Crèche Syndrome

A lot of time and effort goes into the selection and enrolment of your child into the right crèche. Not only is this first step away from parents and home associated with an extra financial burden for the parents but often also with unexpected health problems for the little one.

The initial excitement often gives way to the reality of a chronically sick child. This is only made worse by different advices from everybody around you mixed with a degree of criticism of your parenting skills if not interference by the grandparents.

It is important for you as parent to understand as much as possible about the reasons behind crèche acquired infections, their possible prevention as well as reasonable treatment in order to make the right decisions that will affect your child’s and your own wellbeing.

Background on Creches

Although first day care centres appeared in the middle of the 19th century it is only for the last 30 years that creches have become an almost integral part especially of urban and suburban societies throughout the world.

The reasons are many and include increased urbanisation, double income or single parents, lack of space for caretakers at home, financial consideration, geographical distance from grandparents, stimulation for the child and others.

Therefore for the first time in human history do we pool children, as young as three months or younger, into large groups often in confined spaces. They are entrusted to caregivers, who are often overburdened and sometimes lack adequate training for this task.

What is Creche Syndrome

Large numbers of kids in a small confined space allow organisms such as viruses, bacteria but also fungi and even lice or fleas to spread easily from child to child. Sharing of dummies, bottles, eating utensils and toys help spread disease but so do staff members, who fail to wash their hands or flit back and forth between different age groups of children thereby making the arbitrary separation between them futile.

In addition little children have an immature immune system. They are relatively new “earthlings” and as such have not been exposed to all the bugs and germs that an adult has already dealt with and built up immunity against. Hence every virus introduced into the day care centre is most likely unknown to your baby’s immune system and therefore results in a full-blown cold or flu (see Immune System).

Remember also that many children in day care have older siblings in pre-school or school, who are a further outside source for infections brought into the crèche.

Another important point is the ability of viruses to change their appearance (mutate). This allows them to re-infect a child that has already build up immunity to the virus before the mutation. Despite the fascinating abilities of our immune system we have to acknowledge that viruses are in fact two steps ahead of us.

Finally several anatomical features in small children render them more susceptible to infections. This can be simply due to smaller diameters of air pipes in the lungs or length of e.g. the Eustachian tube resulting in bronchiolitis or middle ear infections (see ABC).

Considering the above conditions, the stage is set for frequently recurring and more often chronic infections in the crèche-going child.

Therefore crèche syndrome is not a disease as such but continuous infections and illnesses that often go over into one another without healthy periods in between.

The Maelstrom of Creche Syndrome

The chronically runny or blocked nose, coughs, raised temperature, lack of appetite, frequent waking at night, fidgeting with the ears, skin rashes, bouts of diarrhoea, sore throats and vomiting become part of your daily life. Feedback from the caretaker that your child is feverish or refuses to eat worsens the already gnawing feeling of guilt. Medical or specialist help often fails to make a difference. Hospitalisation is frequently necessary. This in turn puts more pressure on the parent trying to balance between work, household, family and partner. The resulting stress is further aggravated by confusing and contrarian advice from media, family, friends, colleagues and medical personnel.

The effect of all this on the parents is often not even considered as the focus is on the child. However the negative feedback that a stressed-out parent has in turn on the wellbeing of the child is another important factor.

More often than not there is no quality time to spend with your child and the early years of development are at best captured in photos but lack in your memories.

The Good

Beside all the social advantages of a crèche, there are medical benefits for the child as well. Every sniffle and cold in the end translates into immunity for that specific organism. You might regard this almost as an immunisation.

Little kids are amazingly tough and resilient. Although they might have a snotty nose or a rather persistent cough they often continue with their daily activities as though nothing is wrong. Rather than further compromising the child, play, laughter and activities boost the child’s immune system.

At some stage of our lives we have to confront all the common viruses and bacteria and build up immunity (see Immune System). If this only happens once the child goes to school it will automatically translate into school days lost, which is less desirable than a few days out of crèche.

Creche syndrome does not last forever. Your child’s immune system strengthens and becomes better and better at identifying and dealing with bugs surrounding us. After the first two to four years you will notice that infections become fewer and often less severe. Eventually your child has basically the same number of colds or flus as you have as an adult.

The number of kids in a crèche is directly linked to the frequency of infections. The smaller the number the smaller the pool of organisms. Although children in a small play-group will still share viruses it is often a distinct episode followed by weeks or even months of no health issues rather than permanent infections that become indistinguishable from one another. Ideally groups of not more than five to six children should be sought out.

If at all possible delay the entry into the crèche until the child is two-and-a-half to three years old. Firstly many of the anatomical shortcomings of very young kids will have been overcome (see Anatomy) and hence the child will almost have “outgrown” specific “size-related” health problems. Secondly the older child can communicate much better and is able to e.g. localize pain or cooperate better towards obtaining a diagnosis or during administering treatment.

The Bad

Often however it is not possible to delay your child’s entry into kindergarten until it is “old enough” nor is it easy to find small groups conveniently close to home or work. In this scenario your kid will most likely become ill frequently. Some children seem to go through crèche without any significant medical problems and others have to be taken out of crèche because of uncontrollable health issues. The vast majority of children however will have regular upper and lower airway infections and to a lesser extent tummy and skin diseases i.e. crèche syndrome. And crèche syndrome cannot be cured.

More important than anything else: make peace with the fact that your child’s health is not going to be the same as before it went to crèche. Often the children are less perturbed by their runny nose, cough or temperature than their parents. It is therefore paramount to approach the ensuing medical consequences of crèche-going with reason, empathy (for the child and yourself as parent) and above all knowledge. This is equally important for the medical staff that is being consulted.

The Ugly

The maelstrom scenario (see above) leads the desperate parent to frequently seek medical or other help in order to escape the repeated or chronic nature of the child’s symptoms. However parent’s expectations of a completely healthy child can simply not be met. Remember crèche syndrome is “incurable” and you have to accept some symptoms showing that your child’s immune system is working.

Instead parents put pressure on themselves and health professionals to” cure the incurable”. Both parties are at fault when this results in unnecessary, sometimes harmful and often expensive tests, investigations and therapies.

Due to the ongoing nature of the child’s symptoms chronic medication is often initiated, which fails to improve the condition. All medication has side effects, which might even cause worsening of your kid’s condition.

Antihistamines or drying-up medication will reduce the runny nose but at the same time thicken mucus in nose, sinuses and lungs. Thick secretions cannot be cleared so easily by the membranes and can clog passages in nose or lungs leading to worse infections.

Antibiotics are often given liberally for infections caused by viruses, for which they do not work. They will however kill good bacteria in our body. This in turn negatively affects our immune system. Wrong use of antibiotics will also lead to the development of resistance and when it really becomes mandatory to use them they may not be able to eradicate the offending bacteria.

Investigations must have a definite goal and should, depending on the findings, influence further treatment. If regardless of the test result, the treatment will be the same, the test might not be warranted. Blood tests are always associated with a painful needle prick. X-ray and especially CT investigations subject your child to radiation. Especially when such investigations are performed repeatedly it can lead to harmful doses of radiation on the growing child.

Again sound knowledge on your part as parent and mutual trust between you and the doctor will prevent these unfavourable scenarios.

Treatment

Since there is no cure for crèche syndrome, the treatment must be symptomatic and supportive. Bear in mind that the vast majority of infections acquired in crèche are viral and will be dealt with by the immune system of your child. Antibiotics cannot kill viruses but are only effective against bacteria.

Classically viral respiratory infections are highly contagious and will therefore affect many children simultaneously or shortly after one another. This is already a good measure for parents and medical practitioners to gauge whether a condition is viral or bacterial. If half the crèche is sick with similar symptoms then it is most likely “a virus doing the rounds”.

The expected symptoms are:

Fever

Increased temperature is a response of the body towards an infection and can help the immune system to fight the infectious agent. At the same time increased temperatures can slow the growth of offending microorganisms. Slightly raised temperatures can be monitored safely and especially if the child is playful, eating, drinking and sleeping normally medication should be withheld. Temperatures above 38 to 38.5 degrees will often be associated with malaise, loss of playfulness and a poor appetite. The response of a child to fever is very individual and treatment should not necessarily be guided by a specific temperature value but rather by the symptoms of the child. The standard medications comprise Paracetamol (Panado), Ibuprofen ( Brufen), Mefenamic acid (Ponstan) and Diclofenac (Voltaren).

Many viral infections are characterised by fluctuating temperatures. Fevers can reach 41 degrees and more and will be associated with a lethargic, miserable child with glassy eyes, a child who does not want to play, feed or sleep. With or often even without treatment this temperature can come down to normal values (below 37) and your child is acting normally again only to be struck by increasing fever again some hours later. In certain viral infections this pattern can repeat itself for several days.

Concern should be raised by higher temperatures (above 38.5) that do not respond to fever medication.

Runny nose

The membranes lining the nose and sinuses will produce mucus as a response to any irritation. This can be dust, smoke, pollen or in the case of the crèche-going child most commonly viruses. The mucus is a defence mechanism and helps clean the nasal passages from irritants or infectious agents. A runny nose is therefore a sign of the local immune system at work and beneficial in restoring healthy clean membranes. Attempts to dry up the secretions are counter-productive and should be avoided; the motto should rather be ‘the wetter the better”.

Application of topical hypertonic saline-bicarbonate solutions (Kuraflo) is recommended. This will further help the nose at self-cleansing. Crusting is prevented or at least limited, swelling of membranes is reduced and thereby nasal breathing and general comfort for the child improved.

The nose will always be more blocked at night and if saline applications are not effective enough at opening the passages and allowing the child to breathe comfortably, topical decongestants such as Oxymetazoline or Xylometazoline (Iliadin, Otrivin) may be used. This should be limited to use at night for the sole purpose of maintaining an open nose for a good night’s rest. During the day the use of hypertonic saline should be continued.

Any medication aimed at drying up the nose should be used with caution. Although it will look a lot better if the nose stops running, what actually happens inside nose, sinuses and chest is that secretions are still being produced but become thicker and more viscous. This can lead to clogging of nasal passages, sinus canals, obstruction of Eustachian tube or clogging of small air pipes (bronchioli) in the lungs. The membranes will find it more difficult to get rid of these thicker secretions and often the fine hair (cilia) on the membranes will cease working. Thick mucus is full of protein, warm and wet and therefore the perfect breeding ground for bacteria. The chance for bacterial infections taking place on top of the original viral infection (superinfection) is thereby increased.

Chestiness

Hypertonic saline-bicarbonate solutions (Kuraflo) can be applied as a direct nasal spray or nebulised to reach lungs and bronchi. It is completely safe and devoid of side effects and may be used frequently (up to hourly intervals) depending on the severity of symptoms.

Physiotherapy for the chest in combination with the hypertonic saline nebulisations helps the child to cough up the secretions. Especially very small children are naturally “lazy coughers”. Despite having a phlegmy chest they would not initiate a cough trying to rid themselves of the sputum as older children or adults would do.

Cough suppressants should be avoided for this reason. Cough is a natural reflex to forcefully clean the lungs from loose phlegm and secretions or even foreign material. Sneezing is another powerful method of the body to propel out sputum and mucus.

Moist membranes allow the lungs to clean themselves, transporting secretions upward toward the throat where they are coughed out or swallowed. Nebulisation of hypertonic saline-bicarbonate solution directly dilutes secretions in the airways. Added bicarbonate further thins very thick, viscous phlegm. In addition the hypertonic solution triggers the production of more clear mucus in the bronchi, which “washes out” more unwanted infectious or foreign material and similar to its use in the nose reduces swelling of the lining membranes.

Medical or specialist advice must be sought when the condition of your child becomes worse despite your efforts at alleviating the symptoms.

Summary

Respiratory infections in crèche are very common and must be managed reasonably. The vast majority of these cases can be treated conservatively with symptomatic support for the child and do not require antibiotics.

First line treatment should consist of hypertonic saline-bicarbonate nebulisations for chest problems and hypertonic saline-bicarbonate sprays for nasal and sinus conditions in order to support the membrane function in the airways. Fever medication is used if increased temperature affects the child’s wellbeing or fever increases above 38 to 38.5 degrees.