Hygiene of Toys in Day Care Centers : a Care With Children *

Background: Toys enable nursing care qualification and extension because they provide a range of possibilities that can temper children’s coping with several different situations, by which means they can express feelings and establish confidence ties with the professionals that care for them. However, there is evidence in the literature that toys are vehicles of microorganism transmission and a source of cross-infection.


Introduction
Attention to the child by educators involves care with the hygiene, safety and food, whether this individual demand or from the group [1].
The concern with child hygiene is not recent.There have been reports that Florence Nightingale, a forerunner of nursing, advocated hygiene and recreational care for the child as a method of controlling the spread of microorganisms in crowded areas [2].
This care may be even more necessary in environments that have objects shared in their routines, as it happen in day care centers, due to the recognized risk of the dissemination of microorganisms by fomites, including the toy [3,5].
Studies on bacteriological conditions and their pathogenic potential in toys and in the hands of children in the hospital and outpatient settings highlight the importance of choosing the appropriate product for cleaning and disinfection [3][4][5][6].
However, there are few findings in the literature involving the relationship between the hygiene of toy in day care centers.
Research has shown that there is an environmental risk factor associated with the transmission of enterobiasis in children that attending day care centers [7], as well as the risk of transmission of respiratory diseases, having as a vehicle the contaminated hands of these children [5].
In addition, by raising the causes of infant deaths in Brazil in 2014, out of a total of 38,432 deaths on the List of Mortality CID-10, 1,909 were respiratory diseases, 1,712 for some infectious and parasitic diseases, 457 for diarrhea and gastroenteritis of infectious origin and 73 for other infectious intestinal diseases, and the microorganisms involved in these diseases can use the toy as a transmission vehicle [8].
In relation to the child's developmental stages, the child moves from play with its hands and mouth to play with its feet and mouth and from the exploration of the environment, from the reach of objects, such as toys, and can carry both to the mouth [9].
Even, analyzing the toy as a vehicle for the dissemination of microorganisms, comparative research among different environments show the contamination rate of day care centers and household toys, concluding that 67.5% presented bacterial growth with pathogenic potential, 25.9% were positive for negative coagulase staphylococci, 29.6% showed the presence of Bacillus species and 55.6% were positive for coliforms.By facting of the toys used in the kindergarten have a higher rate of contamination than the toys used by children in their homes, at 75% and 60%, respectively, scholars disagree with the practice of bringing personal toys to the kindergartens school and bringing them back home routinely [12].
As a consequence, although the toy is an instrument of teaching and social interaction among children, its potential as a vector of diseases can present significant risks if its hygiene does not occur in an adequate way.
This study aimed to investigate how the hygiene of toys used in day care centers and the possible trends in the processes are done.

Methods
A descriptive, cross-sectional study, developed between March and July of 2013, having as a unit of observation 51 day care centers in the interior of São Paulo, these municipal institutions being co-located.These institutions receive children from birth to five years, 11 months and 29 days, totaling 7552 children.
The 51 day care centers were visited on previously scheduled days, to characterize the procedure and frequency of hygiene of the toys adopted by these institutions.The answers were obtained by inter-view and recorded in an electronic instrument of data collection.The questionnaire online was written by the software LymeSurvey, a free open source software.
Aiming to reach the proposed objective, a descriptive analysis of the data was adopted, in which the frequency distributions of the analyzed variables were presented by means of absolute frequencies and relative percentages of the studied institutions, shown in figures and tables.The application software used for data tabulation was the Statistical Package for the Social Sciences (SPSS) 15.0 for Windows.
In order to investigate the stages of the hygiene of the toys used by day care centers, were elaborated questions related to this topic based on a technical bulletin of the National Agency of Sanitary Surveillance [13], added to the research experience and publications resulting from this [14,15] .The sanitization steps were classified as described below [13]: Step 1. Pre-cleaning: made with cold water as early as possible to prevent drying of organic material such as blood and secretions or dirt from its use.Step 2. Cleaning: You can use brushes, such as those used for hand washing, to remove the dirt.Special attention should be paid to the grooves, corners, crevices, where the dirt may be housed.Step 3. Rinse: remove the dirt and the residual detergent or product used during its sanitization.
Step 4. Drying: Unless the object is disinfected, it must be completely dry in order to avoid the growth of microorganisms.If the object is disinfected with chemical liquids, the presence of water will dilute it and reduce its residual biocidal potential.Due to the lack of description in the literature of the technique of hygiene of the toy according to the material with which it is constituted, the steps of this procedure were adequate according to the concept adopted for cleaning surfaces and objects in Surgical Centers.
In this study we consider that the institution had "intention to carry out of the procedure of hygiene of the toys" when it declared not to perform some of the steps previously described, only configuring the partial development of the action, without accomplishing the hygiene of the toys.
In the study of unit responses, descriptive statistics were used, involving the frequency distributions of the analyzed variables.The distributions were presented by means of absolute frequencies and relative percentages of the two institutions combined in the same table.
The study complied with the formal requirements contained in national and international standards for research involving human subjects.It was submitted to the Research Ethics Committee of Botucatu Medical School -UNESP, under Protocol no.4399 -2012, approved at a meeting held on November 5, 2012 and conducted with the assistance of the Foundation for Research Support of the State of São Paulo (FAPESP), Case No. 13/00820-8.After receiving clarification on the research, the interviewees signed a Free and Informed Consent Form.

Results
Among the units under study, 100% of the institutions reported using toys in their activities with children.
When investigating the main constitution of the toys, the plastic and the fabric were the most frequent ones, being used in 100.0% of the institutions, followed by toys made of wood, equivalent to 84.3% (Table 1).
Regarding the frequency of hygiene of toys after the use, the most frequently reported periodicity was once a week, corresponding to 25.5% of the units; however, more than a half of these institutions report twice a month or more.Six units (11.8%) sta-ted that they did not perform the hygiene of the toys (Table 2).
As for the product used during the hygiene of the toys, the association of the water and the soap was the most used option (72.5%), followed by Alcohol 70 (21.6%),according to Table 3.
Regarding to the moment that the institutions aim to sanitize the toys, 47.1% do not have a fixed period to carry out the procedure and 11.8% carry out of the hygiene of the toys before the opening of the unit.
In relation to the technique of pre-cleaning of the toys, nine municipal institutions (22.0%) do not carry out this hygiene step.
The toy cleaning technique "sponge/sponge scrub" is the most used, in 61.0% of the municipal institutions and 70.0% of the contracted institutions, followed by the "washing machine" option, which corresponded to 29.3 % for municipal institutions and 50.0%for contracted institutions.
The option to rinse with running water was adopted in most of institutions, the equivalent to 78.0% for municipal units and 90.0% for contracted units.
In the fourth step of the toy hygiene technique, outdoor drying predominated, corresponding to 80.5% in the municipal units and 100.0% in the contracted units.

Discussion
In this study, we alerted to the possible existence of a systematic information bias due to the data collection having been through interview and not through direct observation of the researcher.
However, with the possession of these data, it will be possible to establish Assistance Protocols and/or Standard Operational Procedures, with an approach for professionals working in day care centers, schools and children's recreation areas, as well as for the care of domestic toys by parents or guardians.As a subsidy for the preparation of these documents, this study aims to trigger additional re-   search to detect the relationship between the composition of the toy and the best hygiene procedure to be carried out, including the proper choice of the disinfectant against the microbiological load of these objects.
Considering toy as a potential reservoir and possible disseminator of microorganisms, is greater the importance of hygiene of the toy used by pre-school and school age groups, because these children are still in the motor and cognitive development stage [9] and do not have knowledge or ability of bodily hygiene, such as when using the bathroom [3].
Although we identify some research on the hygiene of toys in health settings [6,16], the study of their use related to teaching and learning also needs special attention, since it is known that day care centers are considered important sites for direct transmission and indirect use of infectious microorganisms [4,[10][11][12][17][18].
When analyzing the phases of the hygiene procedure of the toys under study (pre-cleaning, cleaning, rinsing and drying), it was verified that the most of the institutions perform all the phases, but any differentiation of hygiene procedure was reported regarding the type of composition of the toys.These data are in contrast to the recommendations in the literature, which clarify that specific hygiene procedures should be applied to the various types of toy's composition [3,[19][20].
In the present study, when analyzing the product used by day care centers during the hygienization procedure, there was the predominance of water and soap, of the alcohol 70 % and the hypochlorite, regardless of the composition of the sanitized toy.There are studies that evaluated the effectiveness of products in disinfecting and cleaning surfaces, furniture and utensils in general in the reduction and/or elimination of microorganisms, regardless of the composition of the inanimate surface, because there is no differentiation in the product choice considering the composition of the object [17,21].
There were no reports of specific products for the hygiene of toy surfaces.
In investigating the periodicity of hygiene of the toys adopted by the institutions, the current study identified that the most frequent periodicity for performing this procedure for the toys was once a week, which is contrary to the recommendations of the Centers for Disease Control and Prevention) [22] and another researcher [19], who recommend washing and disinfecting the toys between uses or, at least once at the end of the day, a coherent fact, considering the transmission of microorganisms through the shared use of objects.
Thus in relation to the hygiene procedure, depending on the material for which the toy is made, this factor will directly affect the effectiveness of its hygiene, as well as the procedure adopted should be adequate to its constitution [13].

Conclusions
Considering the elements presented, we conclude that the day care centers do not have routine toys hygiene procedures and there is a minority that does not perform any hygiene procedure of these objects after the development of activities.However, the institutions that develop this procedure do not have any guiding instrument that determines guidelines for the control of the dissemination of microorganisms through the shared use of objects, in this case the toy.
In the view of the scenario studied, it is recommended to use the professionals who work in day care centers to deal with the issue of toys as a potential reservoir of micro-organisms and a source of cross-infection.Therefore, it is necessary to raise awareness about the establishment of a routine of hygiene procedure in the institutions that use the toy as an instrument of teaching and communication.

Table 1 .
Distribution of frequencies of the main constitution of the toy.

Table 3 .
Distribution of frequency of the product used during the hygiene of the toys.

Table 2 .
Distribution of frequency of the hygiene of the toys according to the units surveyed.