Rudolph's Pediatrics, 22nd Ed.

CHAPTER 97. Nonparental Childcare

Nerissa S. Bauer


With more women seeking employment outside the home, about 11 million children under the age of 5 years spend a significant amount of time in nonparental childcare (NPCC) arrangements.1 Political, cultural, and economic factors contribute to the increasing number of children in NPCC settings in the United States. In 2006, 67 million women were employed and 75% worked full-time.2 Changes in family structure influenced the economic needs of households. Currently, about 70% of children live with two married parents. Children living in mother-only households increased steadily to 23% and in father-only households to 5% in 2006.3 Preschool-age children of working mothers spend an average of 36 hours in child-care each week.1

Primary care clinicians need to understand NPCC options available to families, current research on the effect of NPCC on child development and behavior, how to counsel families on choosing quality childcare within the family budget, and how to advocate for quality childcare on a local and national level.4


Over 70% of children 5 years and younger with employed parents are in nonparental childcare (NPCC) arrangements.5 The primary types of care include (1) center-based care, such as childcare centers, daycare centers, preschools, prekindergarten, and Head Start programs; (2) home-based care, such as that provided in a nonrelative’s home or care provided by a nanny or babysitter who comes to the child’s home; and (3) school-age care, such as before-and after-school programs. NPCC can be forprofit or nonprofit, faith-based or nondenominational, private or public6 (Table 97-1).

State childcare licensing regulations and monitoring ensure the protection and safety of children in nonparental care. Most states license childcare facilities. Licensing regulations address child-staff ratios and group size, frequency of inspections, caregiver roles, age requirements, qualifications and ongoing training, supervision and care of children, and facility requirements. Requirements for licensing vary considerably by type of NPCC arrangement and by state.7


Quality childcare is critical to ensure that a child’s health, safety, emotional, and social needs are met. Quality childcare refers to consistent and stable providers who nurture and provide basic physical needs and who encourage learning through an enriched, stimulating, and safe environment.

Table 97-1. Types of Nonparental Childcare7

In a national poll of over 600 families, child-care priorities included the caregivers’ ability to provide a safe and healthy environment while providing school-readiness skills.8 Another desirable childcare quality was care-givers who were trained in child development. Only 12 states (California, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, Vermont, and Wisconsin) require care-givers employed in childcare centers to have training in early childhood education. Of the parents polled, 65% assumed caregivers have this training prior to working with children. In this same poll, nearly 8 in 10 parents favored a $10 increase in taxes to improve quality of childcare.8 Quality among family-based child-care and center-based care providers can vary. Ten states require licensing for all family child-care homes, while a minority of other states license either small or large family childcare homes with a training requirement.8

Cost is a critical factor that may make quality childcare inaccessible. About a third of children under the age of 5 years participate in center-based care.5 The average annual cost to an American family for full-time, center-based infant care ranges from $4,020 to $14,225. The annual cost for a child 4 years of age who attends full-time childcare is slightly lower ($3,900–$10,200 dollars).1

Accreditation status of a particular provider can become a decisive factor for families wanting high-quality childcare options. There are three national program-accrediting bodies—the National Association for the Education of Young Children (NAEYC), the National Association for Family Child Care (NAFCC) and the National AfterSchool Association (NAA). These accrediting bodies have the same common goal of providing high-quality care and education for children. All three national programs have partnered together to disseminate information about their accreditation process to promote quality improvement that is evidence-based. Each association’s Web site provides useful information for primary care clinicians, caregivers, and individual families who wish to educate themselves about the accreditation process.


Research in early brain and child development has promoted a national movement for quality assurance and safety standards in nonparental childcare (NPCC) to optimize learning at the earliest ages. Parents are a child’s first teachers, and the quality of parenting, of maternal sensitivity, and of mother–child play is associated with positive peer competence in later years. Yet, children who spend time in NPCC arrangements can benefit from their experiences with caregivers and peers who are outside the family, as measured by a variety of outcomes. Children who attend high-quality childcare receive benefits that can persist into the early school years.9 The Cost, Quality and Child Outcomes in Child Care Centers study examined the effects of childcare on children’s development through the preschool years and into the transition to the formal educational system.10 Quality of childcare was linked to improved performance on measures of cognitive abilities (eg, language and math) and social skills for all children regardless of family background.10 Effects were sustained for most children through kindergarten and as they entered second grade. Higher quality classroom practices (eg, teacher sensitivity and teaching style and quality of child-care environment) and the closeness of a child’s relationship with a childcare teacher/provider were key predictors.10 In addition, center-based classrooms meeting appropriate recommendations of child-to-adult ratios and having teachers educated in child development has been associated with better language skills by the age of 36 months.11Additional long-term academic benefits attributed to quality childcare include decreases in grade retention, lower rates of special education placement, and higher rates of school completion.12

The National Institute of Child Health and Human Development (NICHD) Study of Early Child Care is a multisite prospective study, with over 1000 children participating to ascertain how quality childcare impacts children’s development. This longitudinal database provides primary data, including objective systematic observations of children in their childcare and home settings.

Given the unique advantages of this database, researchers have been able to study how quality childcare impacts a child’s social-emotional development. Caregivers with more sensitivity and positive responsiveness tended to supervise children who were more positive in their play with peers. This finding was true after controlling for a variety of child and family factors. Greater cumulative experience in non-parental childcare allowed for the development of peer competence by giving children multiple trials of relatively benign conflicts over space and objects. When observed in natural play, these children exhibited positive conflict-resolution skills and more complex social play.13 Children enrolled in this study upon entering 6th grade continued to fare well academically (ie, scoring better on vocabulary tests).14

The NICHD Early Child Care Research Network examined cognitive and behavioral outcomes for children when childcare centers met recommended care standards. Child-to-staff ratios, group sizes, caregiver training and education were examined in relation to children’s development at 24 and 36 months of age. Most centers were unable to meet standards for infants and toddlers.15 The child-to-staff ratios exceeded the recommended level by one child per adult at 6 to 15 months, the recommended ratio is 3:1 versus the observed 4:1, at 24 months, the recommended ratio is 4:1 versus the observed 5:1. A similar pattern emerged for meeting recommendations for center classroom group sizes. The capacity of centers to meet a greater total amount of standards for children in their care was more likely as the children grew older. Most outcomes were better when children attended classrooms that met recommended child-to-staff ratios and recommended levels of caregiver training and education. Evidence from these studies is useful for parents and primary care clinicians who want to advocate for quality childcare at both the local and national levels.


Parents may experience guilt, frustration, helplessness, or sadness when considering childcare options. The source of these emotions may be an uncertainty about whether they can trust anyone with the care of their infant/child. Primary care clinicians can provide useful information and guidance about nonparental childcare to individual families. Clinicians may inquire about parental decisions about childcare early (eg, at the prenatal visit, at discharge from the hospital, and at well-child visits) as an opportunity to provide guidance and ongoing support to working parents.

Family composition and income influences the type of childcare option a family considers,5 as a two-parent household typically has more resources, time, and money. Clinicians can help the parents weigh the potential benefits of childcare options while taking into account the individual child’s temperament16 and family resources. Pediatric counseling may be especially critical for children at risk.17,18

In addition to potential benefits, there are potential risks to children in nonparental child-care, including increased doctor visits for minor communicable illnesses19 and the time a parent needs to take time off work for medical care.

Families can be encouraged to observe several childcare facilities before making a decision. Clinicians can recommend several guidelines for the observation visit and can provide specific questions to ask. Childcare providers should be welcoming to all children and should encourage both a mix of individual and group activity. Parents should watch child-and-provider interactions to see how sensitive caregivers are to each individual child’s needs. Low child-to-staff ratios help ensure that staff can adequately supervise and attend to the children in their care. Parents should assess if they feel able to communicate comfortably with a potential caregiver. A useful checklist to guide parents during the process of selection of a child-care setting is provided in eTable 97.1 . Clinicians can use these guidelines to stimulate discussion about nonparental childcare. Child Care Aware ( provides families with useful information about childcare options and directs them to local agencies with current contact information for childcare facilities in the family’s area.

Pediatricians can participate at the local and national level to advocate for quality child-care. They can serve as childcare consultants by working with childcare centers to ensure safety and health standards, provide consult on behavioral and developmental concerns, and partner with centers to provide educational sessions for parents and staff. At the national level, clinicians can become involved as members of advisory boards for a local Head Start program or can serve on a board of directors for a childcare resource and referral agency. In addition, clinicians can join early childhood professional organizations and can serve on childcare planning committees.9 Legislative advocacy is another area in which physicians can become involved in promoting higher standards in nonparental childcare and in ensuring equal access to all families, regardless of income.