities and relay this information to families. Working with obstetrics colleagues to encourage discussion of child care resources with expectant mothers can raise awareness about the positive effects of stable and high-quality child care on parental and child well-being. Often, waitlists for day cares and Early Head Start programs require parents to act even before the child’s birth to secure an available spot in time. Patient navigators or social work colleagues in the clinical setting, already crucial to families navigating social supports, can help parents identify and connect to practical community child care options. Discussing this as soon as the newborn visit can help families consider their options early.

Child care is an overlooked but crucial social determinant of health that has the power to significantly benefit both children and their families through improved cognitive development and increased maternal workforce participation, particularly during the COVID-19 pandemic. We hope that advocating clearly for child care can raise awareness and mobilize resources toward further assisting parents with this crucial need. We recommend routinely inquiring about child care arrangements and facilitating connections with high-quality programs at pediatric visits and advocating for public policies that increase access and capacity to high-quality child care. The health of a child is often the start of promoting health in families, and the benefits of high-quality child care are indisputable.

Drs Kalluri and Kelly conceptualized and designed the article, drafted the initial manuscript, and revised subsequent manuscript drafts; Dr Garg coordinated manuscript writing and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

The guidelines/recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement.

FUNDING: No external funding.

     
  • COVID-19

    coronavirus disease 2019

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Garg receives salary support from the National Institutes of Health and the Patient-Centered Outcomes Research Institute; and Drs Kalluri and Kelly have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.