- Email: [email protected]
Health considerations for pregnant child care staff
Rene R. Gratz,
PhD,
and Pamla
Boulton,
MS
ChiEd care is a profession comprised predominantly of young women of child-bearing age. Yet the pregnancy of child care staff has been discussed only incidentally in the health literature on early childhood. Because nursing professionals serve in a number of roles in child care centers, this is an important topic to include for health inservices and consultations. This article reviews what is currently known and recommended for pregnant child care staff regarding illnesses, stress, and the ergonomics of the job. The occupational he&h research that included women employed in child care is examined. Guidelines and recommendations for staying healthy and managing classroom activities during pregnancy are suggested. J PEDIATR HEALTH CARE. (1994). 8, 18-26
C
hild care is a profession comprised predominantly of young women of child-bearing age (Whitebook, Howes, & Phillips, 1990). Yet the pregnancy of child care staff is discussed only incidentally in the adult/occupational health sections of the early childhood and nursing literature. Because pediatric nurses and nurse practitioners often serve as consultants and in a number of other roles in child care centers and various early childhood education programs, occupational health during pregnancy is an important topic for in-services and other interactions with child care directors and staff. The occupational health of staff and teachers has been only a secondary focus for most studies of health in child care centers. Epidemiologic research has focused on the health of the children. However, the health of the adults who work in early childhood education settings is vitally important for the health of these children. While pregnant the child care staff member may need to pay special attention to health issues for herself A well-informed health care professional working with an early childhood program can be an important source of information and support. Any assessment of working during pregnancy must consider three separate factors: the woman, the pregnancy, and the job. If all are normal, healthy, and with-
Rene K. Cratz, PhD, IS an associate professor for the Department of Health Sciences at the llrwersity d Wisconsin-Milwaukee, Milwaukee, Wisconsin. Pamla Boulton, MS, is the director University of Wisconsin-Milwaukee,
of the UWM Child Care Center Milwaukee, Wisconsin.
Reprint requests: Rene Gratz, PhD, Department of Health Sciences, of Wisconsin-Milwaukee, PO Box 413, Milwaukee, WI 53201. Copyright 0 1994 by the National 6: Practitioners. 0891-5245/94/$3.00
18
i- 0
Association
25/l/47890
of Pediatric
at the
University
Nurse Associates
out “perceived risk,” work can continue without change (Keleher, 1991). Work does continue without interruption for many women during pregnancy. Rayburn and Yorker ( 199 1) report increasing numbers of women continue to work, with more than an estimated 60% of pregnant women employed during pregnancy. As stated in the “Occupational Considerations” section of the Standardc for Obstetric-Gynecucologic Servicesof the American College of Obstetricians and Gynecologists (ACOG, 1989), if the potential hazards of the work environment pose no greater risks than those encountered in everyday life, a woman with an uncomplicated pregnancy can work without interruption until delivery. This article reviews what is currently known about and recommended for pregnant child care staff. Relevant research on work and pregnancy and the special child care exposures of infectious disease, stress, and ergonomics are discussed. Guidelines and recommendations for pregnant child care staff are suggested. n
LITERATURE REVIEW
Conducting research on workplace hazards and occupational health risks presents a very complicated task because workers are seldom exposed to only one agent or factor (Keleher, 1991). Very few of the empirical studies currently extant on work and pregnancy have included child care staff as an occupational group. Studies conducted in Canada (Armstrong, Nolin, & McDonald, 1989; McDonald et al., 1987; MacDonald et al., 1988), Sweden (Gothe & Hillert, 1992), France (Mamelle, Laumon, & Lazar, 1984), and Finland (Nurminen, Lusa, Ilmarrinen, & Kurppa, 1989) examine relevant work and pregnancy. McDonald et al. (1987) used data collected in Montreal in the early 1980s. Analyses by occupation compared rates of miscarriage, stillbirth, congenital defects, JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care January-February 1994
low birth weight, and prematurity. Of the 104,649 pregnancies studied, 215 were women employed in child care. These pregnancies involved 14 births where children had some congenital defect, defined here as a physical abnmmality. This statistically significant finding was attributed to increased exposure to infections. Those women classified as “primary school teacher” (n = 1296) also had an increased ratio for congenital defects, however not at a level that was statistically significant. Two other studies from Montreal more closely examined the relationship between occupational groups, low birth weight (less than 2500 gm), and prematurity (gestation less than 37 weeks). McDonald et al. (1988) included 117 women employed in child care as part of their sample (n = 22,761). No statistically significant associations were found for child care, however, low birth weight and prematurity were related to jobs with high levels of heavy lifting, fatigue, and long work hours. Certainly in some centers this could describe the work environment in child care. Armstrong et al. (1989) reanalyzed birth weight data to more closely examine the role of the noted factors; some association was found for the women in child care. Specifically, long hours and fatigue shorten gestation but do not affect birth weight. Retardation in fetal growth was related to lifting heavy weights more than 15 times per day. Heavy lifting, they suggest, decreases predicted birth weight and increases the risk of preterm birth. A study of the spontaneous abortions of day nursery “child-minders” in Stockholm, Sweden, was recently reported by Gothe and Hillert (1992). They found miscarriage rates to increase significantly when mothers worked in day nurseries (classified as “exposed pregnancies”) as compared to when the same women had other types of employment or were unemployed (“unexposed pregnancies”). Their case-control design found no statistically significant differences beween exposed and unexposed pregnancies for prematurity or congenital malformations. Gothe and Hillert (1992) also analyzed this interview data for relationships between other prenatal hazards such as personal habits of smoking and alcohol use, with no significant increases noted. If a mother’s own children were in a child care setting, an increased frequency of miscarriage was reported, however, with only borderline statistical significance. Although the authors state that drawing any “general conclusions” from their work is impossible, they suggest that the cause of increased levels of spontaneous abortions in child care workers could be a “contagious agent” transmitted by the children. Nurminen et al. (1989) do not cite child care workers
Gratz & Boulton 19
in their investigation of physical workload and fetal development; however, their assessment can be applied to the demands of child care work. Using data obtained from health departments in Finland for congenital malformations, they construct an assessment of physical workload categorized by major level of activity. From the descriptors given, child care might be rated as a “moderate” to “high physical load.” A statistical relationship was established between increased work loads and growth retardation of the fetus and increased hypertension of the mother. Studies of physical effort are particularly important in light of the ergonomics of child care. Mamelle et al. (1984), using a sample of French mothers (n = 3437), analyzed job components isolating five sources of fatigue as an index to highlight strenuous working conditions. They posit that the maternal body undergoes modifications to adapt to the needs of the fetus, particularly in cardiovascular and respiratory functions. During physical effort, these functions undergo variations, and thus it is probable that physical effort causes greater
Studies important care.
of physical effort are particularly in light of the ergonomics of child
reactions in the pregnant woman. Sources of occupational fatigue are summarized in an Occupational Fatigue Index (Table 1). A source is scored as “high” if one or more elements of the job listed are present. Fatigue is rated as “intense” if three or more sources are rated as “high.” Although Mamelle et al. (1984) did not have child care stain their sample, they did include teachers. Only 2.4% of the teachers scored in the intense levels of fatigue; however, the grade level was not specitied. n
DISCUSSION
ACOG materials (1985) divide pregnancy-related disabilities into three categories: (a) disabilities of pregnancy itself, (b) disability related to complications, and (c) disability related to job exposures. ACOG defines disability as the inability to work because of physical problems that could interfere with job performance. The disability of pregnancy itself refers to those side effects of pregnancy that may cause a temporary disability, such as nausea, vomiting, indigestion, dizziness, and swollen legs and ankles. Although some women experience these symptoms, they usually have only minor complications and short-term, if any, disability. Disability related to complications present more serious conditions, for example, infections, bleeding, and rupture of the amniotic sac. They may also include med-
]ournal
20
q
Cratz & Boulton
TABLE
1 Occupational
Adapted from Mamelle, 311 and 322. Reprinted
fatigue index
N., Laumon, 8., & Lazar, with permission.
P. (1984).
PrematuriW
and occupational
ical conditions existing before conception such as heart disease, diabetes, or high blood pressure. These situations may result in greater limitations in work and necessitate recurring evaiuation by the woman’s health care provider. Disability as related to job exposure results from occupational situations that put the woman and the fetus at risk because of high levels of various environmental exposures. Work-related hazards in pregnancy are not as well documented as might be expected. Studies have investigated the effects of chemicals, metals, ionizing radiation, anesthetic gases (Bernhard& 1990; Council on Scientific AfEairs, 1985; Rudolph & Forest, 1990), and heavy physical work (Council on Scientific Affairs, 1984a) with tzdkthg results (ACOG, 1985). In child care, atthough exposure to infectious disease is the most often noted job exposure, stress and poor ergonomics are also potential occupational hazards. n
of Pediatric Health Care Volume 8. Number 1
1NFECTIOUS DISEASES
Child cam staff are consistently cited among individuals with increased occupational risk of exposure to infectious diseases during pregnancy as are hospital personnel (nurses, doctors, lab workers), teachers, and parents.
activity
during
pregnancy.
American
/ournal
of Epidemiology,
119,
The TORCH infections (toxoplasmosis, rubella, cytomegalovirus, herpes type 2), hepatitis B, and human immunodeficiency virus/acquired immunodeficiency syndrome present risks for the development of congenital problems (Keleher, 1991; Kendall & Moukaddem, 1992). The effects and prevention of these illnesses are summarized in Table 2. Of special concern in child care are rubella, cytomegalovirus, fifth disease, and varicella (Donowitz, 1991; Dutkiewciz, Jablonski, & Olenchock, 1988; Rosenberg & Clever, 1990). Rubella
Approximately 10% to 15% of all women in the United States are not protected against rubella, which affects one to two of every 10,000 deliveries (Keleher, 1991). Hayden (1991) recommends that all child care staff provide evidence of either a documented history of serologic evidence of immunity. If a case of rubella occurs in the center, all susceptible staff members should be determined, and those who are pregnant should be advised to contact their health care provider. Keleher (1991) suggests vaccination of all unprotected, nonpregnant women and regular screening of employees and pregnant women for their rubella titer status.
Journal of Pediatric Health January-February 1994
n
TABLE
2 Possible
Care
Gratz
effects
and
prevention
of illness
and
stress
ILLNESS
Rubella (German
Hepatitis
Cytomegalovirus
Varicella
zoster (chicken
Fifth disease (parvovirus
PREVENTION
Depends on gestational age at time of exposure Deafness, microcephaly, CNS disease, heart defects, cataracts Prematurity, psychomotor retardation, newborn disease Visual-hearing impairments, cognitive and motor deficits, CNS disease, microcephaly, mental retardation, jaundice, hepatosplenomegaly, chorioretinitis, stillbirth First trimester Miscarriage, muscle atrophy, clubbed feet, CNS disease, cataracts Perinatally Neonatal death Stillbirths, miscarriage; fetal hydrops: anemia, jaundice, enlarged liver Various congenital defects
B
pox)
B19)
Toxoplasmosis
Human immunodeficiency virus/acquired immunodeficiency syndrome Herpes simplex 2 Stress
21
in pregnancy
EFFECT
measles)
& Boulton
Fetal infection Spontaneous abortions, prematurity, microcephaly, fetal infection Miscarriage, prematurity, toxemia, preeclampsia, nausea, prolonged
Avoid contact if not immune; vaccinate if not pregnant. Avoid contact with blood products; vaccinate if not pregnant. Handwashing, gloving when handling blood and body fluids; if pregnant and not immune, avoid contact with children <2 years old during first 24 weeks of pregnancy. Avoid contact if not immune.
Handwashing;
avoid shared utensils.
Care in preparation of raw meat; thorough handwashing after handling raw meat and vegetables, after cleaning a cat litter box, outdoor sandbox, or after gardening Appropriate precautions handling blood and body fluids Handwashing, gloving Decrease sources of stress; relaxation techniques; good diet; exercise
labor CM, Central nervous system. Sources: Keleher (1991, p. 24); Adler et al. (1992).
(1991);
Koch (1991);
Canadian
Paediatric
Cytomegalovirus
Cytomegalovirus, a type of herpesvirus, is transmitted through contact with blood and other bodily secretions containing the virus (Adler, 1991, 1992; Rosenberg & Clever, 1990). Children shed cytomegalovirus in saliva and urine with no apparent symptoms (Kendall & Moukkadem, 1992). Child care providers experience a high level of occupational cytomegalovirus exposure (American Public Health Association/American Academy of Pediatrics [Al?HA/AAP], 1992). Although the rate of congenital Section for exposed susceptible women is high (40%), only 10% to 15% of these exposures result in vision, hearing, or intellectual deficits (Al?HA/AAl?, 1992; Reves & Pickering, 1992). Caregivers for children younger than 2 years of age are at greatest exposure because of the high infection rate of this age group in child care and the nature of their
Society
(1992),
Hayden
(1991),
Kendall
& Moukaddem
(1992),
Osterholm
caretaking, which involves increased exposure to and contact with bodily fluids (Adler, 1992). Pregnant women should not be excluded from working in child care centers because of cytomegalovirus exposure (Infectious Diseases and Immunization Cornmittee, 1990). However, some disagreement exists in the literature regarding routine screening for cytomegalovirus status. Tookey and Peckham (1991) argue that staff should not be routinely screened because cytomegalovirus is a common Section with no vaccine available; and as they see it, no clear advice can be given as a result of the screen. Adler (1991; 1992), however, suggests that before pregnancy all women in child care should be tested for immunoglobin G antibody immunity. If they show no immunity, that is test seronegative, they should be advised to avoid contact with children younger than 2 years of age during the first 6 months
Journal
22
Gratz & Boulton
of gestation or to avoid intimate contact with young children, particularly with their urine and saliva. The efficacy of cytomegalovirus control measures require further validation; however, transmission can probably be reduced through proper hygienic practices (Thacker, Addis, Goodman, Holloway, & Spencer, 1992). Osterholm, Reves, Murph, and Pickering ( 1992) recommend frequent handwashing, especially after diapering, toileting, or contact with oral and/or nasal secretions; proper disposal of tissues and diapers; and cleaning/disinfecting mouthed toys and environmental surfaces. Child care staff should be routinely counseled regarding the risks of cytomegalovirus exposure during pregnancy (APHAIAAP, 1992). Varicella
Varicella outbreaks are common in groups of young chiidren; however, maternai chickenpox is a relatively rare occurrence affecting one in 7500 pregnancies (Keleher, 1991). Most adults are seropositive as a result of their own childhood exposures (Grimsley, Jacobs, & Perkins, 1992). Reves and Pickering (1992) reviewed research citing adults as more likely than children to experience pneumonia and other complications of primary variceIla infection. If varicella is contracted during pregnancy it may present a risk to the developing fetus during the first trimester and perinatally. Although gestational exposure in child care is thought to carry minimal risk for the fetus, susceptible pregnant staff who are occupationally exposed to varicella should be advised to receive counseling from a health care professional within 24 hours after exposure is recognized (APHA/AAP, 1992). Fifth Disease
Fifth disease (erythema infectiosum), a benign rash illness of childhood sometimes called “slapped cheek” syndrome, is caused by parvovirus B19 (Koch, 1991). Exposure during pregnancy can result in transplacental infection (Reves & Pickering, 1992). Although the level or time of greatest prenatal risk is not currently known (Koch, 1991), Osterholm et al. (1992) discuss gestational infection outcomes particularly during the first and second trimester. They state that, because miscarriage can occur after asymptomatic maternal infection, the incidence of fetal loss due to fifth disease is not certain; however, recent research findings put risk of spontaneous abortion after infection at 3% to 9% during the first half of gestation. The risk of contracting erythema infectiosum has been found to be increased for teachers and child care providers who work with younger children (Cartter et al., 1991; Gillespie et al., 1990). Although serious consequences can result from prenatal infection, the risk is
of Pediatric Volume
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Care
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1
relatively low because of the prevalence of naturally acquired immunity and the apparently low risk of fetal infection (Reves & Pickering, 1992). Koch (1991) recommends pregnant child care staff minimize exposure by proper handwashing and avoiding shared utensils; although it is not necessary to exclude staff if a case occurs, serologic testing for the presence of anti-B19 IgG is helpful to identify teachers already immune. n
STRESS
Psychosocial factors, such as stress, are very complex and present a wide range of responses that may be difficult to quantify. Occupational stress may produce both psychologic and physical disabilities. Seward (1990) has discussed the links between stress and disease focusing on mental illness, cardiovascular and gastrointestinal diseases, and accidents. Among those workplace stressors that have been investigated are organization and organizational relationships (House & Wills, 1977; LaRocco, House, & French, 1980), career issues, one’s role in the organization and the task(s) performed (Seward, 1990), and work environment (Klitzman, House, Israel, & Mero, 1990). Teachers in early childhood programs and child care staff experience special job stresses (Hyson, 1982). The stress of child care work can intensify to a level of staff “burn-out” caused by the interaction of the nature of the work, personalities of the staff, and the structure of the center (Maslach & Pines, 1977). Whitebook et al. (1982) suggest that working conditions, for example, low pay, lack of benefits, unpaid overtime, significantly affect job dissatisfaction, which can lead to burn-out. Although no specific studies of stress and child care staff pregnancies have been as yet conducted, various studies have found that women experiencing stress have difficulty conceiving, higher rates of miscarriage, and complications such as toxemia, preeclampsia, nausea, hyperemesis, and prolonged labor (Keleher, 1991). The effects and prevention of stress are also included in Table 2. The control of work stress is best accomplished through preventive strategies, which recognize problems and early clinical or behavioral signs (Seward, 1990). n
ERGONOMICS
Ergovwrnics is defined as the relationship between physical stressors found in the environment and a worker’s physical condition. Waitresses, physical therapists, nurses, airline workers, aerobic instructors, and athletes are often cited as having jobs with poor ergonomics (Keleher, 1991). Currently no published studies of the ergonomics of child care exist; however, our contention is that staff who care for children have aspects of all of the jobs mentioned-waitresses, nurses, aerobic in-
Journal of Pediatric Health Care January-February 1994
Gratz & Boulton
structors, athletes-included in their daily routine. In a recent presentation, Owen (1992) reported that the physical requirements of child care work, that is frequent bending, squatting, floor-sitting, and lifting, present the potential for musculoskeletal disorders. Factors to be assessed specific to lifting include the frequency and duration of the lifts, weight, size, and techniques of the lifter (Owen, 1992). This awareness becomes particualrly important during pregnancy. Keleher (1991) discusses ergonomically appropriate recommendations to avoid heavy lifting, that is a load that is maximum in early pregnancy should be reduced 20% to 25% in late pregnancy, and situations that have an increased risk of accidental injury. Although citing the need for more empirical documentation, the Council on Scientific Affairs (1984b) of the American Medical Association presented guidelines for continuing levels of work activity for healthy women with normal pregnancies. Those activities commonly found as part of the child care work day are excerpted as Table 3. Back problems are a common complaint in pregnancy with approximately 50% of women experiencing some back difficulties (Jacobson, 1991); swollen feet and varicose veins frequently present problems as well (Aronson, 1987). Recommendations for child care staff should include a review of good standing and seated posture. An appropriate stance uses the pelvic tilt; proper seating decreases the lumbar curve and supports the lumbar spine. Attention to pushing, lifting, and carrying is especially important. A significant portion of the interaction with young children may include physically strenuous lifting and carrying. At all times, but particularly during pregnancy, proper techniques should be used. Because child care staff can spend large amounts of time on their feet, which contributes to varicose viens and swollen feet, support hose, exercise, frequent changes of position, and putting one’s feet up are recommended (Aronson, 1987). w GUIDELINES
AND
RECOMMENDATIONS
The effects of pregnancy on work have only recently been investigated and remain outside the mainstream of occupational health research. The Council on Scientific Affairs (1984b) presents a discussion largely in terms of how little is known. Cited as an example is the advice given by “generations of doctors” that has historically been due to social and cultural beliefs rather than documented medical experience with employed women. There is also a lack of empirical information regarding the stages of pregnancy and impact on work. Minimal data are available to validate the frequency or occurrence of symptoms such as nausea and fatigue in early pregnancy. The Council also stated (almost a decade ago) that research is needed on the postpartum
TABLE 3 Guidelines for continuation levels of work during pregnancy
n
jOB
FUNCTION
Standing Prolonged C-4 hr) Intermittent >30 min/hr ~30 min/hr Stooping and bending Below knee level Repetitive (>lO times/hr) Intermittent ( 2 times/hr) (~2 timesihr) Stairs Repetitive (~4 times/%hr shift) Intermittent (<4 times/8-hr shift) Lifting Repetitive >23 kg <23> 11 kg <11 kg Intermittent >23 kg <23> 11 kg
23
of various WEEJC OF GESTATION
24 32 40
20 28 40 28 40
20 24 40 30 40 40
Adapted from Council on Scientific Affairs (1984). Effects of pregnancy on work performance. /AMA. 25 1, 1996-l 997. Copyright 1984, American Medical Association. Reprinted with permission.
period and return to work. The “magic” 6 weeks that is recommended may be no more medically appropriate when rationally evaluated than 2 weeks. Although hard data are lacking, ,guidelines are presented in a number of sources ostensibly based on anecdotal evidence. The same Council on Scientific Affairs (1984b) article noting this lack nonetheless published a timeline for the termination of various levels of work during pregnancy, excerpted here as Table 3. These guidelines for healthy women with normal pregnancies were reviewed and reaffirmed, underscoring the idea that decisions should be made on a case-by-case basis (Bohigian, 1988). The American Medical Association’s table indicates the time period in which healthy employees with uncomplicated pregnancies should be able to perform various tasks “without undue difficulty or risk to pregnancy” and should not be interpreted as either dates at which all employees must continue to perform or stop performing these activities (Bohigian, 1988; Council on Scientific Aflairs, 1984b). Keleher (1991) cites various sources to present overall recommendations for pregnant workers with normal pregnancies. All workers are cautioned to avoid exhaustion, disconiiort, strenuous exercise, extreme tempera-
Journal
24
Gratz & Boulton
p TABLE 4 Common problems and recommendations for pregnant child care staff
lYx@ks. Rest on. left &tiei ck&q@reaks and lunch, or with feet @leYd, Keep each .w@day to no more than 8 hours.
Rest when fti&. Exposu~re to infectious diseases
Back probLms
Frequent
SW0&3fl
urination
feet, varicose
veins
Sources:
Aronson
Use frequent-and ‘proper ha~~~~g techtiique. use of gloves, univenal precautions, where appropriate. Es&&ah in~rmational network for p&rents and staff. Alert health care provider of child care Gork and potential for this exposure. Use proper lifting-and carrying techniques. Avoid heavy tt&ng. Maintain good standing and seated posture. Use ad&size furniture; bring an adult-size, easily movable, cornfortabte chair from home, if necessary. Avoid floor-sitting. To, avoid constant bending, have ehi&en climb up to teacher, if developmentally appropriate. Trade strenuous chores of lifting/moving‘heavy objects with other staff. Mave other staff avail@le to cover room assignment- to m&n&in staff-ch&i ratbs. Wear wpport Rose. Exercise. Chanp position frequently. Rest with feet etevated.
(19871, Child Care Employee
Project (1989),
K&her
(1991).
tures, smoking areas, noxious odors and chemical finnes, ladder climbing, heavy lifting, and trauma to the abdomen. All employed pregnant women need to take frequent breaks, rest on the,lefi side during lunch, rest when fatigued, take walks, wear support hose, and elevate legs when possible. For more “strenuous” jobs it is important to keep each shift to 8 hours, stop or reduce
of Pediatric Health Care Volume 8, Number 1
work 2 to 4 weeks before the due date, empty the bladder every 2 hours, and avoid heavy lifting. Specific to child care, the Child Care Employee Project (CCEP, 1989) has presented recommendations for both staying healthy and enhancing classroom life during pregnancy. Common problems of and recommendations for pregnant child care staff are summarized in Table 4. Staying healthy involves (a) frequent and proper handwashing, (b) informational networks where staff and parents can notify each other of possible exposures to illness, (c) communication to the staffmember’s health care provider that she works in child care and therefore has the potential to be exposed to childhood illnesses, and (d) prevention of back injuries through proper lifting and carrying techniques (CCEP, 1989). Day-to-day activities within the classroom and in dealing with young children also bear special consideration during pregnancy. The CCEP (1989) suggests that if adult-size furniture is not available in the room, a comfortable chair that can be easily moved should be brought from home. If developmentally appropriate, children should be encouraged to climb up to the pregnant teacher for special attention rather than having the teacher constantly bending to the children, Trading chores that involve lifting or moving heavy objects and cleaning fluids or toxic substances is advised. As Keleher (1991) also recommends, the pregnant staff member should always take scheduled breaks and rest during the lunch period either lying down or with feet elevated. For unscheduled breaks, for example more frequent use of the restroom, other staff may be needed to step in and assist with a group of children so that required adult-to-child ratios can be maintained. Pregnancy is a common occurrence among child care staff and as such is a frequent health concern in early childhood educational settings. Nursing professionals are important sources of health care information for these preschool programs and can provide directors and staff with consultations and in-services when pregnancy becomes a health consideration or even, perhaps, on an annual basis. As health care providers and screeners in child care centers, nurses are a vital part of identifying and controlling infectious diseases. As discussed, staff pregnancy is a time for increased awareness of the adult consequences for contracting infectious diseases and the importance of reporting contagious illnesses of staff, children, and the parents and siblings of children enrolled in the center. More research in the area of occupational health is needed for child care generally. With a predominantly female work force, specific health and safety issues related to pregnancy in these settings need further examination. Nursing professionals in child care programs
Journal of Pediatric Health January-February 1994
Care
are in an excellent position to gather such data both empirically and anecdotally and could make timely and important contributions both to the health and wellbeing of child care staff and to the quality of care they provide the children in their care. H REFERENCES
American College of Obstetricians and Gynecologists. (1985). I’qnanqv and the working womun. Patient Education Pamphlet APO44 Washington, DC: American College of Obstetricians and Gynecologists. American College of Obstetricians and Gynecologists. (1989). Standardr fw Obstetrh and GynecologicServices.(7th ed) Washington, DC: American College of Obstetricians and Gynecologists. Adler, S. I’. (1991). Cytomegalovirus. In L. Donowitz (Ed.).Inf&n control in the child care center and preschool (pp. 122-124). Baltimore: Williams & Wilkins. Adler, S. P. (1992). Cytomegalovirus transmission and child day care. Advances in Pediatric Infectiuw Diseases,7, 109-122. American Public Health Association/American Academy of Pediatrics. (1992). Caring for OUYchildren. National health and safety perjhmance standarh: Guidelines fm out-of-home child cureprograms. Washington, DC: Author. Armstrong, B. G., Nolin, A. D., & McDonald, A. D. (1989). Work in pregnancy and birth weight for gestational age. Btitirb Journal ofIndustrial Mea%&, 46, 196-199. Aronson, S. (1987, May). Coping with the physical requirements of caregiving. Chsld Care Excbu~e, 39-40. Bemhardt, J. H. (1990). Potential workplace hazards to reproductive health. Information for primary prevention. Journal of Obstehcaf, Qnecological, and Neonatal Nursing, 19, 53-62. Bohigian, G. M. (1988). Effects of pregnancy on work performance. InfomtatMnal Report of the Council on S&n@ Affaim Chicago: American Medical Association. Canadian Paediatric Society (1992). Pregnancy and caregivers. In Well-beings: A @de to promote the p&ml health, safety and emt&al well-being of children in child care centres and family airy care homes (pp. 711-715). Toronto: Creative Premises. Cartter, M. L., Farley, T. A., Rosengren, S., Quinn, D., Gillespie, S. M., Gary, G. W., & Hadler, J. L. (1991). Occupational risk factors for infection with parvovirus B19 among pregnant women. The Journal of In&t&s Diseases,163, 282-285. Child Care Employee Project. (1989). When child care workers become pregnant. Workiqfbr qua&v child care, unit II: Creating a better work environment (pp. 64-68). Berkeley: Child Care Employee Project. Council on Scientific Affairs (1984a). Effects of physical forces on the reproductive cycle. JM, 251, 247-250. Ch~cil OQ Scientific Affairs (1984b). Effects of pregnancy on work performance. Jm, 251, 1995-1997. Co~cil on Scientific Alfairs ( 1985). Effects of toxic chemicals on the reproductive system. JAIMA, 253, 3421-3437. Donowitz, L. G. (Ed.) (1991). InfectMn wntrol in the child care center andprescbool. Baltimore: Williams & Wilkins. Dutkiewicz, J., Jablonski, L., & Olenchock, S. A. (1988). Occupational biohazards: a review. American Journal of Indwstriul Medicine, 14, 605-623. Gillespie, S. M., Cartter, M. L., Asch, S., Rokos, J. B., Gary, W., Tsou, C. J., Hall, D. B., Anderson, L. J., & Hurwitz, E. S. (1990). Occupational risk of human parvovirus B19 infection for school and day-care personnel during an outbreak of erythema infectiosum. JAMI, 263, 2061-2065. Gothe, C.-J., & HiBert, L. (1992). Spontaneous abortions and work
Gratz & Boulton
25
in day nurseries. Acta Obstetric& et Qnewkyica Scandinaviuz 71, 284-292. Grimsley, L. F., Jacobs, R. R., & Perkins, J. L. (1992). Varicellaroster susceptibility in day-care workers. Applied Occupahmal and Envirvmnental Hy~ime, 7, 191-194. Hayden, G. F. (1991). Rubella (German measles). In L. Donowitz (Ed.). I@ction control in the child care center andpreschool (pp. 246250). Baltimore: Williams & Wilkins. House, J. S., &Wills, J. A. (1977). Occupational stress,social support and health. In: McLean, A. A. (Ed.). Red&g occupational strers. Washington: NIOSH. Hyson, M. C. (1982). Playing with kids all day: job stress in early childhood education. roung Children, 37, 25-32. Infectious Diseases and Immunization Commit-tee. (1990). Cytomegalovirus infection in day-care centres: Risks to pregnant women. Canadiun Medical Associathn Journal, 142, 547-549. Jacobson, H. (1991). Protecting the back during pregnancy. AAOHN Journal, 39, 286-291. Keleher, K. C. (1991). Occupational health: How work environments can effect reproductive capacity and outcome. Ntrrse PraccitMner, 16, 23-37. Kendall, E. D., & Moukaddem, V. E. (1992). Who’s vulnerable in infant child care centers? Youw Children, 47, 72-78. Klitzman, S., House, J. S., Israel, B. A., &Mero, R. P. (1990). Work stress, nonwork stress and health. Journal of Behatial Medicine, 13, 221-243. Koch, W. C. (1991). Parvovirus B19 (fifth disease, erythema infectiosum). In L. Donowia (Ed.). Infection control in the child care wnterandpreschml (pp. 211-214). Baltimore: Williams&Wilkins. LaDou, J. L. (Ed.) (1990). Occupational vnedicine. Nonvalk, CT: Appleton & Lange. LaRocco, J. M., House, J. S., &French, J. R. (1980). Social support, occupational stress, and health. Jooumal of Health and Social Behaviur, 21, 202-218. Mamelle, N., Laumon, B., & Lazar, P. (1984). Prematurity and occupational activity during pregnancy. American Journal of Epzdemiolqy, 119, 309-322. Maslach, C., & Pines, A. (1977). The burnout syndrome in the day care setting. Child Care Qurte~& 6, 100-l 13. McDonald, A. D., McDonald, J. C., Armstrong, B, Cherry, N, Delmore, C., Nolin, A. D., & Robert, D. (1987). Occupation and pregnancy outcome. Britirb Journal ofZndustriulMedicine, 44, 521526. McDonald, A. D., McDonald, J. C., Armstrong, B., Cherry, N. M., Nolin, A. D., & Robert, D. (1988). Prematurity and work in pregnancy. British Journal of Industrhl Medicine, 45, 56-62. Nurminen, T., Lusa, S., Ilmarinen, J., & Kurppa, K. (1989). Physical work load, fetal development and course of pregnancy. Scandinavian Journal of Wmb Environment and Health, 15, 404-414. Osterholm, M. T., Reves, R. R., Murph, J. R., & Pickering, L. K. (1992). Infectious diseases and child day care. Pediatric Injztiuw DizeaseJournal, 11, S31S41. Owen, B. (1992, June 16). Intervention J% mwculoskeletd diwmb achild cart worb. Paper presented at the International Conference on Child Day Care Health: Science, Prevention, and Practice, Atlanta, GA. Raybum, S. K., & Yorker, B. A. (1991). Maternal rights in the workplace. AAOHN Journal, 39, 534-536. Reves, R. R., & Pickering, L. K. (1992). Impact of child day care on infectious diseases in adults. Infectahw Diceasc Clink of North America, 6, 239-250. Rosenberg, J., & Clever, L. H. (1990). Medical surveillance of infectious disease end-points. Occn@mal Medicine: State of the Art Reviews, 5, 583-605. Rudolph, L., &Forest, C. S. (1990). Female reproductive toxicology.
journal
26
Gratz
& Boulton
In J. L. LaDou (Ed.). Occlrpational me&&e (pp 275-287). Norwalk, CT: Appleton & Lange. Seward J. P. (1990). Occupational stress. In J. L. LaDou (Ed.). Ocnrpatwtpnl me&c& (pp 467-480). Norwalk, CT: Appleton & Lange. Thacker, S. B., Addiss, D. G., Goodman, R. A., Holloway, B. R., & Spencer, H. C. (1992). Infectious diseases and injuries in child day care. Journal of the A merican Medical Associutiov, 268, 17201726. Tookey, P., & Peckham, C. (1991). Does cytomegalovirus present
of Pediatric Health Care Volume 8, Number 1
an occupational risk? Archives of Dkeme in Childhood, 66, 10091010. Whitebrook M., Howes, C., Dar&, I’., & Friedman, J. (1982). Caring for the caregivers: staff burnout in child care. In L. G. Katz (Ed.) &went top&x in early childhwd educutian. vol 4 (pp. 211-235). Nonvood, NJ: Ablex Publishing Corporation. Whitebook, M., Howes, C., & Phillips, D. (1990). Who caves? Child care teachers and the quality of care in An&a. Berkeley, CA: Child Care Employee Project.
PhD,
and Pamla
Boulton,
MS
ChiEd care is a profession comprised predominantly of young women of child-bearing age. Yet the pregnancy of child care staff has been discussed only incidentally in the health literature on early childhood. Because nursing professionals serve in a number of roles in child care centers, this is an important topic to include for health inservices and consultations. This article reviews what is currently known and recommended for pregnant child care staff regarding illnesses, stress, and the ergonomics of the job. The occupational he&h research that included women employed in child care is examined. Guidelines and recommendations for staying healthy and managing classroom activities during pregnancy are suggested. J PEDIATR HEALTH CARE. (1994). 8, 18-26
C
hild care is a profession comprised predominantly of young women of child-bearing age (Whitebook, Howes, & Phillips, 1990). Yet the pregnancy of child care staff is discussed only incidentally in the adult/occupational health sections of the early childhood and nursing literature. Because pediatric nurses and nurse practitioners often serve as consultants and in a number of other roles in child care centers and various early childhood education programs, occupational health during pregnancy is an important topic for in-services and other interactions with child care directors and staff. The occupational health of staff and teachers has been only a secondary focus for most studies of health in child care centers. Epidemiologic research has focused on the health of the children. However, the health of the adults who work in early childhood education settings is vitally important for the health of these children. While pregnant the child care staff member may need to pay special attention to health issues for herself A well-informed health care professional working with an early childhood program can be an important source of information and support. Any assessment of working during pregnancy must consider three separate factors: the woman, the pregnancy, and the job. If all are normal, healthy, and with-
Rene K. Cratz, PhD, IS an associate professor for the Department of Health Sciences at the llrwersity d Wisconsin-Milwaukee, Milwaukee, Wisconsin. Pamla Boulton, MS, is the director University of Wisconsin-Milwaukee,
of the UWM Child Care Center Milwaukee, Wisconsin.
Reprint requests: Rene Gratz, PhD, Department of Health Sciences, of Wisconsin-Milwaukee, PO Box 413, Milwaukee, WI 53201. Copyright 0 1994 by the National 6: Practitioners. 0891-5245/94/$3.00
18
i- 0
Association
25/l/47890
of Pediatric
at the
University
Nurse Associates
out “perceived risk,” work can continue without change (Keleher, 1991). Work does continue without interruption for many women during pregnancy. Rayburn and Yorker ( 199 1) report increasing numbers of women continue to work, with more than an estimated 60% of pregnant women employed during pregnancy. As stated in the “Occupational Considerations” section of the Standardc for Obstetric-Gynecucologic Servicesof the American College of Obstetricians and Gynecologists (ACOG, 1989), if the potential hazards of the work environment pose no greater risks than those encountered in everyday life, a woman with an uncomplicated pregnancy can work without interruption until delivery. This article reviews what is currently known about and recommended for pregnant child care staff. Relevant research on work and pregnancy and the special child care exposures of infectious disease, stress, and ergonomics are discussed. Guidelines and recommendations for pregnant child care staff are suggested. n
LITERATURE REVIEW
Conducting research on workplace hazards and occupational health risks presents a very complicated task because workers are seldom exposed to only one agent or factor (Keleher, 1991). Very few of the empirical studies currently extant on work and pregnancy have included child care staff as an occupational group. Studies conducted in Canada (Armstrong, Nolin, & McDonald, 1989; McDonald et al., 1987; MacDonald et al., 1988), Sweden (Gothe & Hillert, 1992), France (Mamelle, Laumon, & Lazar, 1984), and Finland (Nurminen, Lusa, Ilmarrinen, & Kurppa, 1989) examine relevant work and pregnancy. McDonald et al. (1987) used data collected in Montreal in the early 1980s. Analyses by occupation compared rates of miscarriage, stillbirth, congenital defects, JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care January-February 1994
low birth weight, and prematurity. Of the 104,649 pregnancies studied, 215 were women employed in child care. These pregnancies involved 14 births where children had some congenital defect, defined here as a physical abnmmality. This statistically significant finding was attributed to increased exposure to infections. Those women classified as “primary school teacher” (n = 1296) also had an increased ratio for congenital defects, however not at a level that was statistically significant. Two other studies from Montreal more closely examined the relationship between occupational groups, low birth weight (less than 2500 gm), and prematurity (gestation less than 37 weeks). McDonald et al. (1988) included 117 women employed in child care as part of their sample (n = 22,761). No statistically significant associations were found for child care, however, low birth weight and prematurity were related to jobs with high levels of heavy lifting, fatigue, and long work hours. Certainly in some centers this could describe the work environment in child care. Armstrong et al. (1989) reanalyzed birth weight data to more closely examine the role of the noted factors; some association was found for the women in child care. Specifically, long hours and fatigue shorten gestation but do not affect birth weight. Retardation in fetal growth was related to lifting heavy weights more than 15 times per day. Heavy lifting, they suggest, decreases predicted birth weight and increases the risk of preterm birth. A study of the spontaneous abortions of day nursery “child-minders” in Stockholm, Sweden, was recently reported by Gothe and Hillert (1992). They found miscarriage rates to increase significantly when mothers worked in day nurseries (classified as “exposed pregnancies”) as compared to when the same women had other types of employment or were unemployed (“unexposed pregnancies”). Their case-control design found no statistically significant differences beween exposed and unexposed pregnancies for prematurity or congenital malformations. Gothe and Hillert (1992) also analyzed this interview data for relationships between other prenatal hazards such as personal habits of smoking and alcohol use, with no significant increases noted. If a mother’s own children were in a child care setting, an increased frequency of miscarriage was reported, however, with only borderline statistical significance. Although the authors state that drawing any “general conclusions” from their work is impossible, they suggest that the cause of increased levels of spontaneous abortions in child care workers could be a “contagious agent” transmitted by the children. Nurminen et al. (1989) do not cite child care workers
Gratz & Boulton 19
in their investigation of physical workload and fetal development; however, their assessment can be applied to the demands of child care work. Using data obtained from health departments in Finland for congenital malformations, they construct an assessment of physical workload categorized by major level of activity. From the descriptors given, child care might be rated as a “moderate” to “high physical load.” A statistical relationship was established between increased work loads and growth retardation of the fetus and increased hypertension of the mother. Studies of physical effort are particularly important in light of the ergonomics of child care. Mamelle et al. (1984), using a sample of French mothers (n = 3437), analyzed job components isolating five sources of fatigue as an index to highlight strenuous working conditions. They posit that the maternal body undergoes modifications to adapt to the needs of the fetus, particularly in cardiovascular and respiratory functions. During physical effort, these functions undergo variations, and thus it is probable that physical effort causes greater
Studies important care.
of physical effort are particularly in light of the ergonomics of child
reactions in the pregnant woman. Sources of occupational fatigue are summarized in an Occupational Fatigue Index (Table 1). A source is scored as “high” if one or more elements of the job listed are present. Fatigue is rated as “intense” if three or more sources are rated as “high.” Although Mamelle et al. (1984) did not have child care stain their sample, they did include teachers. Only 2.4% of the teachers scored in the intense levels of fatigue; however, the grade level was not specitied. n
DISCUSSION
ACOG materials (1985) divide pregnancy-related disabilities into three categories: (a) disabilities of pregnancy itself, (b) disability related to complications, and (c) disability related to job exposures. ACOG defines disability as the inability to work because of physical problems that could interfere with job performance. The disability of pregnancy itself refers to those side effects of pregnancy that may cause a temporary disability, such as nausea, vomiting, indigestion, dizziness, and swollen legs and ankles. Although some women experience these symptoms, they usually have only minor complications and short-term, if any, disability. Disability related to complications present more serious conditions, for example, infections, bleeding, and rupture of the amniotic sac. They may also include med-
]ournal
20
q
Cratz & Boulton
TABLE
1 Occupational
Adapted from Mamelle, 311 and 322. Reprinted
fatigue index
N., Laumon, 8., & Lazar, with permission.
P. (1984).
PrematuriW
and occupational
ical conditions existing before conception such as heart disease, diabetes, or high blood pressure. These situations may result in greater limitations in work and necessitate recurring evaiuation by the woman’s health care provider. Disability as related to job exposure results from occupational situations that put the woman and the fetus at risk because of high levels of various environmental exposures. Work-related hazards in pregnancy are not as well documented as might be expected. Studies have investigated the effects of chemicals, metals, ionizing radiation, anesthetic gases (Bernhard& 1990; Council on Scientific AfEairs, 1985; Rudolph & Forest, 1990), and heavy physical work (Council on Scientific Affairs, 1984a) with tzdkthg results (ACOG, 1985). In child care, atthough exposure to infectious disease is the most often noted job exposure, stress and poor ergonomics are also potential occupational hazards. n
of Pediatric Health Care Volume 8. Number 1
1NFECTIOUS DISEASES
Child cam staff are consistently cited among individuals with increased occupational risk of exposure to infectious diseases during pregnancy as are hospital personnel (nurses, doctors, lab workers), teachers, and parents.
activity
during
pregnancy.
American
/ournal
of Epidemiology,
119,
The TORCH infections (toxoplasmosis, rubella, cytomegalovirus, herpes type 2), hepatitis B, and human immunodeficiency virus/acquired immunodeficiency syndrome present risks for the development of congenital problems (Keleher, 1991; Kendall & Moukaddem, 1992). The effects and prevention of these illnesses are summarized in Table 2. Of special concern in child care are rubella, cytomegalovirus, fifth disease, and varicella (Donowitz, 1991; Dutkiewciz, Jablonski, & Olenchock, 1988; Rosenberg & Clever, 1990). Rubella
Approximately 10% to 15% of all women in the United States are not protected against rubella, which affects one to two of every 10,000 deliveries (Keleher, 1991). Hayden (1991) recommends that all child care staff provide evidence of either a documented history of serologic evidence of immunity. If a case of rubella occurs in the center, all susceptible staff members should be determined, and those who are pregnant should be advised to contact their health care provider. Keleher (1991) suggests vaccination of all unprotected, nonpregnant women and regular screening of employees and pregnant women for their rubella titer status.
Journal of Pediatric Health January-February 1994
n
TABLE
2 Possible
Care
Gratz
effects
and
prevention
of illness
and
stress
ILLNESS
Rubella (German
Hepatitis
Cytomegalovirus
Varicella
zoster (chicken
Fifth disease (parvovirus
PREVENTION
Depends on gestational age at time of exposure Deafness, microcephaly, CNS disease, heart defects, cataracts Prematurity, psychomotor retardation, newborn disease Visual-hearing impairments, cognitive and motor deficits, CNS disease, microcephaly, mental retardation, jaundice, hepatosplenomegaly, chorioretinitis, stillbirth First trimester Miscarriage, muscle atrophy, clubbed feet, CNS disease, cataracts Perinatally Neonatal death Stillbirths, miscarriage; fetal hydrops: anemia, jaundice, enlarged liver Various congenital defects
B
pox)
B19)
Toxoplasmosis
Human immunodeficiency virus/acquired immunodeficiency syndrome Herpes simplex 2 Stress
21
in pregnancy
EFFECT
measles)
& Boulton
Fetal infection Spontaneous abortions, prematurity, microcephaly, fetal infection Miscarriage, prematurity, toxemia, preeclampsia, nausea, prolonged
Avoid contact if not immune; vaccinate if not pregnant. Avoid contact with blood products; vaccinate if not pregnant. Handwashing, gloving when handling blood and body fluids; if pregnant and not immune, avoid contact with children <2 years old during first 24 weeks of pregnancy. Avoid contact if not immune.
Handwashing;
avoid shared utensils.
Care in preparation of raw meat; thorough handwashing after handling raw meat and vegetables, after cleaning a cat litter box, outdoor sandbox, or after gardening Appropriate precautions handling blood and body fluids Handwashing, gloving Decrease sources of stress; relaxation techniques; good diet; exercise
labor CM, Central nervous system. Sources: Keleher (1991, p. 24); Adler et al. (1992).
(1991);
Koch (1991);
Canadian
Paediatric
Cytomegalovirus
Cytomegalovirus, a type of herpesvirus, is transmitted through contact with blood and other bodily secretions containing the virus (Adler, 1991, 1992; Rosenberg & Clever, 1990). Children shed cytomegalovirus in saliva and urine with no apparent symptoms (Kendall & Moukkadem, 1992). Child care providers experience a high level of occupational cytomegalovirus exposure (American Public Health Association/American Academy of Pediatrics [Al?HA/AAP], 1992). Although the rate of congenital Section for exposed susceptible women is high (40%), only 10% to 15% of these exposures result in vision, hearing, or intellectual deficits (Al?HA/AAl?, 1992; Reves & Pickering, 1992). Caregivers for children younger than 2 years of age are at greatest exposure because of the high infection rate of this age group in child care and the nature of their
Society
(1992),
Hayden
(1991),
Kendall
& Moukaddem
(1992),
Osterholm
caretaking, which involves increased exposure to and contact with bodily fluids (Adler, 1992). Pregnant women should not be excluded from working in child care centers because of cytomegalovirus exposure (Infectious Diseases and Immunization Cornmittee, 1990). However, some disagreement exists in the literature regarding routine screening for cytomegalovirus status. Tookey and Peckham (1991) argue that staff should not be routinely screened because cytomegalovirus is a common Section with no vaccine available; and as they see it, no clear advice can be given as a result of the screen. Adler (1991; 1992), however, suggests that before pregnancy all women in child care should be tested for immunoglobin G antibody immunity. If they show no immunity, that is test seronegative, they should be advised to avoid contact with children younger than 2 years of age during the first 6 months
Journal
22
Gratz & Boulton
of gestation or to avoid intimate contact with young children, particularly with their urine and saliva. The efficacy of cytomegalovirus control measures require further validation; however, transmission can probably be reduced through proper hygienic practices (Thacker, Addis, Goodman, Holloway, & Spencer, 1992). Osterholm, Reves, Murph, and Pickering ( 1992) recommend frequent handwashing, especially after diapering, toileting, or contact with oral and/or nasal secretions; proper disposal of tissues and diapers; and cleaning/disinfecting mouthed toys and environmental surfaces. Child care staff should be routinely counseled regarding the risks of cytomegalovirus exposure during pregnancy (APHAIAAP, 1992). Varicella
Varicella outbreaks are common in groups of young chiidren; however, maternai chickenpox is a relatively rare occurrence affecting one in 7500 pregnancies (Keleher, 1991). Most adults are seropositive as a result of their own childhood exposures (Grimsley, Jacobs, & Perkins, 1992). Reves and Pickering (1992) reviewed research citing adults as more likely than children to experience pneumonia and other complications of primary variceIla infection. If varicella is contracted during pregnancy it may present a risk to the developing fetus during the first trimester and perinatally. Although gestational exposure in child care is thought to carry minimal risk for the fetus, susceptible pregnant staff who are occupationally exposed to varicella should be advised to receive counseling from a health care professional within 24 hours after exposure is recognized (APHA/AAP, 1992). Fifth Disease
Fifth disease (erythema infectiosum), a benign rash illness of childhood sometimes called “slapped cheek” syndrome, is caused by parvovirus B19 (Koch, 1991). Exposure during pregnancy can result in transplacental infection (Reves & Pickering, 1992). Although the level or time of greatest prenatal risk is not currently known (Koch, 1991), Osterholm et al. (1992) discuss gestational infection outcomes particularly during the first and second trimester. They state that, because miscarriage can occur after asymptomatic maternal infection, the incidence of fetal loss due to fifth disease is not certain; however, recent research findings put risk of spontaneous abortion after infection at 3% to 9% during the first half of gestation. The risk of contracting erythema infectiosum has been found to be increased for teachers and child care providers who work with younger children (Cartter et al., 1991; Gillespie et al., 1990). Although serious consequences can result from prenatal infection, the risk is
of Pediatric Volume
Health
Care
8, Number
1
relatively low because of the prevalence of naturally acquired immunity and the apparently low risk of fetal infection (Reves & Pickering, 1992). Koch (1991) recommends pregnant child care staff minimize exposure by proper handwashing and avoiding shared utensils; although it is not necessary to exclude staff if a case occurs, serologic testing for the presence of anti-B19 IgG is helpful to identify teachers already immune. n
STRESS
Psychosocial factors, such as stress, are very complex and present a wide range of responses that may be difficult to quantify. Occupational stress may produce both psychologic and physical disabilities. Seward (1990) has discussed the links between stress and disease focusing on mental illness, cardiovascular and gastrointestinal diseases, and accidents. Among those workplace stressors that have been investigated are organization and organizational relationships (House & Wills, 1977; LaRocco, House, & French, 1980), career issues, one’s role in the organization and the task(s) performed (Seward, 1990), and work environment (Klitzman, House, Israel, & Mero, 1990). Teachers in early childhood programs and child care staff experience special job stresses (Hyson, 1982). The stress of child care work can intensify to a level of staff “burn-out” caused by the interaction of the nature of the work, personalities of the staff, and the structure of the center (Maslach & Pines, 1977). Whitebook et al. (1982) suggest that working conditions, for example, low pay, lack of benefits, unpaid overtime, significantly affect job dissatisfaction, which can lead to burn-out. Although no specific studies of stress and child care staff pregnancies have been as yet conducted, various studies have found that women experiencing stress have difficulty conceiving, higher rates of miscarriage, and complications such as toxemia, preeclampsia, nausea, hyperemesis, and prolonged labor (Keleher, 1991). The effects and prevention of stress are also included in Table 2. The control of work stress is best accomplished through preventive strategies, which recognize problems and early clinical or behavioral signs (Seward, 1990). n
ERGONOMICS
Ergovwrnics is defined as the relationship between physical stressors found in the environment and a worker’s physical condition. Waitresses, physical therapists, nurses, airline workers, aerobic instructors, and athletes are often cited as having jobs with poor ergonomics (Keleher, 1991). Currently no published studies of the ergonomics of child care exist; however, our contention is that staff who care for children have aspects of all of the jobs mentioned-waitresses, nurses, aerobic in-
Journal of Pediatric Health Care January-February 1994
Gratz & Boulton
structors, athletes-included in their daily routine. In a recent presentation, Owen (1992) reported that the physical requirements of child care work, that is frequent bending, squatting, floor-sitting, and lifting, present the potential for musculoskeletal disorders. Factors to be assessed specific to lifting include the frequency and duration of the lifts, weight, size, and techniques of the lifter (Owen, 1992). This awareness becomes particualrly important during pregnancy. Keleher (1991) discusses ergonomically appropriate recommendations to avoid heavy lifting, that is a load that is maximum in early pregnancy should be reduced 20% to 25% in late pregnancy, and situations that have an increased risk of accidental injury. Although citing the need for more empirical documentation, the Council on Scientific Affairs (1984b) of the American Medical Association presented guidelines for continuing levels of work activity for healthy women with normal pregnancies. Those activities commonly found as part of the child care work day are excerpted as Table 3. Back problems are a common complaint in pregnancy with approximately 50% of women experiencing some back difficulties (Jacobson, 1991); swollen feet and varicose veins frequently present problems as well (Aronson, 1987). Recommendations for child care staff should include a review of good standing and seated posture. An appropriate stance uses the pelvic tilt; proper seating decreases the lumbar curve and supports the lumbar spine. Attention to pushing, lifting, and carrying is especially important. A significant portion of the interaction with young children may include physically strenuous lifting and carrying. At all times, but particularly during pregnancy, proper techniques should be used. Because child care staff can spend large amounts of time on their feet, which contributes to varicose viens and swollen feet, support hose, exercise, frequent changes of position, and putting one’s feet up are recommended (Aronson, 1987). w GUIDELINES
AND
RECOMMENDATIONS
The effects of pregnancy on work have only recently been investigated and remain outside the mainstream of occupational health research. The Council on Scientific Affairs (1984b) presents a discussion largely in terms of how little is known. Cited as an example is the advice given by “generations of doctors” that has historically been due to social and cultural beliefs rather than documented medical experience with employed women. There is also a lack of empirical information regarding the stages of pregnancy and impact on work. Minimal data are available to validate the frequency or occurrence of symptoms such as nausea and fatigue in early pregnancy. The Council also stated (almost a decade ago) that research is needed on the postpartum
TABLE 3 Guidelines for continuation levels of work during pregnancy
n
jOB
FUNCTION
Standing Prolonged C-4 hr) Intermittent >30 min/hr ~30 min/hr Stooping and bending Below knee level Repetitive (>lO times/hr) Intermittent (
23
of various WEEJC OF GESTATION
24 32 40
20 28 40 28 40
20 24 40 30 40 40
Adapted from Council on Scientific Affairs (1984). Effects of pregnancy on work performance. /AMA. 25 1, 1996-l 997. Copyright 1984, American Medical Association. Reprinted with permission.
period and return to work. The “magic” 6 weeks that is recommended may be no more medically appropriate when rationally evaluated than 2 weeks. Although hard data are lacking, ,guidelines are presented in a number of sources ostensibly based on anecdotal evidence. The same Council on Scientific Affairs (1984b) article noting this lack nonetheless published a timeline for the termination of various levels of work during pregnancy, excerpted here as Table 3. These guidelines for healthy women with normal pregnancies were reviewed and reaffirmed, underscoring the idea that decisions should be made on a case-by-case basis (Bohigian, 1988). The American Medical Association’s table indicates the time period in which healthy employees with uncomplicated pregnancies should be able to perform various tasks “without undue difficulty or risk to pregnancy” and should not be interpreted as either dates at which all employees must continue to perform or stop performing these activities (Bohigian, 1988; Council on Scientific Aflairs, 1984b). Keleher (1991) cites various sources to present overall recommendations for pregnant workers with normal pregnancies. All workers are cautioned to avoid exhaustion, disconiiort, strenuous exercise, extreme tempera-
Journal
24
Gratz & Boulton
p TABLE 4 Common problems and recommendations for pregnant child care staff
lYx@ks. Rest on. left &tiei ck&q@reaks and lunch, or with feet @leYd, Keep each .w@day to no more than 8 hours.
Rest when fti&. Exposu~re to infectious diseases
Back probLms
Frequent
SW0&3fl
urination
feet, varicose
veins
Sources:
Aronson
Use frequent-and ‘proper ha~~~~g techtiique. use of gloves, univenal precautions, where appropriate. Es&&ah in~rmational network for p&rents and staff. Alert health care provider of child care Gork and potential for this exposure. Use proper lifting-and carrying techniques. Avoid heavy tt&ng. Maintain good standing and seated posture. Use ad&size furniture; bring an adult-size, easily movable, cornfortabte chair from home, if necessary. Avoid floor-sitting. To, avoid constant bending, have ehi&en climb up to teacher, if developmentally appropriate. Trade strenuous chores of lifting/moving‘heavy objects with other staff. Mave other staff avail@le to cover room assignment- to m&n&in staff-ch&i ratbs. Wear wpport Rose. Exercise. Chanp position frequently. Rest with feet etevated.
(19871, Child Care Employee
Project (1989),
K&her
(1991).
tures, smoking areas, noxious odors and chemical finnes, ladder climbing, heavy lifting, and trauma to the abdomen. All employed pregnant women need to take frequent breaks, rest on the,lefi side during lunch, rest when fatigued, take walks, wear support hose, and elevate legs when possible. For more “strenuous” jobs it is important to keep each shift to 8 hours, stop or reduce
of Pediatric Health Care Volume 8, Number 1
work 2 to 4 weeks before the due date, empty the bladder every 2 hours, and avoid heavy lifting. Specific to child care, the Child Care Employee Project (CCEP, 1989) has presented recommendations for both staying healthy and enhancing classroom life during pregnancy. Common problems of and recommendations for pregnant child care staff are summarized in Table 4. Staying healthy involves (a) frequent and proper handwashing, (b) informational networks where staff and parents can notify each other of possible exposures to illness, (c) communication to the staffmember’s health care provider that she works in child care and therefore has the potential to be exposed to childhood illnesses, and (d) prevention of back injuries through proper lifting and carrying techniques (CCEP, 1989). Day-to-day activities within the classroom and in dealing with young children also bear special consideration during pregnancy. The CCEP (1989) suggests that if adult-size furniture is not available in the room, a comfortable chair that can be easily moved should be brought from home. If developmentally appropriate, children should be encouraged to climb up to the pregnant teacher for special attention rather than having the teacher constantly bending to the children, Trading chores that involve lifting or moving heavy objects and cleaning fluids or toxic substances is advised. As Keleher (1991) also recommends, the pregnant staff member should always take scheduled breaks and rest during the lunch period either lying down or with feet elevated. For unscheduled breaks, for example more frequent use of the restroom, other staff may be needed to step in and assist with a group of children so that required adult-to-child ratios can be maintained. Pregnancy is a common occurrence among child care staff and as such is a frequent health concern in early childhood educational settings. Nursing professionals are important sources of health care information for these preschool programs and can provide directors and staff with consultations and in-services when pregnancy becomes a health consideration or even, perhaps, on an annual basis. As health care providers and screeners in child care centers, nurses are a vital part of identifying and controlling infectious diseases. As discussed, staff pregnancy is a time for increased awareness of the adult consequences for contracting infectious diseases and the importance of reporting contagious illnesses of staff, children, and the parents and siblings of children enrolled in the center. More research in the area of occupational health is needed for child care generally. With a predominantly female work force, specific health and safety issues related to pregnancy in these settings need further examination. Nursing professionals in child care programs
Journal of Pediatric Health January-February 1994
Care
are in an excellent position to gather such data both empirically and anecdotally and could make timely and important contributions both to the health and wellbeing of child care staff and to the quality of care they provide the children in their care. H REFERENCES
American College of Obstetricians and Gynecologists. (1985). I’qnanqv and the working womun. Patient Education Pamphlet APO44 Washington, DC: American College of Obstetricians and Gynecologists. American College of Obstetricians and Gynecologists. (1989). Standardr fw Obstetrh and GynecologicServices.(7th ed) Washington, DC: American College of Obstetricians and Gynecologists. Adler, S. I’. (1991). Cytomegalovirus. In L. Donowitz (Ed.).Inf&n control in the child care center and preschool (pp. 122-124). Baltimore: Williams & Wilkins. Adler, S. P. (1992). Cytomegalovirus transmission and child day care. Advances in Pediatric Infectiuw Diseases,7, 109-122. American Public Health Association/American Academy of Pediatrics. (1992). Caring for OUYchildren. National health and safety perjhmance standarh: Guidelines fm out-of-home child cureprograms. Washington, DC: Author. Armstrong, B. G., Nolin, A. D., & McDonald, A. D. (1989). Work in pregnancy and birth weight for gestational age. Btitirb Journal ofIndustrial Mea%&, 46, 196-199. Aronson, S. (1987, May). Coping with the physical requirements of caregiving. Chsld Care Excbu~e, 39-40. Bemhardt, J. H. (1990). Potential workplace hazards to reproductive health. Information for primary prevention. Journal of Obstehcaf, Qnecological, and Neonatal Nursing, 19, 53-62. Bohigian, G. M. (1988). Effects of pregnancy on work performance. InfomtatMnal Report of the Council on S&n@ Affaim Chicago: American Medical Association. Canadian Paediatric Society (1992). Pregnancy and caregivers. In Well-beings: A @de to promote the p&ml health, safety and emt&al well-being of children in child care centres and family airy care homes (pp. 711-715). Toronto: Creative Premises. Cartter, M. L., Farley, T. A., Rosengren, S., Quinn, D., Gillespie, S. M., Gary, G. W., & Hadler, J. L. (1991). Occupational risk factors for infection with parvovirus B19 among pregnant women. The Journal of In&t&s Diseases,163, 282-285. Child Care Employee Project. (1989). When child care workers become pregnant. Workiqfbr qua&v child care, unit II: Creating a better work environment (pp. 64-68). Berkeley: Child Care Employee Project. Council on Scientific Affairs (1984a). Effects of physical forces on the reproductive cycle. JM, 251, 247-250. Ch~cil OQ Scientific Affairs (1984b). Effects of pregnancy on work performance. Jm, 251, 1995-1997. Co~cil on Scientific Alfairs ( 1985). Effects of toxic chemicals on the reproductive system. JAIMA, 253, 3421-3437. Donowitz, L. G. (Ed.) (1991). InfectMn wntrol in the child care center andprescbool. Baltimore: Williams & Wilkins. Dutkiewicz, J., Jablonski, L., & Olenchock, S. A. (1988). Occupational biohazards: a review. American Journal of Indwstriul Medicine, 14, 605-623. Gillespie, S. M., Cartter, M. L., Asch, S., Rokos, J. B., Gary, W., Tsou, C. J., Hall, D. B., Anderson, L. J., & Hurwitz, E. S. (1990). Occupational risk of human parvovirus B19 infection for school and day-care personnel during an outbreak of erythema infectiosum. JAMI, 263, 2061-2065. Gothe, C.-J., & HiBert, L. (1992). Spontaneous abortions and work
Gratz & Boulton
25
in day nurseries. Acta Obstetric& et Qnewkyica Scandinaviuz 71, 284-292. Grimsley, L. F., Jacobs, R. R., & Perkins, J. L. (1992). Varicellaroster susceptibility in day-care workers. Applied Occupahmal and Envirvmnental Hy~ime, 7, 191-194. Hayden, G. F. (1991). Rubella (German measles). In L. Donowitz (Ed.). I@ction control in the child care center andpreschool (pp. 246250). Baltimore: Williams & Wilkins. House, J. S., &Wills, J. A. (1977). Occupational stress,social support and health. In: McLean, A. A. (Ed.). Red&g occupational strers. Washington: NIOSH. Hyson, M. C. (1982). Playing with kids all day: job stress in early childhood education. roung Children, 37, 25-32. Infectious Diseases and Immunization Commit-tee. (1990). Cytomegalovirus infection in day-care centres: Risks to pregnant women. Canadiun Medical Associathn Journal, 142, 547-549. Jacobson, H. (1991). Protecting the back during pregnancy. AAOHN Journal, 39, 286-291. Keleher, K. C. (1991). Occupational health: How work environments can effect reproductive capacity and outcome. Ntrrse PraccitMner, 16, 23-37. Kendall, E. D., & Moukaddem, V. E. (1992). Who’s vulnerable in infant child care centers? Youw Children, 47, 72-78. Klitzman, S., House, J. S., Israel, B. A., &Mero, R. P. (1990). Work stress, nonwork stress and health. Journal of Behatial Medicine, 13, 221-243. Koch, W. C. (1991). Parvovirus B19 (fifth disease, erythema infectiosum). In L. Donowia (Ed.). Infection control in the child care wnterandpreschml (pp. 211-214). Baltimore: Williams&Wilkins. LaDou, J. L. (Ed.) (1990). Occupational vnedicine. Nonvalk, CT: Appleton & Lange. LaRocco, J. M., House, J. S., &French, J. R. (1980). Social support, occupational stress, and health. Jooumal of Health and Social Behaviur, 21, 202-218. Mamelle, N., Laumon, B., & Lazar, P. (1984). Prematurity and occupational activity during pregnancy. American Journal of Epzdemiolqy, 119, 309-322. Maslach, C., & Pines, A. (1977). The burnout syndrome in the day care setting. Child Care Qurte~& 6, 100-l 13. McDonald, A. D., McDonald, J. C., Armstrong, B, Cherry, N, Delmore, C., Nolin, A. D., & Robert, D. (1987). Occupation and pregnancy outcome. Britirb Journal ofZndustriulMedicine, 44, 521526. McDonald, A. D., McDonald, J. C., Armstrong, B., Cherry, N. M., Nolin, A. D., & Robert, D. (1988). Prematurity and work in pregnancy. British Journal of Industrhl Medicine, 45, 56-62. Nurminen, T., Lusa, S., Ilmarinen, J., & Kurppa, K. (1989). Physical work load, fetal development and course of pregnancy. Scandinavian Journal of Wmb Environment and Health, 15, 404-414. Osterholm, M. T., Reves, R. R., Murph, J. R., & Pickering, L. K. (1992). Infectious diseases and child day care. Pediatric Injztiuw DizeaseJournal, 11, S31S41. Owen, B. (1992, June 16). Intervention J% mwculoskeletd diwmb achild cart worb. Paper presented at the International Conference on Child Day Care Health: Science, Prevention, and Practice, Atlanta, GA. Raybum, S. K., & Yorker, B. A. (1991). Maternal rights in the workplace. AAOHN Journal, 39, 534-536. Reves, R. R., & Pickering, L. K. (1992). Impact of child day care on infectious diseases in adults. Infectahw Diceasc Clink of North America, 6, 239-250. Rosenberg, J., & Clever, L. H. (1990). Medical surveillance of infectious disease end-points. Occn@mal Medicine: State of the Art Reviews, 5, 583-605. Rudolph, L., &Forest, C. S. (1990). Female reproductive toxicology.
journal
26
Gratz
& Boulton
In J. L. LaDou (Ed.). Occlrpational me&&e (pp 275-287). Norwalk, CT: Appleton & Lange. Seward J. P. (1990). Occupational stress. In J. L. LaDou (Ed.). Ocnrpatwtpnl me&c& (pp 467-480). Norwalk, CT: Appleton & Lange. Thacker, S. B., Addiss, D. G., Goodman, R. A., Holloway, B. R., & Spencer, H. C. (1992). Infectious diseases and injuries in child day care. Journal of the A merican Medical Associutiov, 268, 17201726. Tookey, P., & Peckham, C. (1991). Does cytomegalovirus present
of Pediatric Health Care Volume 8, Number 1
an occupational risk? Archives of Dkeme in Childhood, 66, 10091010. Whitebrook M., Howes, C., Dar&, I’., & Friedman, J. (1982). Caring for the caregivers: staff burnout in child care. In L. G. Katz (Ed.) &went top&x in early childhwd educutian. vol 4 (pp. 211-235). Nonvood, NJ: Ablex Publishing Corporation. Whitebook, M., Howes, C., & Phillips, D. (1990). Who caves? Child care teachers and the quality of care in An&a. Berkeley, CA: Child Care Employee Project.