Navigating your childcare options in a post-COVID world

03/15/2023

by Kelly E. Hathorn, MD , David W. Creighton, MD

When we found out we were expecting our first child, we were ecstatic. Our excitement soon gave way to panic, however, as we realized that we needed a plan for childcare. As full-time physicians early in our careers, neither of us was prepared to drop to part-time or become a stay-at-home caregiver. Not knowing where to start, we turned to our friends and colleagues, and of course, the Internet, for advice on our options.

In our research, we discovered three things. First, with COVID-19, the cost of childcare has skyrocketed, and availability has decreased. Second, there are several options for childcare, each with its own benefits and drawbacks. Third, there is no one-size-fits-all solution. Our goal for this article is to provide an overview of the common childcare solutions and provide some practical tips to help other physicians determine what might work best for their family and situation.

Family

Using family members to provide childcare is often cost-effective and provides a familiar, supportive environment for children. Proximity does not guarantee a willingness or ability to provide long-term care, however, and it can cause strain on family relationships, lead to intrusions and boundary issues, and create feelings of obligation and guilt. It is important to have very honest, up-front discussions with family members about hopes and expectations if this is your childcare plan.

Daycare, facility-based

Daycare centers are commercial facilities that offer care to multiple children of varying ages, starting from as young as 6 weeks. They have trained professionals and provide structured activities and educational programs for children. Many daycares also provide snacks and lunch, which is included in their tuition. They are a popular choice for families seeking full-time childcare and the social and educational benefits that come with a structured setting.

Daycares also have some downsides. They usually operate during normal workday hours, from 7:00 a.m. to 6:00 p.m., which may not be convenient for physicians who work outside of these hours. Even with feasible hours, getting children dressed, ready, and dropped off each morning could add significant time and stress to your morning routine. Additionally, most daycares have policies that prohibit attendance if a child is sick or febrile, which is a common occurrence, particularly for daycare kids. In case of an illness outbreak, the daycare may even close for several days. Both scenarios require at least one parent to take a day off or have an alternative childcare plan available on short notice.

Availability of daycare can be limited, particularly since the COVID pandemic, creating waitlists that can be several months long. Early registration, even during pregnancy, is recommended to secure a spot. It can be helpful to find out if your employer has an agreement with a specific daycare that has “physician-friendly” hours and gives waitlist priority to trainees or even attending physicians. The cost of daycare for one child is typically affordable, around $12,000 per year on average, but can be as high as $25,000 in cities with high cost of living. A sibling discount may be offered, but the cost of daycare for multiple children could still exceed in-home childcare options.¹

Daycare, home-based (also known as family care centers)

Family care centers offer a home-like alternative to daycares, with smaller staff-to-child ratios and often more personalized care. They are favored by families seeking a more intimate setting. They might offer more flexible scheduling and are typically less expensive than facility-based daycares, at up to 25% lower cost.¹ They may lack the same structure and educational opportunities as facility-based daycares, however, and are not subject to the same health and safety regulations.

Nannies

Nannies are professional caregivers who provide in-home childcare services. Their responsibilities may include feeding, changing, dressing, bathing, and playing with children. In some cases, they may also be expected to do light housekeeping tasks like meal preparation, laundry, and cleaning. It is common for nannies in high-demand markets to refuse to perform these additional tasks, however. Nannies are preferred by families with hectic schedules due to their flexibility. They can work early, late, or even overnight shifts, and provide care in the comfort of your home, avoiding the hassle of drop-off and pick-up times. Nannies also can provide personalized care to meet each child’s specific needs, and they can care for children who are sick or febrile.

When hiring a nanny, it is important to have a written contract outlining their expected hours, wages, benefits, and duties to prevent misunderstandings in the future. Finding a trustworthy and reliable nanny can be a challenge, and families have several options for finding one. They can post jobs on free websites and browse nanny CVs or use a fee-based nanny agency. The cost of using an agency can range from a few hundred to several thousand dollars, so it is important to ask friends and colleagues for recommendations before paying for an agency’s services.

The cost of hiring a nanny is one of its main drawbacks. Nannies typically earn $15 to $30 per hour, and if they work in the family’s home, they are typically considered “household employees” by the IRS. Household employees are entitled to overtime pay for work beyond 40 hours per week, and the employer (you!) is responsible for payroll taxes, withholding, and providing an annual W-2 tax statement.² There are affordable online nanny payroll services that handle payroll and tax-filing to simplify the process, however. The average annual cost of a full-time nanny is around $40,000 and can be as high as $75,000 in some markets.¹ A nanny-share with other families can lower costs, but it may also result in less control over the caregiver and schedule.

It is important to consult a tax professional or the IRS for guidance on nanny wages, taxes, and payroll, as a nanny might rarely be considered an “independent contractor” if they meet certain criteria.

Au pair

An au pair is a live-in childcare provider who travels to a host family’s home from a foreign country on a special J-1 visa. The goal is to provide care for children and participate in cultural exchange activities. Au pairs bring many benefits, such as cost savings compared to traditional childcare options and greater flexibility and customization. They can work up to 10 hours per day and 45 hours a week, performing tasks such as light housekeeping, meal preparation, and transportation for the children. Host families must provide a safe and comfortable living environment, including a private room, meals, and some travel and education expenses.¹

The process of hiring an au pair involves working with a designated agency that matches families with applicants and sponsors the J-1 visa. The entire process can take several months, and average program fees cost around $10,000 per placement. Au pairs are hired on a 12-month J-1 visa, which can be extended for up to an additional 12 months, allowing families up to 2 years with the same au pair before needing to find a new placement.

Au pairs earn a minimum weekly stipend of $195.75, set forth by the U.S. State Department.³ Currently, au pairs are not subject to local and state wage requirements, but legal proceedings in various states have recently questioned whether au pairs should be protected under local regulations. Massachusetts has been the most progressive, explicitly protecting au pairs as domestic workers under state labor laws, raising their weekly stipend to roughly $600 to comply with state minimum wage requirements.⁴ The federal government is expected to provide clarity on this issue, but for the time being, au pairs remain an affordable alternative to a nanny in most states.

Conclusion

Choosing childcare is a complicated process with multiple factors to consider. Figure 1 breaks down the estimated annual cost of each of the options outlined above for a single child in low, average, and high cost-of-living areas. But your decision likely hinges on much more than just cost, and may include family dynamics, scheduling needs, and personal preferences. Gather as much advice and information as possible, but remember to trust your instincts and make the decision that works best for your family. At the end of the day, what matters most is the happiness and well-being of your child.

Dr. Hathorn and Dr. Creighton are married, and both work full-time with a 1-year-old child. Dr. Hathorn is a bariatric and advanced therapeutic endoscopist at the University of North Carolina at Chapel Hill. Dr. Creighton is an anesthesiologist at UNC Chapel Hill. Neither reported any conflicts of interest.

Disclaimer

The financial and tax information presented in this article are believed to be true and accurate at the time of writing. However, it’s important to note that tax laws and regulations are subject to change. The authors are not certified financial advisers or tax specialists. It is recommended to seek verification from a local tax expert or the Internal Revenue Service to discuss your specific situation.

Summary content

The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?

Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.

Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?

Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).

Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?

Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.

The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?

Dr. Staller: I define “refractory” with three anchors.

1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).

2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.

3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).

What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?

Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.

The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?

Dr. Staller: I see three major areas.

1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).

2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.

3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.

Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.

Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.