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Impact of early daycare on healthcare resource use related to upper respiratory tract infections during childhood: prospective WHISTLER cohort study

Marieke LA de Hoog1*, Roderick P Venekamp12, Cornelis K van der Ent3, Anne Schilder125, Elisabeth AM Sanders4, Roger AMJ Damoiseaux1, Debby Bogaert4, Cuno SPM Uiterwaal1, Henriette A Smit1 and Patricia Bruijning-Verhagen16

Author Affiliations

1 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands

2 Department of Otorhinolaryngology, Division Surgical Specialties, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3508 AB Utrecht, The Netherlands

3 Department of Paediatric Pulmonology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3508 AB Utrecht, The Netherlands

4 Department Paediatric Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3508 AB Utrecht, The Netherlands

5 evidENT, Ear Institute, University College London, WC1X8EE London, UK

6 National Institute for Public Health and the environment (RIVM), 3720 BA Bilthoven, The Netherlands

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BMC Medicine 2014, 12:107  doi:10.1186/1741-7015-12-107

Published: 26 June 2014



Daycare attendance is an established risk factor for upper respiratory tract infections (URTI) and acute otitis media (AOM). Whether this results in higher use of healthcare resources during childhood remains unknown. We aim to assess the effect of first year daycare attendance on the timing and use of healthcare resources for URTI and AOM episodes during early childhood.


In the Wheezing-Illnesses-STudy-LEidsche-Rijn birth cohort, 2,217 children were prospectively followed up to age six years. Children were categorized according to first-year daycare attendance (yes versus no) and age at entry when applicable (age 0 to 2 months, 3 to 5 months and 6 to 12 months). Information on general practitioner (GP) diagnosed URTI and AOM, GP consultations, antibiotic prescriptions and specialist referral was collected from medical records. Daycare attendance was recorded by monthly questionnaires during the first year of life.


First-year daycare attendees and non-attendees had similar total six-year rates of GP-diagnosed URTI and AOM episodes (59/100 child-years, 95% confidence interval 57 to 61 versus 56/100 child-years, 53 to 59). Daycare attendees had more GP-diagnosed URTI and AOM episodes before the age of one year and fewer beyond the age of four years than non-attendees (Pinteraction <0.001). Daycare attendees had higher total six-year rates for GP consultation (adjusted rate ratio 1.15, 1.00 to 1.31) and higher risk for specialist referrals (hazard ratio: 1.43, 1.01 to 2.03). The number of antibiotic prescriptions in the first six years of life was only significantly increased among children who entered daycare between six to twelve months of age (rate ratio 1.32, 1.04 to 1.67). This subgroup of child-care attendees also had the highest overall URTI and AOM incidence rates, GP consultation rates and risk for specialist referral.


Children who enter daycare in the first year of life, have URTI and AOM at an earlier age, leading to higher use of healthcare resources compared to non-attendees, especially when entering daycare between six to twelve months. These findings emphasize the need for improved prevention strategies in daycare facilities to lower infection rates at the early ages.

Upper respiratory infection; Otitis media; Daycare; Healthcare utilization; Paediatric; Cohort study