Drop a kid with a cold into a child care setting, and you can watch an outbreak unfold in real time. As sticky little hands go from runny noses to cheese puffs to other noses and other sticky little hands, and as uncovered sneezes and coughs fill the air with mists of toddler goo, you’ll soon realize that groups of small children make ideal networks for the spread of communicable diseases. If a child shows up to child care sick, many of the other kids there will get whatever ick they have.

The stakes are especially high right now: Many kids are getting infections for the first time, which is leading to more severe illnesses and overwhelmed pediatric hospitals. And because many child care providers don’t allow mildly ill kids to attend — and with paid parental leave to care for sick children being far from guaranteed in the US — child care illness outbreaks translate to lost productivity and income for many adults.

Is there any way to make child care settings less germy?

Because of children’s naturally exploratory behavior, child care will never be an entirely germ-free place. Still, the five experts at the intersection of child care and health I interviewed told me there are ways to help minimize the spread of infections among children — and strategies to support child care providers in the longer term that can have broader impacts on children’s health. Some of these changes can be adopted by individuals, but other, more systemic changes can’t happen without government support.

All of them have the potential to improve the well-being of everyone in child care settings — to a point. There’s only so much you can do to curb disease transmission among creatures who spend eight hours a day sneezing on each other and playing with each others’ mouths, several experts said. At the end of the day, children are children.

Kids are innately gross, so manage your expectations

When I asked Andrea Shane, a pediatric infectious disease expert at Children’s Healthcare of Atlanta who studies infection control in early learning settings, whether there was anything parents could do to keep their kid from constantly bringing home colds from child care, her answer was simple: “No.”

She was kidding — sort of. Shane said that while there are some things parents and day care providers can do to somewhat reduce disease transmission among small children, there’s just a certain level of germiness that comes with the child care territory. “We sometimes affectionately refer to child care centers as Petri dishes,” she said. Preschool-aged children “share everything — including saliva and mucus and all of their secretions —with other children,” she said.

Child care in the US takes place in lots of different settings. In 2019, more than half of the 21 million American children under age 5 were attending center-based care — programs in commercial buildings, often with many children in a classroom-style environment. Another 20 percent were receiving home-based care from a non-relative provider — that is, care in a residential space, often one where the provider and their own family live.

Because children are so tactile, they transmit a wide variety of infections when they crowd together, from skin conditions (like scabies) to gastrointestinal conditions (like norovirus) to respiratory infections (like RSV, flu, and colds).

Most of the transmission is no mystery: Infections in child care settings are often spread through direct contact with skin or a surface contaminated by a sick person’s body fluids. And while the spray from nearby mouths and noses also spreads infection through the air, Covid-19 raised the prospect that more infections than previously realized are spread through aerosols, tiny clusters of virus and fluid that can hang around in the air for hours after a cough or a sneeze, which small children often do without covering their mouths.

Optimize cheap and accessible strategies, and consider upgrades where more resources are available

There are some hard-to-control factors that lead to more illnesses in kids; various research studies have found that having older siblings, being born by cesarean section, and other factors increase the risk of certain types of infections. But there are others that, even if they can’t be entirely controlled, can at least be optimized by parents and child care providers to reduce infection.

Hand hygiene

“Child care providers are really infectious disease mitigation experts,” said Nicole Garro, who directs early childhood health programs at Child Care Aware of America. Most providers are already extraordinarily attentive to cleaning their own hands and those of the children they care for. That’s for a good reason: Using good hand hygiene — meaning, cleaning hands after using the bathroom, before and after eating, and whenever visibly dirty — is a key way to reduce disease transmission of all kinds among small kids (and everyone else).

But not all hand hygiene strategies are created equal. Although soap and water are best if hands are visibly soiled and there’s time to ensure thorough washing with soap, Shane said sanitizing hands with a small amount of alcohol gel often has the added benefit of making fingers taste bad — which may disincentivize little ones from putting them in their mouths.

Vaccination

Another strategy most parents are already well aware of is getting kids vaccinated on the recommended schedule against common infections, which offers excellent protection against many of the biggest infectious threats of childhood. But parents may not think to ask their child care facility whether the other children and staff are fully vaccinated. That’s something they can and should feel free to do, said Shane.

Smoke exposure

Limiting tobacco smoke exposure makes it more likely that a kid’s mild cold will stay mild. Parents may already know that second-hand smoke exposure can increase children’s risk of respiratory infections and ear problems, and can increase the severity of asthma and related conditions. But they may not be aware that exposure to third-hand smoke — the tiny, sooty particles and residue that tobacco smoke leaves behind — can also have negative effects on children’s health.

Most states prohibit smoking in most child care facilities through licensing requirements, but some facilities are exempt from these rules. In some states, people can smoke in home-based facilities up until the moment the doors open to accept children.

If parents are unsure of their child care center’s smoking policies, they can ask, and can advocate for eliminating exposure to second- and third-hand cigarette smoke.

Space

Child care settings with more resources may be able to consider other strategies for reducing disease spread, several of which require having a fair amount of space. In several studies, increased square footage per child was associated with lower risk of respiratory infections — so if choosing a center with lots of space for kids to move around is an option, parents may consider that aspect a bonus.

A handful of better-resourced child care centers have “sick rooms,” separate spaces within the facility that effectively isolate mildly ill kids from other children, so they can still go to care without infecting the others. If this is an option families can afford, it can dramatically reduce the impact of cold season on their own ability to work.

Air quality

While infection prevention strategies in child care have historically focused on reducing infections spread by direct contact and sprays, Covid-19 has demonstrated the value of using ventilation (air exchange) and filtration (air cleaning) as strategies for preventing airborne disease transmission in classrooms. Schools nationwide used American Rescue Plan dollars to buy portable air cleaners or upgrade HVAC systems, but early childhood care facilities’ access to these funds is more variable, said Hester Paul, who directs a program that evaluates child care facilities’ environmental health practices at the Children’s Environmental Health Network.

Paul’s team is currently conducting research evaluating indoor air quality and child health outcomes across a range of child care settings. Meanwhile, opening windows and spending time outside if weather permits are good ways to increase ventilation. Additionally, said Shane, if a facility can afford to purchase a reputable air cleaner that uses HEPA filtration — or a group of parents can pool resources to buy one — it’s reasonable to try. (Depending on the number and sizes of rooms, expect up-front prices of between $200 and $800, with filter replacements every six to 12 months costing between about $20 and $40.)

But Shane advised parents to manage their expectations about how much air quality-focused interventions can reduce spread among a group that spends so much time with their hands in each others’ mouths. “When there are limited resources, I would focus on things that we can do to interrupt person-to-person transmission,” she said — specifically, the kind that happens through direct contact.

There’s a whole group of professionals devoted to keeping kids healthy in child care, but fewer than half the states use them

It’s great when parents and child care facilities can maximize infection control practices that affect the kids they care for. It’d be better if all child care providers had expert guidance tailored to help them apply the best practices in child health in specific spaces and situations. For about 25 years, a growing group of experts has been aiming to do just that.

Child care health consultants (CCHCs) are licensed health professionals who work with early care and education providers to ensure their programs are doing their best to promote child health and safety. The profession originated in California several decades ago to give child care settings access to the expertise school nurses might offer in K-12 environments.

Now, about 20 states have CCHC programs, with staff whose professional backgrounds range from health education to pediatric medicine providing services to child care providers statewide. A smattering of studies suggest that child care centers that work with CCHCs are better prepared for outbreaks of respiratory illness and conduct more health screenings among children.

Without these consultants around, decisions about how to prevent or manage illness are often made by one person: the child care provider, said Kelly Davydov, the executive director of Child Care Kansas. That can be an extraordinarily stressful situation, she said.

In contrast, child care providers working in states that use CCHCs have a lot more support preparing and providing for the health of the children they care for. For example, they could help providers make policies on how to ensure children with physical disabilities or medical conditions like asthma can safely be in child care, or plan for how to provide emergency care to a child with a seizure disorder, or learn how to deal with an insulin pump for a child with Type 1 diabetes.

But they’re also available to provide real-time guidance when a child develops symptoms of a condition that could spread — for example, a fever. CCHCs can craft policies to help providers figure out in advance how and whether to isolate children with fever, for how long they need to stay home — if at all — and whether they need a doctor’s evaluation before returning to child care. They can also often provide real-time advice on specific cases.

Parents might want to learn more about what these programs do, and talk to their child care provider about whether services like the ones CCHCs provide would be useful to them. And they can advocate to bring programs like these to their state: “Parents need to know how important their voices are to legislators trying to make policy to benefit kids,” said Davydov.

Better pay, benefits, and working conditions for child care providers means better health for the kids they care for

At least one more important barrier stands in the way of making child care settings healthier and less likely to spread illness: the working conditions of child care providers themselves.

People who teach in early childhood care and education programs are among the worst-paid workers in the US, with a mean annual wage of $27,680, according to the Bureau of Labor Statistics. They also rarely have paid sick leave or employer-provided health insurance coverage. And because most child care settings are privately owned, staffing ratios are determined to maximize profit, which means facilities are incentivized to keep child-to-staff ratios as high as possible.

All of this translates to a toxic level of stress among child care workers that experts say is a threat to the health of children.

Pre-pandemic, up to 60 percent of child care professionals reported moderate to high levels of stress, and about 40 percent experienced depressive symptoms, said Cynthia Osborne, a professor of early childhood education at Vanderbilt University who directs the Prenatal-to-3 Policy Impact Center. These factors make workers more susceptible to illness — and they worsened during the pandemic.

Despite a wealth of data linking child care with positive outcomes for children, the nation has failed over and over again — most recently, in August — to fund programs that would improve the working conditions of child care providers.

When sick teachers can’t stay home from work, that not only impedes their recovery, it can also lead to inadvertently introducing infections into child care settings. But without sick leave or health insurance, many are incentivized to keep working through all but the most severe illnesses. Child care providers don’t want to show up to work sick, said Osborne — but for many, the choice is between caring for themselves and making ends meet.

Asking an underpaid, physically and emotionally stressed person who may be experiencing an illness to care for a group of tiny humans engineered to test patience seems like a setup for disaster. Better working conditions would reduce the risk these conditions pose to providers and children — but that requires government funding, said Osborne.

“Parents are paying more than they can afford already, and so this is an example where there really is a market failure,” she said. “There’s no way to do this without public investment.”