Caring for Our Childen, 3rd Edition (CFOC3)

Chapter 1: Staffing

1.1 Child:Staff Ratio, Group Size, and Minimum Age

1.1.1 Child:Staff Ratio and Group Size

1.1.1.1: Ratios for Small Family Child Care Homes


The small family child care home caregiver/teacher child:staff ratios should conform to the following table:

If the small family child care home caregiver/teacher has no children under two years of age in care,

then the small family child care home caregiver/teacher may have one to six children over two years of age in care

If the small family child care home caregiver/teacher has one child under two years of age in care,

then the small family child care home caregiver/teacher may have one to three children over two years of age in care

If the small family child care home caregiver/teacher has two children under two years of age in care,

then the small family child care home caregiver/teacher may have no children over two years of age in care

The small family child care home caregiver’s/teacher’s own children as well as any other children in the home temporarily requiring supervision should be included in the child:staff ratio. During nap time, at least one adult should be physically present in the same room as the children.

RATIONALE
Low child:staff ratios are most critical for infants and toddlers (birth to thirty-six months) (1). Infant and child development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower child:staff ratios (3). Small ratios are very important for young children’s development (7). The recommended group size and child:staff ratio allow three- to five-year-old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4).

The National Fire Protection Association (NFPA) requires in the NFPA 101: Life Safety Code that small family child care homes serve no more than two clients incapable of self-preservation (5).

Direct, warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers/teachers must be recognized as performing a job for groups of children that parents/guardians of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes (6,8).

COMMENTS

It is best practice for the caregiver/teacher to remain in the same room as the infants when they are sleeping to provide constant supervision. However in small family child care programs, this may be difficult in practice because the caregiver/teacher is typically alone, and all of the children most likely will not sleep at the same time. In order to provide constant supervision during sleep, caregivers/teachers could consider discontinuing the practice of placing infant(s) in a separate room for sleep, but instead placing the infant’s crib in the area used by the other children so the caregiver/teacher is able to supervise the sleeping infant(s) while caring for the other children. Care must be taken so that placement of cribs in an area used by other children does not encroach upon the minimum usable floor space requirements. Infants do not require a dark and quiet place for sleep. Once they become accustomed, infants are able to sleep without problems in environments with light and noise. By placing infants (as well as all children in care) on the main (ground) level of the home for sleep and remaining on the same level as the children, the caregiver/teacher is more likely able to evacuate the children in less time; thus, increasing the odds of a successful evacuation in the event of a fire or another emergency. Caregivers/teachers must also continually monitor other children in this area so they are not climbing on or into the cribs. If the caregiver/teacher cannot remain in the same room as the infant(s) when the infant is sleeping, it is recommended that the caregiver/teacher should do visual checks every ten to fifteen minutes to make sure the infant’s head is uncovered, and assess the infant’s breathing, color, etc. Supervision is recommended for toddlers and preschoolers to ensure safety and prevent behaviors such as inappropriate touching or hurting other sleeping children from taking place. These behaviors may go undetected if a caregiver/teacher is not present. If caregiver/teacher is not able to remain in the same room as the children, frequent visual checks are also recommended for toddlers and preschoolers when they are sleeping.

Each state has its own set of regulations that specify child:staff ratios. To view a particular state’s regulations, go to the National Resource Center for Health and Safety in Child Care and Early Education’s (NRC) Website: http://nrckids.org. Some states are setting limits on the number of school-age children that are allowed to be cared for in small family child care homes, e.g., two school-age children in addition to the maximum number allowed for infants/preschool children. No data are available to support using a different ratio where school-age children are in family child care homes. Since school-age children require focused caregiver/teacher time and attention for supervision and adult-child interaction, this standard applies the same ratio to all children three-years-old and over. The family child care caregiver/teacher must be able to have a positive relationship and provide guidance for each child in care. This standard is consistent with ratio requirements for toddlers in centers as described in Standard 1.1.1.2.

Unscheduled inspections encourage compliance with this standard.

RELATED STANDARDS
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.2.1 Minimum Age to Enter Child Care
REFERENCES
  1. Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main .zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact _Sheet.pdf.
  2. National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
  3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
  4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
  5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
  6. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  7. Zigler, E., W. S. Gilliam, S. M. Jones. 2006. A vision for universal preschool education, 107-29. New York: Cambridge University Press.
  8. Stebbins, H. 2007. State policies to improve the odds for the healthy development and school readiness of infants and toddlers. Washington, DC: Zero to Three. http://main.zerotothree.org/site/DocServer/NCCP_article_for_BM_final.pdf.

1.1.1.2: Ratios for Large Family Child Care Homes and Centers


Child:staff ratios in large family child care homes and centers should be maintained as follows during all hours of operation, including in vehicles during transport.

Large Family Child Care Homes

Age

Maximum Child:Staff Ratio

Maximum Group Size

     

≤ 12 months

2:1

6

13-23 months

2:1

8

24-35 months

3:1

12

3-year-olds

7:1

12

4- to 5-year-olds

8:1

12

6- to 8-year-olds

10:1

12

9- to 12-year-olds

12:1

12

During nap time for children birth through thirty months of age, the child:staff ratio must be maintained at all times regardless of how many infants are sleeping. They must also be maintained even during the adult’s break time so that ratios are not relaxed.

Child Care Centers

Age

Maximum Child:Staff Ratio

Maximum Group Size

     

≤ 12 months

3:1

6

13-35 months

4:1

8

3-year-olds

7:1

14

4-year-olds

8:1

16

5-year-olds

8:1

16

6- to 8-year-olds

10:1

20

9- to 12-year-olds

12:1

24

During nap time for children ages thirty-one months and older, at least one adult should be physically present in the same room as the children and maximum group size must be maintained. Children over thirty-one months of age can usually be organized to nap on a schedule, but infants and toddlers as individuals are more likely to nap on different schedules. In the event even one child is not sleeping the child should be moved to another activity where appropriate supervision is provided.

If there is an emergency during nap time other adults should be on the same floor and should immediately assist the staff supervising sleeping children. The caregiver/teacher who is in the same room with the children should be able to summon these adults without leaving the children.

When there are mixed age groups in the same room, the child:staff ratio and group size should be consistent with the age of most of the children. When infants or toddlers are in the mixed age group, the child:staff ratio and group size for infants and toddlers should be maintained. In large family child care homes with two or more caregivers/teachers caring for no more than twelve children, no more than three children younger than two years of age should be in care.

Children with special health care needs or who require more attention due to certain disabilities may require additional staff on-site, depending on their special needs and the extent of their disabilities (1). See Standard 1.1.1.3.

At least one adult who has satisfactorily completed a course in pediatric first aid, including CPR skills within the past three years, should be part of the ratio at all times.

RATIONALE

These child:staff ratios are within the range of recommendations for each age group that the National Association for the Education of Young Children (NAEYC) uses in its accreditation program (5). The NAEYC recommends a range that assumes the director and staff members are highly trained and, by virtue of the accreditation process, have formed a staffing pattern that enables effective staff functioning. The standard for child:staff ratios in this document uses a single desired ratio, rather than a range, for each age group. These ratios are more likely than less stringent ratios to support quality experiences for young children.

Low child:staff ratios for non-ambulatory children are essential for fire safety. The National Fire Protection Association (NFPA), in its NFPA 101: Life Safety Code, recommends that no more than three children younger than two years of age be cared for in large family child care homes where two staff members are caring for up to twelve children (6).

Children benefit from social interactions with peers. However, larger groups are generally associated with less positive interactions and developmental outcomes. Group size and ratio of children to adults are limited to allow for one to one interaction, intimate knowledge of individual children, and consistent caregiving (7).

Studies have found that children (particularly infants and toddlers) in groups that comply with the recommended ratio receive more sensitive and appropriate caregiving and score higher on developmental assessments, particularly vocabulary (1,9).

As is true in small family child care homes, Standard 1.1.1.1, child:staff ratios alone do not predict the quality of care. Direct, warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers/teachers must be recognized as performing a job for groups of children that parents/guardians of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes (10).

Similarly, low child:staff ratios are most critical for infants and young toddlers (birth to twenty-four months) (1). Infant development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower ratios (3). For three- and four-year-old children, the size of the group is even more important than ratios. The recommended group size and child:staff ratio allow three- to five-year-old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4).

In addition, the children’s physical safety and sanitation routines require a staff that is not fragmented by excessive demands. Child:staff ratios in child care settings should be sufficiently low to keep staff stress below levels that might result in anger with children. Caring for too many young children, in particular, increases the possibility of stress to the caregiver/teacher, and may result in loss of the caregiver’s/teacher’s self-control (11).

Although observation of sleeping children does not require the physical presence of more than one caregiver/teacher for sleeping children thirty-one months and older, the staff needed for an emergency response or evacuation of the children must remain available on site for this purpose. Ratios are required to be maintained for children thirty months and younger during nap time due to the need for closer observation and the frequent need to interact with younger children during periods while they are resting. Close proximity of staff to these younger groups enables more rapid response to situations where young children require more assistance than older children, e.g., for evacuation. The requirement that a caregiver/teacher should remain in the sleeping area of children thirty-one months and older is not only to ensure safety, but also to prevent inappropriate behavior from taking place that may go undetected if a caregiver/teacher is not present. While nap time may be the best option for regular staff conferences, staff lunch breaks, and staff training, one staff person should stay in the nap room, and the above staff activities should take place in an area next to the nap room so other staff can assist if emergency evacuation becomes necessary. If a child with a potentially life-threatening special health care need is present, a staff member trained in CPR and pediatric first aid and one trained in administration of any potentially required medication should be available at all times.

COMMENTS

The child:staff ratio indicates the maximum number of children permitted per caregiver/teacher (8). These ratios assume that caregivers/teachers do not have time-consuming bookkeeping and housekeeping duties, so they are free to provide direct care for children. The ratios do not include other personnel (such as bus drivers) necessary for specialized functions (such as driving a vehicle).

Group size is the number of children assigned to a caregiver/teacher or team of caregivers/teachers occupying an individual classroom or well-defined space within a larger room (8). The “group” in child care represents the “home room” for school-age children. It is the psychological base with which the school-aged child identifies and from which the child gains continual guidance and support in various activities. This standard does not prohibit larger numbers of school-aged children from joining in occasional collective activities as long as child:staff ratios and the concept of “home room” are maintained.

Unscheduled inspections encourage compliance with this standard.

These standards are based on what children need for quality nurturing care. Those who question whether these ratios are affordable must consider that efforts to limit costs can result in overlooking the basic needs of children and creating a highly stressful work environment for caregivers/teachers. Community resources, in addition to parent/guardian fees and a greater public investment in child care, can make critical contributions to the achievement of the child:staff ratios and group sizes specified in this standard. Each state has its own set of regulations that specify child:staff ratios. To view a particular state’s regulations, go to the National Resource Center for Health and Safety in Child Care and Early Education’s (NRC) Website: http://nrckids.org.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
REFERENCES
  1. Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main
    .zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact
    _Sheet.pdf.
  2. National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
  3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
  4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
  5. National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.
  6. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
  7. Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being of children. Arch Ped Adolescent Med 161:669-76.
  8. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  9. Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it matter and does it need to be improved? Washington, DC: U.S. Department of Health and Human Services. http://aspe.hhs.gov/hsp/ccquality00/.
  10. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  11. Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in the United States. Am Socio Rev 70:729-57.

1.1.1.3: Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities


Facilities enrolling children with special health care needs and disabilities should determine, by an individual assessment of each child’s needs, whether the facility requires a lower child:staff ratio.
RATIONALE
The child:staff ratio must allow the needs of the children enrolled to be met. The facility should have sufficient direct care professional staff to provide the required programs and services. Integrated facilities with fewer resources may be able to serve children who need fewer services, and the staffing levels may vary accordingly. Adjustment of the ratio allows for the flexibility needed to meet each child’s type and degree of special need and encourage each child to participate comfortably in program activities. Adjustment of the ratio produces flexibility without resulting in a need for care that is greater than the staff can provide without compromising the health and safety of other children. The facility should seek consultation with parents/guardians, a child care health consultant (CCHC), and other professionals, regarding the appropriate child:staff ratio. The facility may wish to increase the number of staff members if the child requires significant special assistance (1).
COMMENTS

These ratios do not include personnel who have other duties that might preclude their involvement in needed supervision while they are performing those duties, such as therapists, cooks, maintenance workers, or bus drivers.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
REFERENCES
  1. University of North Carolina at Chapel Hill, FPG Child Development Institute. The national early childhood technical assistance center. http://www.nectac.org

1.1.1.4: Ratios and Supervision During Transportation


Child:staff ratios established for out-of-home child care should be maintained on all transportation the facility provides or arranges. Drivers should not be included in the ratio. No child of any age should be left unattended in or around a vehicle, when children are in a car, or when they are in a car seat. A face-to-name count of children should be conducted prior to leaving for a destination, when the destination is reached, before departing for return to the facility and upon return. Caregivers/teachers should also remember to take into account in this head count if any children were picked up or dropped off while being transported away from the facility.

RATIONALE

Children must receive direct supervision when they are being transported, in loading zones, and when they get in and out of vehicles. Drivers must be able to focus entirely on driving tasks, leaving the supervision of children to other adults. This is especially important with young children who will be sitting in close proximity to one another in the vehicle and may need care during the trip. In any vehicle making multiple stops to pick up or drop off children, this also permits one adult to get one child out and take that child to a home, while the other adult supervises the children remaining in the vehicle, who would otherwise be unattended for that time (1). Children require supervision at all times, even when buckled in seat restraints. A head count is essential to ensure that no child is inadvertently left behind in or out of the vehicle. Child deaths in child care have occurred when children were mistakenly left in vehicles, thinking the vehicle was empty.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.6.0.1 First Aid and Emergency Supplies
REFERENCES
  1. Aird, L. D. 2007. Moving kids safely in child care: A refresher course. Child Care Exchange (January/February): 25-28. http://www.childcareexchange.com/library/5017325.pdf.

1.1.1.5: Ratios and Supervision for Swimming, Wading, and Water Play


The following child:staff ratios should apply while children are swimming, wading, or engaged in water play:

Developmental Levels

Child:Staff Ratio

Infants

1:1

Toddlers

1:1

Preschoolers

4:1

School-age Children

6:1

Constant and active supervision should be maintained when any child is in or around water (4). During any swimming/wading/water play activities where either an infant or a toddler is present, the ratio should always be one adult to one infant/toddler. The required ratio of adults to older children should be met without including the adults who are required for supervision of infants and/or toddlers. An adult should remain in direct physical contact with an infant at all times during swimming or water play (4). Whenever children thirteen months and up to five years of age are in or around water, the supervising adult should be within an arm’s length providing “touch supervision” (6). The attention of an adult who is supervising children of any age should be focused on the child, and the adult should never be engaged in other distracting activities (4), such as talking on the telephone, socializing, or tending to chores.

A lifeguard should not be counted in the child:staff ratio.

RATIONALE
The circumstances surrounding drownings and water-related injuries of young children suggest that staffing requirements and environmental modifications may reduce the risk of this type of injury. Essential elements are close continuous supervision (1,4), four-sided fencing and self-locking gates around all swimming pools, hot tubs, and spas, and special safety covers on pools when they are not in use (2,7). Five-gallon buckets should not be used for water play (4). Water play using small (one quart) plastic pitchers and plastic containers for pouring water and plastic dish pans or bowls allow children to practice pouring skills. Between 2003 and 2005, a study of drowning deaths of children younger than five years of age attributed the highest percentage of drowning reports to an adult losing contact or knowledge of the whereabouts of the child (5). During the time of lost contact, the child managed to gain access to the pool (3).
COMMENTS
Water play includes wading. Touch supervision means keeping swimming children within arm’s reach and in sight at all times. Drowning is a “silent killer” and children may slip into the water silently without any splashing or screaming.

Ratios for supervision of swimming, wading and water play do not include personnel who have other duties that might preclude their involvement in supervision during swimming/wading/water play activities while they are performing those duties. This ratio excludes cooks, maintenance workers, or lifeguards from being counted in the child:staff ratio if they are involved in specialized duties at the same time. Proper ratios during swimming activities with infants are important. Infant swimming programs have led to water intoxication and seizures because infants may swallow excessive water when they are engaged in any submersion activities (1).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.4 Supervision Near Bodies of Water
6.3.1.3 Sensors or Remote Monitors
6.3.1.4 Safety Covers for Swimming Pools
6.3.1.7 Pool Safety Rules
6.3.2.1 Lifesaving Equipment
6.3.2.2 Lifeline in Pool
6.3.5.2 Water in Containers
6.3.5.3 Portable Wading Pools
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). Pool and spa safety: The Virginia Graeme Baker pool and spa safety act. http://www.poolsafely.gov/wp-content/uploads/VGBA.pdf.
  2. Consumer Product Safety Commission. Steps for safety around the pool: The pool and spa safety act. Pool Safely. http://www.poolsafely.gov/wp-content/uploads/360.pdf.
  3. Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.
  4. Gipson, K. 2009. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: CPSC. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.
  5. U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
  6. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.
  7. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.

1.1.2 Minimum Age

1.1.2.1: Minimum Age to Enter Child Care


Reader’s Note: This standard reflects a desirable goal when sufficient resources are available; it is understood that for some families, waiting until three months of age to enter their infant in child care may not be possible.

Healthy full-term infants can be enrolled in child care settings as early as three months of age. Premature infants or those with chronic health conditions should be evaluated by their primary care providers and developmental specialists to make an individual determination concerning the appropriate age for child care enrollment.

RATIONALE
Brain anatomy, chemistry, and physiology undergo rapid development over the first ten to twelve weeks of life (1-6). Concurrently, and as a direct consequence of these shifts in central nervous system structure and function, infants demonstrate significant growth, irregularity, and eventually, organization of their behavior, physiology, and social responsiveness (1-3,5). Arousal responses to stimulation mature before the ability to self-regulate and control such responses in the first six to eight weeks of life causing infants to demonstrate an expanding range and fluctuation of behavioral state changes from quiet to alert to irritable (1-3,6). Infant behavior is most disorganized, most difficult to read and most frustrating to support at the six to eight week period (2,3). At approximately eight to twelve weeks after birth, full term infants typically undergo changes in brain function and behavior that helps caregivers/teachers understand and respond effectively to infants’ increasingly stable sleep-wake states, attention, self-calming efforts, feeding patterns and patterns of social engagement. Over the course of the third month, infants demonstrate an emerging capacity to sustain states of sleep and alert attention.

Infants, birth to three months of age, can become seriously ill very quickly without obvious signs (7). This increased risk to infants, birth to three months makes it important to minimize their exposure to children and adults outside their family, including exposures in child care (8). In addition, infants of mothers who return to work, particularly full-time, before twelve weeks of age, and are placed in group care may be at even greater risk for developing serious infectious diseases. These infants are less likely to receive recommended well-child care and immunizations and to be breastfed or are likely to have a shorter duration of breastfeeding (16,22).

Researchers report that breastfeeding duration was significantly higher in women with longer maternity leaves as compared to those with less than nine to twelve weeks leave (9,22). A leave of less than six weeks was associated with a much higher likelihood of stopping breastfeeding (10,22). Continuing breastfeeding after returning to work may be particularly difficult for lower income women who may have fewer support systems (11).

It takes women who have given birth about six weeks to return to the physical health they had prior to pregnancy (12). A significant portion of women reported child birth related symptoms five weeks after delivery (17). In contrast, women’s general mental health, vitality, and role function were improved with maternity leaves at twelve weeks or longer (13).

Birth of a child or adoption of a newborn, especially the first, requires significant transition in the family. First time parents/guardians are learning a new role and even with subsequent children, integration of the new family member requires several weeks of adaptation. Families need time to adjust physically and emotionally to the intense needs of a newborn (14,15).

COMMENTS
In an analysis of twenty-one wealthy countries including Australia, New Zealand, Canada, United States, Japan, and several European countries, the U.S. ranked twentieth in terms of unpaid and paid parental leave available to two-parent families with the birth of their child (18,21). Although Switzerland ranked twenty-first with fourteen versus twenty-four weeks as compared to the U.S. for both parents/guardians, eleven weeks of leave are paid in Switzerland. In this study of twenty-one countries, only Australia and the U.S. do not provide for paid leave after the birth of a child (18).

Major social policies in the U.S. were established with the Social Security Act in 1935 at a time when the majority of women were not employed (19,20). The Family and Medical Leave Act (FMLA) of 1993, which allows twelve weeks of leave, established for the first time job protected maternity leave for qualifying employees (16,20). Despite the importance of FMLA, only about 60% of the women in the workforce are eligible for job protected maternity leave. FMLA does not provide paid leave, which may force many women to return to work sooner than preferred (18). FMLA is not transferable between parents/guardians. However, five U.S. states support five to six weeks of paid maternity leave and a few companies allow generous paid leaves for select employees (21).

In a nationally representative sample, 84% of women and 74% of men supported expansion of the FMLA; furthermore, 90% of women and 72% of men reported that employers and government should do more to support families (21).

Substantial evidence exists to strengthen social policies, specifically job protected paid leave for all families, for at least the first twelve weeks of life, in order to promote the health and development of children and families (22). Investing in families during an important life transition, the birth or adoption of a child, reflects a society’s values and may in fact contribute to a healthier and more productive work force.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.1.5 Helping Families Cope with Separation
REFERENCES
  1. Staehelin, K., P. C. Bertea, E. Z. Stutz. 2007. Length of maternity leave and health of mother and child–a review. Int J Public Health 52:202-9.
  2. Guendelman, S., J. L. Kosc, M. Pearl, S. Graham, J. Goodman, M. Kharrazi. 2009. Juggling work and breastfeeding: Effects of maternity leave and occupational characteristics. Pediatrics 123: e38-e46.
  3. McGovern P., B. Dowd, D. Gjerdingen, I. Moscovice, L. Kochevar, W. Lohman. 1997. Time off work and the postpartum health of employed women. Medical Care 35:507-21.
  4. Cunningham, F. G., F. F. Gont, K. J. Leveno, L. C. Gilstrap, J. C. Hauth, K. D. Wenstrom. 2005. Williams obstretrics. 21st ed. New York: McGraw Hill.
  5. Kimbro, R. T. 2006. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Maternal Child Health J 10:19-26.
  6. Carter, B., M. McGoldrick, eds. 2005. The expanded family life cycle: Individual, family, and social perspectives. 3rd ed. New York: Allyn and Bacon Classics.
  7. Ishimine, P. 2006. Fever without source in children 0-36 months. Pediatric Clinics North Am 53:167.
  8. Harper, M. 2004. Update on the management of the febrile infant. Clin Pediatric Emerg Med 5:5-12.
  9. Carey, W. B., A. C. Crocker, E. R. Elias, H. M. Feldman, W. L. Coleman. 2009. Developmental-behavioral pediatrics. 4th ed. Philadelphia: W. B. Saunders.
  10. Parmelee, A. H. Jr, W. Weiner, H. Schultz. 1964. Infant sleep patterns: From birth to 16 weeks of age. J Pediatrics 65:576-82.
  11. Brazelton, T. B. 1962. Crying in infancy. Pediatrics 29:579-88.
  12. Huttenlocher, P. R., C. de Courten. 1987. The development of synapses in striate cortex of man. Human Neurobiology 6:1-9.
  13. Anders, T. F. 1992. Sleeping through the night: A developmental perspective. Pediatrics 90:554-60.
  14. Edelstein, S., J. Sharlin, S. Edelstein. 2008. Life cycle nutrition: An evidence-based approach. Boston: Jones and Bartlett.
  15. Robertson, S. S. 1987. Human cyclic motility: Fetal-newborn continuities and newborn state differences. Devel Psychobiology 20:425-42.
  16. Berger, L. M., J. Hill, J. Waldfogel. 2005. Maternity leave, early maternal employment and child health and development in the US. Economic J 115: F29-F47.
  17. McGovern, P., B. Dowd, D. Gjerdingen, C. R. Gross, S. Kenney, L. Ukestad, D. McCaffrey, U. Lundberg. 2006. Postpartum health of employed mothers 5 weeks after childbirth. Annals Fam Med 4:159-67.
  18. Ray, R., J. C. Gornick, J. Schmitt. 2009. Parental leave policies in 21 countries: Assessing generosity and gender equality. Rev. ed. Washington, DC: Center for Economic and Policy Research.
  19. Social Security Act. 1935. 42 USC 7.
  20. Family and Medical Leave Act. 1993. 29 USC 2601.
  21. Lovell, V., E. O’Neill, S. Olsen. 2007. Maternity leave in the United States: Paid parental leave is still not standard, even among the best U.S. employers. Washington, DC: Institute for Women’s Policy Research. http://iwpr.org/pdf/parentalleaveA131.pdf.
  22. Human Rights Watch. 2011. Failing its families: Lack of paid leave and work-family supports in the U.S. http://www.hrw.org/en/reports/2011/02/23/failing-its-families-0/.

1.2 Recruitment and Background Screening

1.2.0

1.2.0.1: Staff Recruitment


Staff recruitment should be based on a policy of non-discrimination with regard to gender, race, ethnicity, disability, or religion, as required by the Equal Employment Opportunity Act (EEOA). Centers should have a plan of action for recruiting and hiring a diverse staff that is representative of the children in the facility’s care and people in the community with whom the child is likely to have contact as a part of life experience. Staff recruitment policies should adhere to requirements of the Americans with Disabilities Act (ADA) as it applies to employment. The job description for each position should be clearly written, and the suitability of an applicant should be measured with regard to the applicant’s qualifications and abilities to perform the tasks required in the role.
RATIONALE
Child care businesses must adhere to federal law. In addition, child care businesses should model diversity and non-discrimination in their employment practices to enhance the quality of the program by supporting diversity and tolerance for individuals on the staff who are competent caregivers/teachers with different background and orientation in their private lives. Children need to see successful role models from their own ethnic and cultural groups and be able to develop the ability to relate to people who are different from themselves (1).

The goal of the ADA in employment is to reasonably accommodate applicants and employees with disabilities, to provide them equal employment opportunity and to integrate them into the program’s staff to the extent feasible, given the individual’s limitations. Under the ADA, employers are expected to make reasonable accommodations for persons with disabilities. Some disabilities may be accommodated, whereas others may not allow the person to do essential tasks. The fairest way to address this evaluation is to define the tasks and measure the abilities of applicants to perform them (2).

COMMENTS
In staff recruiting, the hiring pool should extend beyond the immediate neighborhood of the child’s residence or location of the facility, to reflect the diversity of the people with whom the child can be expected to have contact as a part of life experience.

Reasons to deny employment include the following:

  1. The applicant or employee is not qualified or is unable to perform the essential functions of the job with or without reasonable accommodations;
  2. Accommodation is unreasonable or will result in undue hardship to the program;
  3. The applicant’s or employee’s condition will pose a significant threat to the health or safety of that individual or of other staff members or children.

Accommodations and undue hardship are based on each individual situation.

The U.S. Equal Employment Opportunity Commission (EEOC) does not enforce the protections that prohibit discrimination and harassment based on sexual orientation, status as a parent, marital status, or political affiliation. However, other federal agencies and many states and municipalities do. For assistance in locating your state or local agency’s rules go to http://www.eeoc.gov/field/ (3).

Caregivers/teachers can obtain copies of the EEOA and the ADA from their local public library. Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the country. These centers can be reached by calling 1-800-949-4232 (callers will be routed to the appropriate region), or by visiting http://www.adata
.org/Static/Home.aspx.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Chang, H. 2006. Developing a skilled, ethnically and linguistically diverse early childhood workforce. Adapted from Getting ready for quality: The critical importance of developing and supporting a skilled, ethnically and linguistically diverse early childhood workforce. http://www.buildinitiative.org/files/DiverseWorkforce.pdf.
  2. U.S. Department of Justice, Civil Rights Division, Disability Rights Section. 1997. Commonly asked questions about child care centers and the Americans with Disabilities Act. http://www.ada.gov/childq%26a.htm.
  3. U.S. Equal Employment Opportunity Commission. Discrimination based on sexual orientation, status as a parent, marital status and political affiliation. http://www.eeoc.gov/federal/otherprotections.cfm.

1.2.0.2: Background Screening

Content in the STANDARD was modified on 5/22/2018.


To ensure their safety and physical and mental health, children should be protected from any risk of abuse or neglect. Directors of centers and large family child care homes and caregivers/teachers in small family child care homes should conduct a complete background screening before employing any staff member, including substitutes, cooks, clerical staff, transportation staff, bus drivers, or custodians who will be on the premises or in vehicles when children are present.

The background screening should include (1-4).

  1. Name and address verification
  2. Social Security number verification
  3. Education verification
  4. Employment history
  5. Alias search
  6. Driving history through state Department of Motor Vehicles records
  7. Background screening of
    1. State, tribal, and federal criminal history records, including fingerprint checks
    2. Child abuse and neglect registries
    3. Licensing history with any other state agencies (eg, foster care, mental health, nursing homes)
    4. Sex offender registries
  8. Court records (misdemeanors and felonies)
  9. Reference checks; These should come from a variety of employment or volunteer sources and should not be limited to an applicant’s family and/or friends (5).
  10. In-person interview; Open-ended questions about establishing appropriate and inappropriate boundaries with young children should be asked to all job applicants during the in-person interview; for example, “How would you handle a situation in which a child asked you to keep a secret?” (6). 

Directors should contact their state child care licensing agency for the appropriate background screening documentation required by their state’s licensing regulations. All family members older than 10 years living in large and small family child care homes should also have background screenings. Drug tests/screens may be incorporated into the background screening. Written permission to obtain the background screening (with or without a drug screen) should be obtained from the prospective employee. Consent to the background investigation should be required for employment consideration. Prospective employers should verbally ask applicants about previous convictions and arrests, investigation findings, or court cases with child abuse/neglect or child sexual abuse. Failure of the prospective employee to disclose previous history of child abuse/neglect or child sexual abuse is grounds for immediate dismissal. Persons should not be hired or allowed to work or volunteer in the child care facility if they acknowledge being sexually attracted to children or having physically or sexually abused children, or if they are known to have committed such acts.

 

Background screenings should be repeated periodically, mirroring state laws and/or requirements. If there are concerns about an employee’s performance or behavior, background screenings should be conducted as needed.

RATIONALE

Properly executed reference checks, as well as in-person interviews, help seek out and prevent possible child abuse from occurring in child care centers. The use of open-ended questions and request for verbal references require personal conversations and, in turn, can uncover a lot of warranted information about the applicant.

Performing diligent background screenings also protects the child care facility against future legal challenges (2,3).

COMMENTS

The following resources can help the director screen individual applicants:

  • If fingerprinting is required, it can be secured at local law enforcement offices or the State Bureau of Investigation.
  • Court records are public information and can be obtained from county court offices; some states have statewide online court records.
  • Driving records are available from the state Department of Motor Vehicles.
  • A Social Security number trace is a report, derived from credit bureau records, that will return all current and reported addresses for the last 7 to 10 years on a specific individual based on his or her Social Security number. If there are alternate names (aliases), these are also reported on the Social Security record.
  • State child abuse registries can be accessed at https://www.adoptuskids.org/for-professionals/interstate-adoptions/state-child-abuse-registries. Sex offender registries can be accessed at https://www.nsopw.gov.
  • Companies also offer background check services. The National Association of Professional Background Screeners (https://www.napbs.com) provides a directory of its membership.

For more information on state licensing requirements regarding criminal background screenings, see the current National Association for Regulatory Administration Licensing Study at www.naralicensing.org/resources.

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
REFERENCES
  1. Child Care and Development Block Grant Act, 42 USC §9857

  2. Social Security Act, 42 USC §618

  3. Child Care and Development Fund, 42 USC §9858f(c)(1)(D), 42 USC §9858f(h)(1)

  4. Head Start Early Childhood Learning & Knowledge Center. 1302.90 personnel policies. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii/1302-90-personnel-policies. Accessed January 11, 2018

  5. Alliance of Schools for Cooperative Insurance Programs. Best Practices for Child Abuse Prevention. Cerritos, CA: Alliance of Schools for Cooperative Insurance Programs; 2015. http://ascip.org/wp-content/uploads/2014/05/Child-Abuse-Best-Practices.pdf. Published April 15, 2015. Accessed January 11, 2018

  6. Berkower F. Preventing child sexual abuse in your organization. Denver’s Early Childhood Council Web site. https://denverearlychildhood.org/preventing-child-sexual-abuse-organization. Published April 23, 2016. Accessed January 11, 2018
NOTES

Content in the STANDARD was modified on 5/22/2018.

1.3 Pre-service Qualifications

1.3.1 Director’s Qualifications

1.3.1.1: General Qualifications of Directors


The director of a center enrolling fewer than sixty children should be at least twenty-one-years-old and should have all the following qualifications:

  1. Have a minimum of a Baccalaureate degree with at least nine credit-bearing hours of specialized college-level course work in administration, leadership, or management, and at least twenty-four credit-bearing hours of specialized college-level course work in early childhood education, child development, elementary education, or early childhood special education that addresses child development, learning from birth through kindergarten, health and safety, and collaboration with consultants OR documents meeting an appropriate combination of relevant education and work experiences (6);
  2. A valid certificate of successful completion of pediatric first aid that includes CPR;
  3. Knowledge of health and safety resources and access to education, health, and mental health consultants;
  4. Knowledge of community resources available to children with special health care needs and the ability to use these resources to make referrals or achieve interagency coordination;
  5. Administrative and management skills in facility operations;
  6. Capability in curriculum design and implementation, ensuring that an effective curriculum is in place;
  7. Oral and written communication skills;
  8. Certificate of satisfactory completion of instruction in medication administration;
  9. Demonstrated life experience skills in working with children in more than one setting;
  10. Interpersonal skills;
  11. Clean background screening.

Knowledge about parenting training/counseling and ability to communicate effectively with parents/guardians about developmental-behavioral issues, child progress, and in creating an intervention plan beginning with how the center will address challenges and how it will help if those efforts are not effective.

The director of a center enrolling more than sixty children should have the above and at least three years experience as a teacher of children in the age group(s) enrolled in the center where the individual will act as the director, plus at least six months experience in administration.

RATIONALE
The director of the facility is the team leader of a small business. Both administrative and child development skills are essential for this individual to manage the facility and set appropriate expectations. College-level coursework has been shown to have a measurable, positive effect on quality child care, whereas experience per se has not (1-3,5).

The director of a center plays a pivotal role in ensuring the day-to-day smooth functioning of the facility within the framework of appropriate child development principles and knowledge of family relationships (6).

The well-being of the children, the confidence of the parents/guardians of children in the facility’s care, and the high morale and consistent professional growth of the staff depend largely upon the knowledge, skills, and dependable presence of a director who is able to respond to long-range and immediate needs and able to engage staff in decision-making that affects their day-to-day practice (5,6). Management skills are important and should be viewed primarily as a means of support for the key role of educational leadership that a director provides (6). A skilled director should know how to use early care and education consultants, such as health, education, mental health, and community resources and to identify specialized personnel to enrich the staff’s understanding of health, development, behavior, and curriculum content. Past experience working in an early childhood setting is essential to running a facility.

Life experience may include experience rearing one’s own children or previous personal experience acquired in any child care setting. Work as a hospital aide or at a camp for children with special health care needs would qualify, as would experience in school settings. This experience, however, must be supplemented by competency-based training to determine and provide whatever new skills are needed to care for children in child care settings.

COMMENTS
The profession of early childhood education is being informed by research on the association of developmental outcomes with specific practices. The exact combination of college coursework and supervised experience is still being developed. For example, the National Association for the Education of Young Children (NAEYC) has published the Standards for Early Childhood Professional Preparation Programs (4). The National Child Care Association (NCCA) has developed a curriculum based on administrator competencies; more information on the NCCA is available at http://www.nccanet.org.
TYPE OF FACILITY
Center
RELATED STANDARDS
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
REFERENCES
  1. Roupp, R., J. Travers, F. M., Glantz, C. Coelen. 1979. Children at the center: Summary findings and their implications. Vol. 1 of Final report of the National day care study. Cambridge, MA: Abt Associates.
  2. Howes, C. 1997. Children’s experiences in center-based child care as a function of teacher background and adult:child ratio. Merrill-Palmer Q 43:404-24.
  3. Helburn, S., ed. 1995. Cost, quality and child outcomes in child care centers. Denver, CO: University of Colorado at Denver.
  4. National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
    .org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
  5.  Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  6. National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.

1.3.1.2: Mixed Director/Teacher Role


Centers enrolling thirty or more children should employ a non-teaching director. Centers with fewer than thirty children may employ a director who teaches as well.
RATIONALE
The duties of a director of a facility with more than thirty children do not allow the director to be involved in the classroom in a meaningful way.
COMMENTS
This standard does not prohibit the director from occasional substitute teaching, as long as the substitute teaching is not a regular and significant duty. Occasional substitute teaching may keep the director in touch with the caregivers’/teachers’ issues.
TYPE OF FACILITY
Center

1.3.2 Caregiver’s/Teacher’s and Other Staff Qualifications

1.3.2.1: Differentiated Roles


Centers should employ a caregiving/teaching staff for direct work with children in a progression of roles, as listed in descending order of responsibility:

  1. Program administrator or training/curriculum specialists;
  2. Lead teachers;
  3. Teachers;
  4. Assistant teachers or teacher aides.

Each role with increased responsibility should require increased educational qualifications and experience, as well as increased salary.

RATIONALE
A progression of roles enables centers to offer career ladders rather than dead-end jobs. It promotes a mix of college-trained staff with other members of a child’s own community who might have entered at the aide level and moved into higher roles through college or on-the-job training.

Professional education and pre-professional in-service training programs provide an opportunity for career progression and can lead to job and pay upgrades and fewer turnovers. Turnover rates in child care positions in 1997 averaged 30% (3).

COMMENTS
Early childhood professional knowledge must be required whether programs are in private centers, public schools, or other settings. The National Association for the Education of Young Children’s (NAEYC) Academy of Early Childhood Programs recommends a multi-level training program that addresses pre-employment educational requirements and continuing education requirements for entry-level assistants, caregivers/teachers, and administrators. It also establishes a table of qualifications for accredited programs (1). The NAEYC requirements include development of an employee compensation plan to increase salaries and benefits to ensure recruitment and retention of qualified staff and continuity of relationships (2). The NAEYC’s recommendations should be consulted in conjunction with the standards in this document.
TYPE OF FACILITY
Center
REFERENCES
  1. National Association for the Education of Young Children (NAEYC). 2005. Accreditation and criteria procedures of the National Academy of Early Childhood Programs. Washington, DC: NAEYC.
  2. National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
    .org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
  3. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.

1.3.2.2: Qualifications of Lead Teachers and Teachers


Lead teachers and teachers should be at least twenty-one years of age and should have at least the following education, experience, and skills:

  1. A Bachelor’s degree in early childhood education, school-age care, child development, social work, nursing, or other child-related field, or an associate’s degree in early childhood education and currently working towards a bachelor’s degree;
  2. A minimum of one year on-the-job training in providing a nurturing indoor and outdoor environment and meeting the child’s out-of-home needs;
  3. One or more years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children in care;
  4. A valid certificate in pediatric first aid, including CPR;
  5. Thorough knowledge of normal child development and early childhood education, as well as knowledge of indicators that a child is not developing typically;
  6. The ability to respond appropriately to children’s needs;
  7. The ability to recognize signs of illness and safety/injury hazards and respond with prevention interventions;
  8. Oral and written communication skills;
  9. Medication administration training (8).

Every center, regardless of setting, should have at least one licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care facility at all times when children are in care.

Additionally, facilities serving children with special health care needs associated with developmental delay should employ an individual who has had a minimum of eight hours of training in inclusion of children with special health care needs.

RATIONALE
Child care that promotes healthy development is based on the developmental needs of infants, toddlers, and preschool children. Caregivers/teachers are chosen for their knowledge of, and ability to respond appropriately to, the needs of children of this age generally, and the unique characteristics of individual children (1-4). Both early childhood and special educational experience are useful in a center. Caregivers/teachers that have received formal education from an accredited college or university have shown to have better quality of care and outcomes of programs. Those teachers with a four-year college degree exhibit optimal teacher behavior and positive effects on children (6).

Caregivers/teachers are more likely to administer medications than to perform CPR. Seven thousand children per year require emergency department visits for problems related to cough and cold medication (7).

COMMENTS
The profession of early childhood education is being informed by the research on early childhood brain development, child development practices related to child outcomes (5). For additional information on qualifications for child care staff, refer to the Standards for Early Childhood Professional Preparation Programs from the National Association for the Education of Young Children (NAEYC) (4). Additional information on the early childhood education profession is available from the Center for the Child Care Workforce (CCW).
TYPE OF FACILITY
Center
RELATED STANDARDS
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
REFERENCES
  1. National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1996. Characteristics of infant child care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306.
  2. Bredekamp, S., C. Copple, eds. 1997. Developmentally appropriate practice in early childhood programs. Rev ed. Washington, DC: National Association for the Education of Young Children.
  3. U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.
  4. National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
    .org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
  5. Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: National Academy Press.
  6. Kagan, S. L., K. Tarrent, K. Kauerz. 2008. The early care and education teaching workforce at the fulcrum, 44-47, 90-91. New York: Teachers College Press.
  7. U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough and cold medication: Unsupervised ingestion accounts for 66 percent of incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/r080128.htm.
  8. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.

1.3.2.3: Qualifications for Assistant Teachers, Teacher Aides, and Volunteers


Assistant teachers and teacher aides should be at least eighteen years of age, have a high school diploma or GED, and participate in on-the-job training, including a structured orientation to the developmental needs of young children and access to consultation, with periodic review, by a supervisory staff member. At least 50% of all assistant teachers and teacher aides must have or be working on either a Child Development Associate (CDA) credential or equivalent, or an associate’s or higher degree in early childhood education/child development or equivalent (9).

Volunteers should be at least sixteen years of age and should participate in on-the-job training, including a structured orientation to the developmental needs of young children. Assistant teachers, teacher aides, and volunteers should work only under the continual supervision of lead teacher or teacher. Assistant teachers, teacher aides, and volunteers should never be left alone with children. Volunteers should not be counted in the child:staff ratio.

All assistant teachers, teacher aides, and volunteers should possess:

  1. The ability to carry out assigned tasks competently under the supervision of another staff member;
  2. An understanding of and the ability to respond appropriately to children’s needs;
  3. Sound judgment;
  4. Emotional maturity; and
  5. Clearly discernible affection for and commitment to the well-being of children.
RATIONALE
While volunteers and students can be as young as sixteen, age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one allows for the maturity necessary to meet the responsibilities of managing a center or independently caring for a group of children who are not one’s own.

Child care that promotes healthy development is based on the developmental needs of infants, toddlers, preschool, and school-age children. Caregivers/teachers should be chosen for their knowledge of, and ability to respond appropriately to, the general needs of children of this age and the unique characteristics of individual children (1,3-5).

Staff training in child development and/or early childhood education is related to positive outcomes for children. This training enables the staff to provide children with a variety of learning and social experiences appropriate to the age of the child. Everyone providing service to, or interacting with, children in a center contributes to the child’s total experience (8).

Adequate compensation for skilled workers will not be given priority until the skills required are recognized and valued. Teaching and caregiving requires skills to promote development and learning by children whose needs and abilities change at a rapid rate.

COMMENTS
Experience and qualifications used by the Child Development Associate (CDA) program and the National Child Care Association (NCCA) credentialing program, and included in degree programs with field placement are valued (10). Early childhood professional knowledge must be required whether programs are in private homes, centers, public schools, or other settings. Go to http://www
.cdacouncil.org/the-cda-credential/how-to-earn-a-cda/ to view appropriate training and qualification information on the CDA Credential.

The National Association for the Education of Young Children’s (NAEYC) National Academy for Early Childhood Program Accreditation, the National Early Childhood Program Accreditation (NECPA) and the National Association of Family Child Care (NAFCC) have established criteria for staff qualifications (2,6,7).

Caregivers/teachers who lack educational qualifications may be employed as continuously supervised personnel while they acquire the necessary educational qualifications if they have personal characteristics, experience, and skills in working with parents, guardians and children, and the potential for development on the job or in a training program.

States may have different age requirements for volunteers.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.5.1.2 Qualifications for Drivers
REFERENCES
  1. National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1996. Characteristics of infant child care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306.
  2. National Association for the Education of Young Children (NAEYC). 2005. Accreditation and criteria procedures of the National Academy of Early Childhood Programs. Washington, DC: NAEYC.
  3. National Association for the Education of Young Children (NAEYC). 2009. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
  4. U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.
  5. National Association for the Education of Young Children (NAEYC). 2009. Standards for Early Childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
    .org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
  6. National Child Care Association (NCCA). NCCA official Website. http://www.nccanet.org.
  7. National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net.
  8. Da Ros-Voseles, D., S. Fowler-Haughey. 2007. Why children’s dispositions should matter to all teachers. Young Children (September): 1-7. http://www.naeyc.org/files/yc/file/200709/
    DaRos-Voseles.pdf.
  9. National Association for the Education of Young Children (NAEYC). Candidacy requirements. http://www.naeyc.org/academy/pursuing/candreq/.
  10. Council for Professional Recognition. 2011. How to obtain a CDA. http://www.cdacouncil.org/the-cda-credential/
    how-to-earn-a-cda/.

1.3.2.4: Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age


Caregivers/teachers should be prepared to work with infants and toddlers and, when asked, should be knowledgeable and demonstrate competency in tasks associated with caring for infants and toddlers:

  1. Diapering and toileting;
  2. Bathing;
  3. Feeding, including support for continuation of breastfeeding;
  4. Holding;
  5. Comforting;
  6. Practicing safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) (3);
  7. Providing warm, consistent, responsive caregiving and opportunities for child-initiated activities;
  8. Stimulating communication and language development and pre-literacy skills through play, shared reading, song, rhyme, and lots of talking;
  9. Promoting cognitive, physical, and social emotional development;
  10. Preventing shaken baby syndrome/abusive head trauma;
  11. Promoting infant mental health;
  12. Promoting positive behaviors;
  13. Setting age-appropriate limits with respect to safety, health, and mutual respect;
  14. Using routines to teach children what to expect from caregivers/teachers and what caregivers/teachers expect from them.

Caregivers/teachers should demonstrate knowledge of development of infants and toddlers as well as knowledge of indicators that a child is not developing typically; knowledge of the importance of attachment for infants and toddlers, the importance of communication and language development, and the importance of nurturing consistent relationships on fostering positive self-efficacy development.

To help manage atypical or undesirable behaviors of children, caregivers/teachers, in collaboration with parents/guardians, should seek professional consultation from the child’s primary care provider, an early childhood mental health professional, or an early childhood mental health consultant.

RATIONALE
The brain development of infants is particularly sensitive to the quality and consistency of interpersonal relationships. Much of the stimulation for brain development comes from the responsive interactions of caregivers/teachers and children during daily routines. Children need to be allowed to pursue their interests within safe limits and to be encouraged to reach for new skills (1-7).
COMMENTS
Since early childhood mental health professionals are not always available to help with the management of challenging behaviors in the early care and education setting early childhood mental health consultants may be able to help. The consultant should be viewed as an important part of the program’s support staff and should collaborate with all regular classroom staff, consultants, and other staff. Qualified potential consultants may be identified by contacting mental health and behavioral providers in the local area, as well as accessing the National Mental Health Information Center (NMHIC) at http://store.samhsa.gov/
mhlocator/ and Healthy Child Care America (HCCA) at http://www.healthychildcare.org/Contacts.html.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.3.1.2 Mixed Director/Teacher Role
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
1.6.0.3 Early Childhood Mental Health Consultants
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
REFERENCES
  1. Shore, R. 1997. Rethinking the brain: New insights into early development. New York: Families and Work Inst.
  2. National Forum on Early Childhood Policy and Programs, National Scientific Council on the Developing Child. 2007. A science-based framework for early childhood policy: Using evidence to improve outcomes in learning, behavior, and health for vulnerable children. http://developingchild.harvard.edu/index.php/library/reports_and_working_papers/policy_framework/.
  3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.
  4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  5. Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.
  6. Shonkoff, J. P., D. A. Phillips, eds. 2000. From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.
  7. Cohen, J., N. Onunaku, S. Clothier, J. Poppe. 2005. Helping young children succeed: Strategies to promote early childhood social and emotional development. Washington, DC: National Conference of State Legislatures; Zero to Three. http://main.zerotothree.org/site/DocServer/help_yng_child_succeed.pdf.

1.3.2.5: Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age


Caregivers/teachers should demonstrate the ability to apply their knowledge and understanding of the following to children three to five years of age within the program setting:

  1. Typical and atypical development of three- to five-year-old children;
  2. Social and emotional development of children, including children’s development of independence, their ability to adapt to their environment and cope with stress, problem solve and engage in conflict resolution, and successfully establish friendships;
  3. Cognitive, language, early literacy, scientific inquiry, and mathematics development of children;
  4. Cultural backgrounds of the children in the facility’s care;
  5. Talking to parents/guardians about observations and concerns and referrals to parents/guardians;
  6. Changing needs of populations served, e.g., culture, income, etc.

To help manage atypical or undesirable behaviors of children three to five years of age, caregivers/teachers serving this age group should seek professional consultation, in collaboration with parents/guardians, from the child’s primary care provider, a mental health professional, a child care health consultant, or an early childhood mental health consultant.

RATIONALE
Three- and four-year-old children continue to depend on the affection, physical care, intellectual guidance, and emotional support of their caregivers/teachers (1,2).

A supportive, nurturing setting that supports a demonstration of feelings and accepts regression as part of development continues to be vital for preschool children. Preschool children need help building a positive self-image, a sense of self as a person of value from a family and a culture of which they are proud. Children should be enabled to view themselves as coping, problem-solving, competent, passionate, expressive, and socially connected to peers and staff (3).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
REFERENCES
  1. National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1999. Child outcomes when child center classes meet recommended standards for quality. Am J Public Health 89:1072-77.
  2. Shore, R. 1997. Rethinking the brain: New insights into early development. New York: Families and Work Inst.
  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

1.3.2.6: Additional Qualifications for Caregivers/Teachers Serving School-Age Children


Caregivers/teachers should demonstrate knowledge about and competence with the social and emotional needs and developmental tasks of five- to twelve-year old children, be able to recognize and appropriately manage difficult behaviors, and know how to implement a socially and cognitively enriching program that has been developed with input from parents/guardians. Issues that are significant within school-age programs include having a sense of community, bullying, sexuality, electronic media, and social networking.

With this age group as well, caregivers/teachers, in collaboration with parents/guardians, should seek professional consultation from the child’s primary care provider, a mental health professional, a child care health consultant, or an early childhood mental health consultant to help manage atypical or undesirable behaviors.

RATIONALE
A school-age child develops a strong, secure sense of identity through positive experiences with adults and peers (1,2). An informal, enriching environment that encourages self-paced cultivation of interests and relationships promotes the self-worth of school-age children (1). Balancing free exploration with organized activities including homework assistance and tutoring among a group of children also supports healthy emotional and social development (1,3).

When children display behaviors that are unusual or difficult to manage, caregivers/teachers should work with parents/guardians to seek a remedy that allows the child to succeed in the child care setting, if possible (4).

COMMENTS
The first resource for addressing behavior problems is the child’s primary care provider. School personnel, including professional serving school-based health clinics may also be able to provide valuable insights. Support from a mental health professional may be needed. If the child’s primary care provider cannot help or obtain help from a mental health professional, the caregiver/teacher and the family may need an early childhood mental health consultant to advise about appropriate management of the child. Local mental health agencies or pediatric departments of medical schools may offer help from child psychiatrists, psychologists, other mental health professionals skilled in the issues of early childhood, and pediatricians who have a subspecialty in developmental and behavioral pediatrics. Local or area education agencies serving children with special health or developmental needs may be useful. State Title V (Children with Special Health Care Needs) may be contacted. All state Maternal Child Health (MCH) programs are required to have a toll-free number to link consumers to appropriate programs for children with special health care needs. The toll-free number listing is located at https://perfdata.hrsa
.gov/MCHB/MCHReports/search/program/prgsch16.asp. Dismissal from the program should be the last resort and only after consultation with the parent/guardian(s).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
REFERENCES
  1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  2. Deschenes, S. N., A. Arbreton, P. M. Little, C. Herrera, J. B. Grossman, H. B. Weiss, D. Lee. 2010. Engaging older youth: Program and city-level strategies to support sustained participation in out-of-school time. http://www.hfrp.org/out-of-school-time/publications-resources/engaging-older-youth-program-and-city
    -level-strategies-to-support-sustained-participation-in-out-of
    -school-time/.
  3. New York State Department of Social Services, Cornell Cooperative Extension. 2004. A parent’s guide to child care for school-age children. National Network for Child Care. http://www
    .nncc.org/choose.quality.care/parents.sac.html#anchor68421/
    . references
  4. Harvard Family Research Project. 2010. Family engagement as a systemic, sustained, and integrated strategy to promote student achievement. http://www.hfrp.org/publications-resources/browse
    -our-publications/family-engagement-as-a-systemic-sustained
    -and-integrated-strategy-to-promote-student-achievement/.

1.3.2.7: Qualifications and Responsibilities for Health Advocates


Each facility should designate at least one administrator or staff person as the health advocate to be responsible for policies and day-to-day issues related to health, development, and safety of individual children, children as a group, staff, and parents/guardians. In large centers it may be important to designate health advocates at both the center and classroom level. The health advocate should be the primary contact for parents/guardians when they have health concerns, including health-related parent/guardian/staff observations, health-related information, and the provision of resources. The health advocate ensures that health and safety is addressed, even when this person does not directly perform all necessary health and safety tasks.

The health advocate should also identify children who have no regular source of health care, health insurance, or positive screening tests with no referral documented in the child’s health record. The health advocate should assist the child’s parent/guardian in locating a Medical Home by referring them to a primary care provider who offers routine child health services.

For centers, the health advocate should be licensed/certified/credentialed as a director or lead teacher or should be a health professional, health educator, or social worker who works at the facility on a regular basis (at least weekly).

The health advocate should have documented training in the following:

  1. Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, and reporting requirements;
  2. Childhood immunization requirements, record-keeping, and at least quarterly review and follow-up for children who need to have updated immunizations;
  3. Child health assessment form review and follow-up of children who need further medical assessment or updating of their information;
  4. How to plan for, recognize, and handle an emergency;
  5. Poison awareness and poison safety;
  6. Recognition of safety, hazards, and injury prevention interventions;
  7. Safe sleep practices and the reduction of the risk of Sudden Infant Death Syndrome (SIDS);
  8. How to help parents/guardians, caregivers/teachers, and children cope with death, severe injury, and natural or man-made catastrophes;
  9. Recognition of child abuse, neglect/child maltreatment, shaken baby syndrome/abusive head trauma (for facilities caring for infants), and knowledge of when to report and to whom suspected abuse/neglect;
  10. Facilitate collaboration with families, primary care providers, and other health service providers to create a health, developmental, or behavioral care plan;
  11. Implementing care plans;
  12. Recognition and handling of acute health related situations such as seizures, respiratory distress, allergic reactions, as well as other conditions as dictated by the special health care needs of children;
  13. Medication administration;
  14. Recognizing and understanding the needs of children with serious behavior and mental health problems;
  15. Maintaining confidentiality;
  16. Healthy nutritional choices;
  17. The promotion of developmentally appropriate types and amounts of physical activity;
  18. How to work collaboratively with parents/guardians and family members;
  19. How to effectively seek, consult, utilize, and collaborate with child care health consultants, and in partnership with a child care health consultant, how to obtain information and support from other education, mental health, nutrition, physical activity, oral health, and social service consultants and resources;
  20. Knowledge of community resources to refer children and families who need health services including access to State Children’s Health Insurance (SCHIP), importance of a primary care provider and medical home, and provision of immunizations and Early Periodic Screening, Diagnosis, and Treatment (EPSDT).
RATIONALE
The effectiveness of an intentionally designated health advocate in improving the quality of performance in a facility has been demonstrated in all types of early childhood settings (1). A designated caregiver/teacher with health training is effective in developing an ongoing relationship with the parents/guardians and a personal interest in the child (2,3). Caregivers/teachers who are better trained are more able to prevent, recognize, and correct health and safety problems. An internal advocate for issues related to health and safety can help integrate these concerns with other factors involved in formulating facility plans.

Children may be current with required immunizations when they enroll, but they sometimes miss scheduled immunizations thereafter. Because the risk of vaccine-preventable disease increases in group settings, assuring appropriate immunizations is an essential responsibility in child care. Caregivers/teachers should contact their child care health consultant or the health department if they have a question regarding immunization updates/schedules. They can also provide information to share with parents/guardians about the importance of vaccines.

Child health records are intended to provide information that indicates that the child has received preventive health services to stay well, and to identify conditions that might interfere with learning or require special care. Review of the information on these records should be performed by someone who can use the information to plan for the care of the child, and recognize when updating of the information by the child’s primary care provider is needed. Children must be healthy to be ready to learn. Those who need accommodation for health problems or are susceptible to vaccine-preventable diseases will suffer if the staff of the child care program is unable to use information provided in child health records to ensure that the child’s needs are met (5,6).

COMMENTS
The director should assign the health advocate role to a staff member who seems to have an interest, aptitude, and training in this area. This person need not perform all the health and safety tasks in the facility but should serve as the person who raises health and safety concerns. This staff person has designated responsibility for seeing that plans are implemented to ensure a safe and healthful facility (1).

A health advocate is a regular member of the staff of a center or large or small family child care home, and is not the same as the child care health consultant recommended in Child Care Health Consultants, Standard 1.6.0.1. The health advocate works with a child care health consultant on health and safety issues that arise in daily interactions (4). For small family child care homes, the health advocate will usually be the caregiver/teacher. If the health advocate is not the child’s caregiver/teacher, the health advocate should work with the child’s caregiver/teacher. The person who is most familiar with the child and the child’s family will recognize atypical behavior in the child and support effective communication with parents/guardians.

A plan for personal contact with parents/guardians should be developed, even though this contact will not be possible daily. A plan for personal contact and documentation of a designated caregiver/teacher as health advocate will ensure specific attempts to have the health advocate communicate directly with caregivers/teachers and families on health-related matters.

The immunization record/compliance review may be accomplished by manual review of child health records or by use of software programs that use algorithms with the currently recommended vaccine schedules and service intervals to test the dates when a child received recommended services and the child’s date of birth to identify any gaps for which referrals should be made. On the Website of the Centers for Disease Control and Prevention (CDC), individual vaccine recommendations for children six years of age and younger can be checked at http://www.cdc.gov/vaccines/recs/scheduler/catchup.htm.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
1.6.0.1 Child Care Health Consultants
3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
8.7.0.3 Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs
REFERENCES
  1. Ulione, M. S. 1997. Health promotion and injury prevention in a child development center. J Pediatr Nurs 12:148-54.
  2. Kendrick, A. S., R. Kaufmann, K. P. Messenger, eds. 1991. Healthy young children: A manual for programs. Washington, DC: National Association for the Education of Young Children.
  3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.
  5. Centers for Disease Control and Prevention (CDC). 2011. Immunization schedules. http://www.cdc.gov/vaccines/recs/schedules/.
  6. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

1.3.3 Family Child Care Home Caregiver/Teacher Qualifications

1.3.3.1: General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home


All caregivers/teachers in large and small family child care homes should be at least twenty-one years of age, hold an official credential as granted by the authorized state agency, meet the general requirements specified in Standard 1.3.2.4 through Standard 1.3.2.6, based on ages of the children served, and those in Section 1.3.3, and should have the following education, experience, and skills:

  1. Current accreditation by the National Association for Family Child Care (NAFCC) (including entry-level qualifications and participation in required training) and a college certificate representing a minimum of three credit hours of early childhood education leadership or master caregiver/teacher training or hold an Associate’s degree in early childhood education or child development;
  2. A provider who has been in the field less than twelve months should be in the self-study phase of NAFCC accreditation;
  3. A valid certificate in pediatric first aid, including CPR;
  4. Pre-service training in health management in child care, including the ability to recognize signs of illness, knowledge of infectious disease prevention and safety injury hazards;
  5. If caring for infants, knowledge on safe sleep practices including reducing the risk of sudden infant death syndrome (SIDS) and prevention of shaken baby syndrome/abusive head trauma (including how to cope with a crying infant);
  6. Knowledge of normal child development, as well as knowledge of indicators that a child is not developing typically;
  7. The ability to respond appropriately to children’s needs;
  8. Good oral and written communication skills;
  9. Willingness to receive ongoing mentoring from other teachers;
  10. Pre-service training in business practices;
  11. Knowledge of the importance of nurturing adult-child relationships on self-efficacy development;
  12. Medication administration training (6).

Additionally, large family child care home caregivers/teachers should have at least one year of experience serving the ages and developmental abilities of the children in their large family child care home.

Assistants, aides, and volunteers employed by a large family child care home should meet the qualifications specified in Standard 1.3.2.3.

RATIONALE
In both large and small family child care homes, staff members must have the education and experience to meet the needs of the children in care (7). Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of small numbers of children in their care.

Most SIDS deaths in child care occur on the first day of care or within the first week; unaccustomed prone (tummy) sleeping increases the risk of SIDS eighteen times (3). Shaken baby syndrome/abusive head trauma is completely preventable. Pre-service training and frequent refresher training can prevent deaths (4).

Caregivers/teachers are more likely to administer medications than to perform CPR. Seven thousand children per year require emergency department visits for problems related to cough and cold medications (5).

Age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one is more likely to be associated with the level of maturity necessary to independently care for a group of children who are not one’s own.

The NAFCC has established an accreditation process to enhance the level of quality and professionalism in small and large family child care (2).

COMMENTS
A large family child care home caregiver/teacher, caring for more than six children and employing one or more assistants, functions as the primary caregiver as well as the facility director. An operator of a large family-child-care home should be offered training relevant to the management of a small child care center, including training on providing a quality work environment for employees.

For more information on assessing the work environment of family child care employees, see Creating Better Family Child Care Jobs: Model Work Standards, a publication by the Center for the Child Care Workforce (CCW) (1).

TYPE OF FACILITY
Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.6 Additional Qualifications for Caregivers/Teachers Serving School-Age Children
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
REFERENCES
  1. Center for Child Care Workforce. 1999. Creating better family child care jobs: Model work standards. Washington, DC: Center for Child Care Workforce.
  2. National Association for Family Child Care. NAFCC official Website. http://nafcc.net.
  3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.
  4. Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.
  5. U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough and cold medication: Unsupervised ingestion accounts for 66 percent of incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/r080128.htm.
  6. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
  7. National Association for Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC.

1.3.3.2: Support Networks for Family Child Care


Large and small family child care home caregivers/teachers should have active membership in a national, and/or state and local early care and education organization(s). National organizations addressing concerns of family child care home caregivers/teachers include the American Academy of Pediatrics (AAP), the National Association for Family Child Care (NAFCC), and the National Association for the Education of Young Children (NAEYC). In addition, belonging to a local network of family child care home caregivers/teachers that offers education, training and networking opportunities provides the opportunity to focus on local needs. Child care resource and referral agencies may provide additional support networks for caregivers/teachers that include professional development opportunities and information about electronic networking.
RATIONALE
Membership in peer professional organizations shows a commitment to quality child care and also provides a conduit for information to otherwise isolated caregivers/teachers. Membership in a family child care association and attendance at meetings indicate the desire to gain new knowledge about how to work with children (1).
COMMENTS
For more information about family child care associations, contact the NAFCC at http://nafcc.net and/or the NAEYC at http://www.naeyc.org. Also, caregivers/teachers should check to see if their state has specific accreditation standards.
TYPE OF FACILITY
Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.3.1.2 Mixed Director/Teacher Role
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
10.6.2.1 Development of Child Care Provider Organizations and Networks
REFERENCES
  1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

1.4 Professional Development/Training

1.4.1 Pre-service Training

1.4.1.1: Pre-service Training


In addition to the credentials listed in Standard 1.3.1.1, upon employment, a director or administrator of a center or the lead caregiver/teacher in a family child care home should provide documentation of at least thirty clock-hours of pre-service training. This training should cover health, psychosocial, and safety issues for out-of-home child care facilities. Small family child care home caregivers/teachers may have up to ninety days to secure training after opening except for training on basic health and safety procedures and regulatory requirements.

All directors or program administrators and caregivers/teachers should document receipt of pre-service training prior to working with children that includes the following content on basic program operations:

  1. Typical and atypical child development and appropriate best practice for a range of developmental and mental health needs including knowledge about the developmental stages for the ages of children enrolled in the facility;
  2. Positive ways to support language, cognitive, social, and emotional development including appropriate guidance and discipline;
  3. Developing and maintaining relationships with families of children enrolled, including the resources to obtain supportive services for children’s unique developmental needs;
  4. Procedures for preventing the spread of infectious disease, including hand hygiene, cough and sneeze etiquette, cleaning and disinfection of toys and equipment, diaper changing, food handling, health department notification of reportable diseases, and health issues related to having animals in the facility;
  5. Teaching child care staff and children about infection control and injury prevention through role modeling;
  6. Safe sleep practices including reducing the risk of Sudden Infant Death Syndrome (SIDS) (infant sleep position and crib safety);
  7. Shaken baby syndrome/abusive head trauma prevention and identification, including how to cope with a crying/fussy infant;
  8. Poison prevention and poison safety;
  9. Immunization requirements for children and staff;
  10. Common childhood illnesses and their management, including child care exclusion policies and recognizing signs and symptoms of serious illness;
  11. Reduction of injury and illness through environmental design and maintenance;
  12. Knowledge of U.S. Consumer Product Safety Commission (CPSC) product recall reports;
  13. Staff occupational health and safety practices, such as proper procedures, in accordance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations;
  14. Emergency procedures and preparedness for disasters, emergencies, other threatening situations (including weather-related, natural disasters), and injury to infants and children in care;
  15. Promotion of health and safety in the child care setting, including staff health and pregnant workers;
  16. First aid including CPR for infants and children;
  17. Recognition and reporting of child abuse and neglect in compliance with state laws and knowledge of protective factors to prevent child maltreatment;
  18. Nutrition and age-appropriate child-feeding including food preparation, choking prevention, menu planning, and breastfeeding supportive practices;
  19. Physical activity, including age-appropriate activities and limiting sedentary behaviors;
  20. Prevention of childhood obesity and related chronic diseases;
  21. Knowledge of environmental health issues for both children and staff;
  22. Knowledge of medication administration policies and practices;
  23. Caring for children with special health care needs, mental health needs, and developmental disabilities in compliance with the Americans with Disabilities Act (ADA);
  24. Strategies for implementing care plans for children with special health care needs and inclusion of all children in activities;
  25. Positive approaches to support diversity;
  26. Positive ways to promote physical and intellectual development.
RATIONALE
The director or program administrator of a center or large family child care home or the small family child care home caregiver/teacher is the person accountable for all policies. Basic entry-level knowledge of health and safety and social and emotional needs is essential to administer the facility. Caregivers/teachers should be knowledgeable about infectious disease and immunizations because properly implemented health policies can reduce the spread of disease, not only among the children but also among staff members, family members, and in the greater community (1). Knowledge of injury prevention measures in child care is essential to control known risks. Pediatric first aid training that includes CPR is important because the director or small family child care home caregiver/teacher is fully responsible for all aspects of the health of the children in care. Medication administration and knowledge about caring for children with special health care needs is essential to maintaining the health and safety of children with special health care needs. Most SIDS deaths in child care occur on the first day of child care or within the first week due to unaccustomed prone (on the stomach) sleeping; the risk of SIDS increases eighteen times when an infant who sleeps supine (on the back) at home is placed in the prone position in child care (2). Shaken baby syndrome/abusive head trauma is completely preventable. It is crucial for caregivers/teachers to be knowledgeable of both syndromes and how to prevent them before they care for infants. Early childhood expertise is necessary to guide the curriculum and opportunities for children in programs (3). The minimum of a Child Development Associate credential with a system of required contact hours, specific content areas, and a set renewal cycle in addition to an assessment requirement would add significantly to the level of care and education for children.

The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training based on the needs of the program and the pre-service qualifications of staff (4). Training should address the following areas:

  1. Health and safety (specifically reducing the risk of SIDS, infant safe sleep practices, shaken baby syndrome/abusive head trauma), and poison prevention and poison safety;
  2. Child growth and development, including motor development and appropriate physical activity;
  3. Nutrition and feeding of children;
  4. Planning learning activities for all children;
  5. Guidance and discipline techniques;
  6. Linkages with community services;
  7. Communication and relations with families;
  8. Detection and reporting of child abuse and neglect;
  9. Advocacy for early childhood programs;
  10. Professional issues (5).

In the early childhood field there is often “crossover” regarding professional preparation (pre-service programs) and ongoing professional development (in-service programs). This field is one in which entry-level requirements differ across various sectors within the field (e.g., nursing, family support, and bookkeeping are also fields with varying entry-level requirements). In early childhood, the requirements differ across center, home, and school based settings. An individual could receive professional preparation (pre-service) to be a teaching staff member in a community-based organization and receive subsequent education and training as part of an ongoing professional development system (in-service). The same individual could also be pursuing a degree for a role as a teacher in a program for which licensure is required—this in-service program would be considered pre-service education for the certified teaching position. Therefore, the labels pre-service and in-service must be seen as related to a position in the field, and not based on the individual’s professional development program (5).

COMMENTS
Training in infectious disease control and injury prevention may be obtained from a child care health consultant, pediatricians, or other qualified personnel of children’s and community hospitals, managed care companies, health agencies, public health departments, EMS and fire professionals, pediatric emergency room physicians, or other health and safety professionals in the community.

For more information about training opportunities, contact the local Child Care Resource and Referral Agency (CCRRA), the local chapter of the American Academy of Pediatrics (AAP) (AAP provides online SIDS and medication administration training), the Healthy Child Care America Project, or the National Resource Center for Health and Safety in Child Care and Early Education (NRC). California Childcare Health Program (CCHP) has free curricula for health and safety for caregivers/teachers to become child care health advocates. The curriculum (English and Spanish) is free to download on the Web at http://www.ucsfchildcare
health.org/html/pandr/trainingcurrmain.htm, and is based on the National Training Institute for Child Care Health Consultants (NTI) curriculum for child care health consultants. Online training for caregivers/teachers is also available through some state agencies.

For more information on social-emotional training, contact the Center on the Social and Emotional Foundations for Early Learning (CSEFEL) at http://csefel.vanderbilt.edu.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.1.1 General Qualifications of Directors
1.4.3.1 First Aid and CPR Training for Staff
1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy
9.4.3.3 Training Record
10.6.1.1 Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services
10.6.1.2 Provision of Training to Facilities by Health Agencies
REFERENCES
  1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  2. Hayney M. S., J. C. Bartell. 2005. An immunization education program for childcare providers. J of School Health 75:147-49.
  3. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
  4. Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC early childhood program standard and related accreditation criteria. Washington, DC: National Association for the Education of Young Children (NAEYC).
  5. National Association for the Education of Young Children. 2010. Definition of early childhood professional development, 12. Eds. M. S. Donovan, J. D. Bransford, J. W. Pellegrino. Washington, DC: National Academy Press.

1.4.2 Orientation Training

1.4.2.1: Initial Orientation of All Staff


All new full-time staff, part-time staff and substitutes should be oriented to the policies listed in Standard 9.2.1.1 and any other aspects of their role. The topics covered and the dates of orientation training should be documented. Caregivers/teachers should also receive continuing education each year, as specified in Continuing Education, Standard 1.4.4.1 through Standard 1.4.6.2.
RATIONALE
Orientation ensures that all staff members receive specific and basic training for the work they will be doing and are informed about their new responsibilities. Because of frequent staff turnover, directors should institute orientation programs on a regular basis (1).

Orientation and ongoing training are especially important for aides and assistant teachers, for whom pre-service educational requirements are limited. Entry into the field at the level of aide or assistant teacher should be attractive and facilitated so that capable members of the families and cultural groups of the children in care can enter the field. Training ensures that staff members are challenged and stimulated, have access to current knowledge (2), and have access to education that will qualify them for new roles.

Use of videos and other passive methods of training should be supplemented by interactive training approaches that help verify content of training has been learned (3).

Health training for child care staff protects the children in care, staff, and the families of the children enrolled. Infectious disease control in child care helps prevent spread of infectious disease in the community. Outbreaks of infectious diseases and intestinal parasites in young children in child care have been shown to be associated with community outbreaks (4).

Child care health consultants can be an excellent resource for providing health and safety orientation or referrals to resources for such training.

COMMENTS
Many states have pre-service education and experience qualifications for caregivers/teachers by role and function. Offering a career ladder and utilizing employee incentives such as Teacher Education and Compensation Helps (TEACH) will attract individuals into the child care field, where labor is in short supply. Colleges, accrediting bodies, and state licensing agencies should examine teacher preparation guidelines and substantially increase the health content of early childhood professional preparation.

Child care staff members are important figures in the lives of the young children in their care and in the well-being of families and the community. Child care staff training should include new developments in children’s health. For example; a new training program could discuss up-to-date information on the prevention of obesity and its impact on early onset of chronic diseases.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
1.6.0.1 Child Care Health Consultants
9.2.1.1 Content of Policies
9.4.3.3 Training Record
REFERENCES
  1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  2. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
  3. National Association for the Education of Young Children (NAEYC). 2008. Leadership and management: A guide to the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC.

  4. Crowley, A. A. 1990. Health services in child day-care centers: A survey. J Pediatr Health Care 4:252-59.

1.4.2.2: Orientation for Care of Children with Special Health Care Needs


When a child care facility enrolls a child with special health care needs, the facility should ensure that all staff members have been oriented in understanding that child’s special health care needs and have the skills to work with that child in a group setting.

Caregivers/teachers in small family child care homes, who care for a child with special health care needs, should meet with the parents/guardians and meet or speak with the child’s primary care provider (if the parent/guardian has provided prior, informed, written consent) or a child care health consultant to ensure that the child’s special health care needs will be met in child care and to learn how these needs may affect his/her developmental progression or play with other children.

In addition to Orientation Training, Standard 1.4.2.1, the orientation provided to staff in child care facilities should be based on the special health care needs of children who will be assigned to their care. All staff oriented for care of children with special health needs should be knowledgeable about the care plans created by the child’s primary care provider in their medical home as well as any care plans created by other health professionals and therapists involved in the child’s care. A template for a care plan for children with special health care needs can be found in Appendix O. Child care health consultants can be an excellent resource for providing health and safety orientation or referrals to resources for such training. This training may include, but is not limited to, the following topics:

  1. Positioning for feeding and handling, and risks for injury for children with physical/mental disabilities;
  2. Toileting techniques;
  3. Knowledge of special treatments or therapies (e.g., PT, OT, speech, nutrition/diet therapies, emotional support and behavioral therapies, medication administration, etc.) the child may need/receive in the child care setting;
  4. Proper use and care of the individual child’s adaptive equipment, including how to recognize defective equipment and to notify parents/guardians that repairs are needed;
  5. How different disabilities affect the child’s ability to participate in group activities;
  6. Methods of helping the child with special health care needs or behavior problems to participate in the facility’s programs, including physical activity programs;
  7. Role modeling, peer socialization, and interaction;
  8. Behavior modification techniques, positive behavioral supports for children, promotion of self-esteem, and other techniques for managing behavior;
  9. Grouping of children by skill levels, taking into account the child’s age and developmental level;
  10. Health services or medical intervention for children with special health care problems;
  11. Communication methods and needs of the child;
  12. Dietary specifications for children who need to avoid specific foods or for children who have their diet modified to maintain their health, including support for continuation of breastfeeding;
  13. Medication administration (for emergencies or on an ongoing basis);
  14. Recognizing signs and symptoms of impending illness or change in health status;
  15. Recognizing signs and symptoms of injury;
  16. Understanding temperament and how individual behavioral differences affect a child’s adaptive skills, motivation, and energy;
  17. Potential hazards of which staff should be aware;
  18. Collaborating with families and outside service providers to create a health, developmental, and behavioral care plan for children with special needs;
  19. Awareness of when to ask for medical advice and recommendations for non-emergent issues that arise in school (e.g., head lice, worms, diarrhea);
  20. Knowledge of professionals with skills in various conditions, e.g., total communication for children with deafness, beginning orientation and mobility training for children with blindness (including arranging the physical environment effectively for such children), language promotion for children with hearing-impairment and language delay/disorder, etc.;
  21. How to work with parents/guardians and other professionals when assistive devices or medications are not consistently brought to the child care program or school;
  22. How to safely transport a child with special health care needs.
RATIONALE
A basic understanding of developmental disabilities and special care requirements of any child in care is a fundamental part of any orientation for new employees. Training is an essential component to ensure that staff members develop and maintain the needed skills. A comprehensive curriculum is required to ensure quality services. However, lack of specialized training for staff does not constitute grounds for exclusion of children with disabilities (1).

Staff members need information about how to help children use and maintain adaptive equipment properly. Staff members need to understand how and why various items are used and how to check for malfunctions. If a problem occurs with adaptive equipment, the staff must recognize the problem and inform the parent/guardian so that the parent/guardian can notify the health care or equipment provider of the problem and request that it be remedied. While the parent/guardian is responsible for arranging for correction of equipment problems, child care staff must be able to observe and report the problem to the parent/guardian. Routine care of adaptive and treatment equipment, such as nebulizers, should be taught.

COMMENTS
These training topics are generally applicable to all personnel serving children with special health care needs and apply to child care facilities. The curriculum may vary depending on the type of facility, classifications of disabilities of the children in the facility, and ages of the children. The staff is assumed to have the training described in Orientation Training, Standard 1.4.2.1, including child growth and development. These additional topics will extend their basic knowledge and skills to help them work more effectively with children who have special health care needs and their families. The number of hours offered in any in-service training program should be determined by the staff’s experience and professional background. Service plans in small family child care homes may require a modified implementation plan.

The parent/guardian is responsible for solving equipment problems. The parent/guardian can request that the child care facility remedy the problem directly if the caregiver/teacher has been trained on the maintenance and repair of the equipment and if the staff agrees to do it.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.2.1 Initial Orientation of All Staff
3.5.0.1 Care Plan for Children with Special Health Care Needs
9.4.3.3 Training Record
Appendix O: Care Plan for Children with Special Health Care Needs
REFERENCES
  1. U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.

1.4.2.3: Orientation Topics


During the first three months of employment, the director of a center or the caregiver/teacher in a large family home should document, for all full-time and part-time staff members, additional orientation in, and the employees’ satisfactory knowledge of, the following topics:

  1. Recognition of symptoms of illness and correct documentation procedures for recording symptoms of illness. This should include the ability to perform a daily health check of children to determine whether any children are ill or injured and, if so, whether a child who is ill should be excluded from the facility;
  2. Exclusion and readmission procedures and policies;
  3. Cleaning, sanitation, and disinfection procedures and policies;
  4. Procedures for administering medication to children and for documenting medication administered to children;
  5. Procedures for notifying parents/guardians of an infectious disease occurring in children or staff within the facility;
  6. Procedures and policies for notifying public health officials about an outbreak of disease or the occurrence of a reportable disease;
  7. Emergency procedures and policies related to unintentional injury, medical emergency, and natural disasters;
  8. Procedure for accessing the child care health consultant for assistance;
  9. Injury prevention strategies and hazard identification procedures specific to the facility, equipment, etc.; and
  10. Proper hand hygiene.

Before being assigned to tasks that involve identifying and responding to illness, staff members should receive orientation training on these topics. Small family child care home caregivers/teachers should not commence operation before receiving orientation on these topics in pre-service training.

RATIONALE
Children in child care are frequently ill (1). Staff members responsible for child care must be able to recognize illness and injury, carry out the measures required to prevent the spread of communicable diseases, handle ill and injured children appropriately, and appropriately administer required medications (2). Hand hygiene is one of the most important means of preventing spread of infectious disease (3).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.1.1 Pre-service Training
3.1.1.1 Conduct of Daily Health Check
3.1.1.2 Documentation of the Daily Health Check
9.4.3.3 Training Record
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
  3. Centers for Disease Control and Prevention (CDC). 2016. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.

1.4.3 First Aid and CPR Training

1.4.3.1: First Aid and CPR Training for Staff


The director of a center or a large family child care home and the caregiver/teacher in a small family child care home should ensure all staff members involved in providing direct care have documentation of satisfactory completion of training in pediatric first aid and pediatric CPR skills. Pediatric CPR skills should be taught by demonstration, practice, and return demonstration to ensure the technique can be performed in an emergency. These skills should be current according to the requirement specified for retraining by the organization that provided the training.

At least one staff person who has successfully completed training in pediatric first aid that includes CPR should be in attendance at all times with a child whose special care plan indicates an increased risk of needing respiratory or cardiac resuscitation.

Records of successful completion of training in pediatric first aid should be maintained in the personnel files of the facility.

RATIONALE
To ensure the health and safety of children in a child care setting, someone who is qualified to respond to life-threatening emergencies must be in attendance at all times (1). A staff trained in pediatric first aid, including pediatric CPR, coupled with a facility that has been designed or modified to ensure the safety of children, can mitigate the consequences of injury, and reduce the potential for death from life-threatening conditions. Knowledge of pediatric first aid, including pediatric CPR which addresses management of a blocked airway and rescue breathing, and the confidence to use these skills, are critically important to the outcome of an emergency situation.

Small family child care home caregivers/teachers often work alone. They must have the necessary skills to manage emergencies while caring for all the children in the group.

Children with special health care needs who have compromised airways may need to be accompanied to child care with nurses who are able to respond to airway problems (e.g., the child who has a tracheostomy and needs suctioning).

First aid skills are the most likely tools caregivers/teachers will need. Minor injuries are common. For emergency situations that require attention from a health professional, first aid procedures can be used to control the situation until a health professional can provide definitive care. However, management of a blocked airway (choking) is a life-threatening emergency that cannot wait for emergency medical personnel to arrive on the scene (2).

Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and in monitoring for proof of compliance.

COMMENTS
The recommendations from the American Heart Association (AHA) changed in 2010 from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest compressions, Airway, Breathing) for adults and pediatric patients (children and infants, excluding newborns). Except for newborns, the ratio of chest compressions to ventilations in the 2010 guidelines is 30:2. CPR skills are lost without practice and ongoing education (3,5).

The most common renewal cycle required by organizations that offer pediatric first aid and pediatric CPR training is to require successful completion of training every three years (4), though the AHA requires successful completion of CPR class every two years.

Inexpensive self-learning kits that require only thirty minutes to review the skills of pediatric CPR with a video and an inflatable manikin are available from the AHA. See “Infant CPR Anytime” and “Family and Friends CPR Anytime” at http://www.heart.org/HEARTORG/.

Child care facilities should consider having an Automated External Defibrillators (AED) on the child care premises for potential use with adults. The use of AEDs with children would be rare.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
9.4.3.3 Training Record
10.6.1.1 Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services
10.6.1.2 Provision of Training to Facilities by Health Agencies
REFERENCES
  1. Alkon, A., P. J. Kaiser, J. M. Tschann, W. T. Boyce, J. L. Genevro, M. Chesney. 1994. Injuries in child-care centers: Rates, severity, and etiology. Pediatrics 94:1043-46.
  2. Stevens, P. B., K. A. Dunn. 1994. Use of cardiopulmonary resuscitation by North Carolina day care providers. J School Health 64:381-83.
  3. American Heart Association (AHA). 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation 122: S640-56.
  4. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, MA: Jones and Bartlett.
  5. American Heart Association (AHA). 2010. Hands-only CPR. http://handsonlycpr.org.

1.4.3.2: Topics Covered in First Aid Training


First aid training should present an overview of Emergency Medical Services (EMS), accessing EMS, poison center services, accessing the poison center, safety at the scene, and isolation of body substances. First aid instruction should include, but not be limited to, recognition and first response of pediatric emergency management in a child care setting of the following situations:

  1. Management of a blocked airway and rescue breathing for infants and children with return demonstration by the learner (pediatric CPR);
  2. Abrasions and lacerations;
  3. Bleeding, including nosebleeds;
  4. Burns;
  5. Fainting;
  6. Poisoning, including swallowed, skin or eye contact, and inhaled;
  7. Puncture wounds, including splinters;
  8. Injuries, including insect, animal, and human bites;
  9. Poison control;
  10. Shock;
  11. Seizure care;
  12. Musculoskeletal injury (such as sprains, fractures);
  13. Dental and mouth injuries/trauma;
  14. Head injuries, including shaken baby syndrome/abusive head trauma;
  15. Allergic reactions, including information about when epinephrine might be required;
  16. Asthmatic reactions, including information about when rescue inhalers must be used;
  17. Eye injuries;
  18. Loss of consciousness;
  19. Electric shock;
  20. Drowning;
  21. Heat-related injuries, including heat exhaustion/heat stroke;
  22. Cold related injuries, including frostbite;
  23. Moving and positioning injured/ill persons;
  24. Illness-related emergencies (such as stiff neck, inexplicable confusion, sudden onset of blood-red or purple rash, severe pain, temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method, and looking/acting severely ill);
  25. Standard Precautions;
  26. Organizing and implementing a plan to meet an emergency for any child with a special health care need;
  27. Addressing the needs of the other children in the group while managing emergencies in a child care setting;
  28. Applying first aid to children with special health care needs.
RATIONALE
First aid for children in the child care setting requires a more child-specific approach than standard adult-oriented first aid offers. To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common injuries and life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including pediatric CPR, coupled with a facility that has been designed or modified to ensure the safety of children, can reduce the potential for death and disability. Knowledge of pediatric first aid, including the ability to demonstrate pediatric CPR skills, and the confidence to use these skills, are critically important to the outcome of an emergency situation (1).

Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of children in care. Such caregivers/teachers must have pediatric first aid competence.

COMMENTS
Other children will have to be supervised while the injury is managed. Parental notification and communication with emergency medical services must be carefully planned. First aid information can be obtained from the American Academy of Pediatrics (AAP) at http://www.aap.org and the American Heart Association (AHA) at http://www.heart.org/HEARTORG/.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.3.1 First Aid and CPR Training for Staff
3.6.1.3 Thermometers for Taking Human Temperatures
5.6.0.1 First Aid and Emergency Supplies
9.4.3.3 Training Record
REFERENCES
  1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, MA: Jones and Bartlett.

1.4.3.3: CPR Training for Swimming and Water Play


Facilities that have a swimming pool should require at least one staff member with current documentation of successful completion of training in infant and child (pediatric) CPR (Cardiopulmonary Resuscitation) be on duty at all times during business hours.

At least one of the caregivers/teachers, volunteers, or other adults who is counted in the child:staff ratio for swimming and water play should have documentation of successful completion of training in basic water safety, proper use of swimming pool rescue equipment, and infant and child CPR according to the criteria of the American Red Cross or the American Heart Association (AHA).

For small family child care homes, the person trained in water safety and CPR should be the caregiver/teacher. Written verification of successful completion of CPR and lifesaving training, water safety instructions, and emergency procedures should be kept on file.

RATIONALE
Drowning involves cessation of breathing and rarely requires cardiac resuscitation of victims. Nevertheless, because of the increased risk for cardiopulmonary arrest related to wading and swimming, the facility should have personnel trained to provide CPR and to deal promptly with a life-threatening drowning emergency. During drowning, cold exposure provides the possibility of protection of the brain from irreversible damage associated with respiratory and cardiac arrest. Children drown in as little as two inches of water. The difference between a life and death situation is the submersion time. Thirty seconds can make a difference. The timely administration of resuscitation efforts by a caregiver/teacher trained in water safety and CPR is critical. Studies have shown that prompt rescue and the presence of a trained resuscitator at the site can save about 30% of the victims without significant neurological consequences (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
2.2.0.4 Supervision Near Bodies of Water
2.2.0.5 Behavior Around a Pool
6.3.1.7 Pool Safety Rules
6.4.1.1 Pool Toys
9.4.3.3 Training Record
REFERENCES
  1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, MA: Jones and Bartlett.

1.4.4 Continuing Education/Professional Development

1.4.4.1: Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes


All directors and caregivers/teachers of centers and large family child care homes should successfully complete at least thirty clock-hours per year of continuing education/professional development in the first year of employment, sixteen clock-hours of which should be in child development programming and fourteen of which should be in child health, safety, and staff health. In the second and each of the following years of employment at a facility, all directors and caregivers/teachers should successfully complete at least twenty-four clock-hours of continuing education based on individual competency needs and any special needs of the children in their care, sixteen hours of which should be in child development programming and eight hours of which should be in child health, safety, and staff health.

Programs should conduct a needs assessment to identify areas of focus, trainer qualifications, adult learning strategies, and create an annual professional development plan for staff based on the needs assessment. The effectiveness of training should be evident by the change in performance as measured by accreditation standards or other quality assurance systems.

RATIONALE
Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the staff member(s) involved. Too often, staff members make training choices based on what they like to learn about (their “wants”) and not the areas in which their performance should be improved (their “needs”). Participation in training does not ensure that the participant will master the information and skills offered in the training experience. Therefore, caregiver/teacher change in behavior or the continuation of appropriate practice resulting from the training, not just participation in training, should be assessed by supervisors and directors (4).

In addition to low child:staff ratio, group size, age mix of children, and stability of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (2). Most skilled roles require training related to the functions and responsibilities the role requires. Staff members who are better trained are better able to prevent, recognize, and correct health and safety problems. The number of training hours recommended in this standard reflects the central focus of caregivers/teachers on child development, health, and safety.

Children may come to child care with identified special health care needs or special needs may be identified while attending child care, so staff should be trained in recognizing health problems as well as in implementing care plans for previously identified needs. Medications are often required either on an emergent or scheduled basis for a child to safely attend child care. Caregivers/teachers should be well trained on medication administration and appropriate policies should be in place.

The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training/professional development based on the needs of the program and the pre-service qualifications of staff (1). Training should address the following areas:

  1. Promoting child growth and development correlated with developmentally appropriate activities;
  2. Infant care;
  3. Recognizing and managing minor illness and injury;
  4. Managing the care of children who require the special procedures listed in Standard 3.5.0.2;
  5. Medication administration;
  6. Business aspects of the small family child care home;
  7. Planning developmentally appropriate activities in mixed age groupings;
  8. Nutrition for children in the context of preparing nutritious meals for the family;
  9. Age-appropriate size servings of food and child feeding practices;
  10. Acceptable methods of discipline/setting limits;
  11. Organizing the home for child care;
  12. Preventing unintentional injuries in the home (e.g., falls, poisoning, burns, drowning);
  13. Available community services;
  14. Detecting, preventing, and reporting child abuse and neglect;
  15. Advocacy skills;
  16. Pediatric first aid, including pediatric CPR;
  17. Methods of effective communication with children and parents/guardians;
  18. Socio-emotional and mental health (positive approaches with consistent and nurturing relationships);
  19. Evacuation and shelter-in-place drill procedures;
  20. Occupational health hazards;
  21. Infant safe sleep environments and practices;
  22. Standard Precautions;
  23. Shaken baby syndrome/abusive head trauma;
  24. Dental issues;
  25. Age-appropriate nutrition and physical activity.

There are few illnesses for which children should be excluded from child care. Decisions about management of ill children are facilitated by skill in assessing the extent to which the behavior suggesting illness requires special management (3). Continuing education on managing infectious diseases helps prepare caregivers/teachers to make these decisions devoid of personal biases (5). Recommendations regarding responses to illnesses may change (e.g., H1N1), so caregivers/teachers need to know where they can find the most current information. All caregivers/teachers should be trained to prevent, assess, and treat injuries common in child care settings and to comfort an injured child and children witnessing an injury.

COMMENTS
Tools for assessment of training needs are part of the accreditation self-study tools available from the NAEYC, the National Association for Family Child Care (NAFCC), National Early Childhood Professional Accreditation (NECPA), Association for Christian Education International (ACEI), National AfterSchool Association (NAA), and the National Child Care Association (NCCA). Successful completion of training can be measured by a performance test at the end of training and by ongoing evaluation of performance on the job.

Resources for training on health and safety issues include:

  1. State and local health departments (health education, environmental health and sanitation, nutrition, public health nursing departments, fire and EMS, etc.);
  2. Networks of child care health consultants;
  3. Graduates of the National Training Institute for Child Care Health Consultants (NTI);
  4. Child care resource and referral agencies;
  5. University Centers for Excellence on Disabilities;
  6. Local children’s hospitals;
  7. State and local chapters of:
    1. American Academy of Pediatrics (AAP), including AAP Chapter Child Care Contacts;
    2. American Academy of Family Physicians (AAFP);
    3. American Nurses’ Association (ANA);
    4. American Public Health Association (APHA);
    5. Visiting Nurse Association (VNA);
    6. National Association of Pediatric Nurse Practitioners (NAPNAP);
    7. National Association for the Education of Young Children (NAEYC);
    8. National Association for Family Child Care (NAFCC);
    9. National Association of School Nurses (NASN);
    10. Emergency Medical Services for Children (EMSC) National Resource Center;
    11. National Association for Sport and Physical Education (NASPE);
    12. American Dietetic Association (ADA);
    13. American Association of Poison Control Centers (AAPCC).

For nutrition training, facilities should check that the nutritionist/registered dietician (RD), who provides advice, has experience with, and knowledge of, child development, infant and early childhood nutrition, school-age child nutrition, prescribed nutrition therapies, food service and food safety issues in the child care setting. Most state Maternal and Child Health (MCH) programs, Child and Adult Care Food Programs (CACFP), and Special Supplemental Nutrition Programs for Women, Infants, and Children (WIC) have a nutrition specialist on staff or access to a local consultant. If this nutrition specialist has knowledge and experience in early childhood and child care, facilities might negotiate for this individual to serve or identify someone to serve as a consultant and trainer for the facility.

Many resources are available for nutritionists/RDs who provide training in food service and nutrition. Some resources to contact include:

  1. Local, county, and state health departments to locate MCH, CACFP, or WIC programs;
  2. State university and college nutrition departments;
  3. Home economists at utility companies;
  4. State affiliates of the American Dietetic Association;
  5. State and regional affiliates of the American Public Health Association;
  6. The American Association of Family and Consumer Services;
  7. National Resource Center for Health and Safety in Child Care and Early Education;
  8. Nutritionist/RD at a hospital;
  9. High school home economics teachers;
  10. The Dairy Council;
  11. The local American Heart Association affiliate;
  12. The local Cancer Society;
  13. The Society for Nutrition Education;
  14. The local Cooperative Extension office;
  15. Local community colleges and trade schools.

Nutrition education resources may be obtained from the Food and Nutrition Information Center at http://fnic.nal.usda.gov. The staff’s continuing education in nutrition may be supplemented by periodic newsletters and/or literature (frequently bilingual) or audiovisual materials prepared or recommended by the Nutrition Specialist.

Caregivers/teachers should have a basic knowledge of special health care needs, supplemented by specialized training for children with special health care needs. The type of special health care needs of the children in care should influence the selection of the training topics. The number of hours offered in any in-service training program should be determined by the experience and professional background of the staff, which is best achieved through a regular staff conference mechanism.

Financial support and accessibility to training programs requires attention to facilitate compliance with this standard. Many states are using federal funds from the Child Care and Development Block Grant to improve access, quality, and affordability of training for early care and education professionals. College courses, either online or face to face, and training workshops can be used to meet the training hours requirement. These training opportunities can also be conducted on site at the child care facility. Completion of training should be documented by a college transcript or a training certificate that includes title/content of training, contact hours, name and credentials of trainer or course instructor and date of training. Whenever possible the submission of documentation that shows how the learner implemented the concepts taught in the training in the child care program should be documented. Although on-site training can be costly, it may be a more effective approach than participation in training at a remote location.

Projects and Outreach: Early Childhood Research and Evaluation Projects, Midwest Child Care Research Consortium at http://ccfl.unl.edu/projects_outreach/projects/current/ecp/mwcrc.php, identifies the number of hours for education of staff and fourteen indicators of quality from a study conducted in four Midwestern states.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.8.2.2 Annual Staff Competency Evaluation
3.5.0.2 Caring for Children Who Require Medical Procedures
3.6.3.1 Medication Administration
9.4.3.3 Training Record
10.3.3.4 Licensing Agency Provision of Child Abuse Prevention Materials
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs
10.6.1.1 Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services
10.6.1.2 Provision of Training to Facilities by Health Agencies
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
REFERENCES
  1. National Association for the Education of Young Children (NAEYC). 2009. Standards for Early Childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
    .org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
  2. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
  3. Crowley, A. A. 1990. Health services in child care day care centers: A survey. J Pediatr Health Care 4:252-59.
  4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  5. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

1.4.4.2: Continuing Education for Small Family Child Care Home Caregivers/Teachers


Small family child care home caregivers/teachers should have at least thirty clock-hours per year (2) of continuing education in areas determined by self-assessment and, where possible, by a performance review of a skilled mentor or peer reviewer.
RATIONALE
In addition to low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (1). Most skilled roles require training related to the functions and responsibilities the role requires. Caregivers/teachers who engage in on-going training are more likely to decrease morbidity and mortality in their setting (3) and are better able to prevent, recognize, and correct health and safety problems.

Children may come to child care with identified special health care needs or may develop them while attending child care, so staff must be trained in recognizing health problems as well as in implementing care plans for previously identified needs.

Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the caregiver/teacher. Provision of workshops and courses on all facets of a small family child care business may be difficult to access and may lead to caregivers/teachers enrolling in training opportunities in curriculum related areas only. Too often, caregivers/teachers make training choices based on what they like to learn about (their “wants”) and not the areas in which their performance should be improved (their “needs”).

Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of small numbers of children in care. Peer review is part of the process for accreditation of family child care and can be valuable in assisting the caregiver/teacher in the identification of areas of need for training. Self-evaluation may not identify training needs or focus on areas in which the caregiver/teacher is particularly interested and may be skilled already.

COMMENTS
The content of continuing education for small family child care home caregivers/teachers should include the following topics:
  1. Promoting child growth and development correlated with developmentally appropriate activities;
  2. Infant care;
  3. Recognizing and managing minor illness and injury;
  4. Managing the care of children who require the special procedures listed in Standard 3.5.0.2;
  5. Medication administration;
  6. Business aspects of the small family child care home;
  7. Planning developmentally appropriate activities in mixed age groupings;
  8. Nutrition for children in the context of preparing nutritious meals for the family;
  9. Age-appropriate size servings of food and child feeding practices;
  10. Acceptable methods of discipline/setting limits;
  11. Organizing the home for child care;
  12. Preventing unintentional injuries in the home (falls, poisoning, burns, drowning);
  13. Available community services;
  14. Detecting, preventing, and reporting child abuse and neglect;
  15. Advocacy skills;
  16. Pediatric first aid, including pediatric CPR;
  17. Methods of effective communication with children and parents/guardians;
  18. Socio-emotional and mental health (positive approaches with consistent and nurturing relationships);
  19. Evacuation and shelter-in-place drill procedures;
  20. Occupational health hazards;
  21. Infant-safe sleep environments and practices;
  22. Standard Precautions;
  23. Shaken baby syndrome/abusive head trauma;
  24. Dental issues;
  25. Age-appropriate nutrition and physical activity.

Small family child care home caregivers/teachers should maintain current contact lists of community pediatric primary care providers, specialists for health issues of individual children in their care and child care health consultants who could provide training when needed.

In-home training alternatives to group training for small family child care home caregivers/teachers are available, such as distance courses on the Internet, listening to audiotapes or viewing media (e.g., DVDs) with self-checklists. These training alternatives provide more flexibility for caregivers/teachers who are remote from central training locations or have difficulty arranging coverage for their child care duties to attend training. Nevertheless, gathering family child care home caregivers/teachers for training when possible provides a break from the isolation of their work and promotes networking and support. Satellite training via down links at local extension service sites, high schools, and community colleges scheduled at convenient evening or weekend times is another way to mix quality training with local availability and some networking.

RELATED STANDARDS
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.7.0.4 Occupational Hazards
3.5.0.2 Caring for Children Who Require Medical Procedures
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy
9.4.3.3 Training Record
REFERENCES
  1. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The national child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
  2. The National Association of Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf.
  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

1.4.5 Specialized Training/Education

1.4.5.1: Training of Staff Who Handle Food


All staff members with food handling responsibilities should obtain training in food service and safety. The director of a center or a large family child care home or the designated supervisor for food service should be a certified food protection manager or equivalent as demonstrated by completing an accredited food protection manager course. Small family child care personnel should secure training in food service and safety appropriate for their setting.
RATIONALE
Outbreaks of foodborne illness have occurred in many settings, including child care facilities. Some of these outbreaks have led to fatalities and severe disabilities. Young children are particularly susceptible to foodborne illness, due to their body size and immature immune systems. Because large centers serve more meals daily than many restaurants do, the supervisors of food handlers in these settings should have successfully completed food service certification, and the food handlers in these settings should have successfully completed courses on appropriate food handling (1).
COMMENTS
Sponsors of the Child and Adult Care Food Program (CACFP) provide this training for some small family child care home caregivers/teachers. For training in food handling, caregivers/teachers should contact the state or local health department, or the delegate agencies that handle nutrition and environmental health inspection programs for the child care facility. Training for food workers is mandatory in some jurisdictions. Other sources for food safety information are the Food and Drug Administration (FDA) Food Code, family child care associations, child care resource and referral agencies, licensing agencies, and state departments of education.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.4.3.3 Training Record
REFERENCES
  1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. Food code 2009. College Park, MD: FDA. http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/default.htm.

1.4.5.2: Child Abuse and Neglect Education

Content in the STANDARD was modified on 5/22/2018


Caregivers/teachers are mandatory reporters of child abuse and neglect. Caregivers/teachers should attend child abuse and neglect prevention education programs to educate themselves and establish child abuse and neglect prevention and recognition guidelines for the children, caregivers/teachers, and parents/guardians. The prevention education program should address physical, sexual, and psychological or emotional abuse and neglect. The dangers of shaking infants and toddlers and repeated exposure to domestic violence should be included in the education and prevention materials. Caregivers/teachers should also receive education on promoting protective factors to prevent child maltreatment. (Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (e.g., clergy, coach, teacher, etc.) (1).  Caregivers/teachers should be able to identify signs of stress in families and assist families by providing support and access/referral to resources when needed. Children with disabilities are at a higher risk of being abused than healthy children. Special training in child abuse and neglect of children with disabilities should be provided (2). 

 

Risk factors for victimization include a child’s age and special needs that may require increased attention from the caregiver. Risk factors for perpetration include young parental age, single parenthood, many dependent children, low parental income or parental unemployment, substance abuse, and family history of child abuse/neglect, violence, and/or mental illness (2,3).  Caregivers/teachers should be aware of these factors so they can support parenting practices when appropriate. Caregivers/teachers should be trained in compliance with their state’s child abuse and neglect reporting laws. Child abuse reporting requirements are available from the child care regulation department in each state (4). 

 

Child abuse and neglect materials should be designed for nonmedical audiences.

RATIONALE

Education is important in identifying manifestations of child maltreatment that can increase the likelihood of appropriate reports to child protection and law enforcement agencies (5). 

COMMENTS

Child abuse and neglect resources are available from the American Academy of Pediatrics at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Child-Abuse-and-Neglect.aspx, the Child Welfare Information Gateway at www.childwelfare.gov, Prevent Child Abuse America at www.preventchildabuse.org, and The Early Childhood Learning & Knowledge Center at https://eclkc.ohs.acf.hhs.gov/browse/keyword/child-abuse.

 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.4.2.1 Health and Safety Education Topics for Staff
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.2.1.1 Content of Policies
9.4.3.3 Training Record
REFERENCES
  1. Centers for Disease Control and Prevention. Child abuse and neglect prevention. https://www.cdc.gov/violenceprevention/childmaltreatment/index.html. Updated April 17, 2017. Accessed March 8, 2018

  2. Centers for Disease Control and Prevention. Violence prevention. Child abuse and neglect: risk and protective factors. https://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html. Updated April 18, 2017. Accessed January 11, 2018

  3. Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical-Package.pdf. Accessed January 11, 2018

  4. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2014. http://www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf. Published 2016. Accessed January 11, 2018

  5. Admon Livny K, Katz C. Schools, families, and the prevention of child maltreatment: lessons that can be learned from a literature review. Trauma Violence Abuse. 2016;pii:1524838016650186

NOTES

Content in the STANDARD was modified on 5/22/2018

1.4.5.3: Training on Occupational Risk Related to Handling Body Fluids


All caregivers/teachers who are at risk of occupational exposure to blood or other blood-containing body fluids should be offered hepatitis B immunizations and should receive annual training in Standard Precautions and exposure control planning. Training should be consistent with applicable standards of the Occupational Safety and Health Administration (OSHA) Standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens” and local occupational health requirements and should include, but not be limited to:

  1. Modes of transmission of bloodborne pathogens;
  2. Standard Precautions;
  3. Hepatitis B vaccine use according to OSHA requirements;
  4. Program policies and procedures regarding exposure to blood/body fluid;
  5. Reporting procedures under the exposure control plan to ensure that all first-aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs (1).
RATIONALE
Providing first aid in situations where blood is present is an intrinsic part of a caregiver’s/teacher’s job. Split lips, scraped knees, and other minor injuries associated with bleeding are common in child care.

Caregivers/teachers who are designated as responsible for rendering first aid or medical assistance as part of their job duties are covered by the scope of this standard.

COMMENTS
OSHA has model exposure control plan materials for use by child care facilities. Using the model exposure control plan materials, caregivers/teachers can prepare a plan to comply with the OSHA requirements. The model plan materials are available from regional offices of OSHA.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.4.3.3 Training Record
Appendix L: Cleaning Up Body Fluids
REFERENCES
  1. U.S. Department of Labor, Occupational Safety and Health Administration. 2008. Toxic and hazardous substances: Bloodborne pathogens. http://www.osha.gov/pls/oshaweb/owadisp.show
    _document?p_table=STANDARDS&p_id=10051.

1.4.5.4: Education of Center Staff


Centers should educate staff to support the cultural, language, and ethnic backgrounds of children enrolled in the program. In addition, all staff members should participate in diversity training that will ensure respectful service delivery to all families and a staff that works well together (2).
RATIONALE
Young children’s identities cannot be separated from family, culture, and their home language. Children need both to see successful role models from their own ethnic and cultural groups and to develop the ability to relate to people who are different from themselves (1).
TYPE OF FACILITY
Center
RELATED STANDARDS
9.4.3.3 Training Record
REFERENCES
  1. Chang, H. 2006. Developing a skilled, ethnically and linguistically diverse early childhood workforce. Adapted from Getting ready for quality: The critical importance of developing and supporting a skilled, ethnically and linguistically diverse early childhood workforce. http://www.buildinitiative.org/files/DiverseWorkforce.pdf.
  2. National Association for the Education of Young Children (NAEYC). 2009. Quality benchmark for cultural competence project. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/policy/state/QBCC_Tool.pdf.

1.4.6 Educational Leave/Compensation

1.4.6.1: Training Time and Professional Development Leave


A center, large family child care home or a support agency for a network of small family child care homes should make provisions for paid training time for staff to participate in required professional development (that includes training as well as education) during work hours, or reimburse staff for time spent attending professional development outside of regular work hours. Any hours worked in excess of forty hours in a week must be paid according to state and federal wage and hour regulations.
RATIONALE
Most caregivers/teachers work long hours and most are poorly paid (1). Using personal time for education required as a condition of employment is an unfair expectation until compensation for work done in child care is much more equitable. Many child care workers also employed in another vocation work at other jobs to make a living wage and would miss income from their other jobs or risk losing that employment. Additionally, the caregiver/teacher may incur stress in their family life when required to take time outside of child care hours to participate in work-related training.
COMMENTS
Professional development in child care often takes place when the participant is not released from other work-related duties, such as caring for children or answering phones. Providing substitutes and released time during work hours for such training is likely to enhance the effectiveness of training; and improve employee satisfaction/retention.

Large family child care homes employ staff in the same way as centers, except for size and location in a residence. For small family child care home caregivers/teachers, released time and compensation while engaged in training can be arranged only if the small family child care home caregiver/teacher is part of a support network that makes such arrangements. This standard does not apply to small family child care home caregivers/teachers independent of networks.

The Fair Labor Standard Act mandates payment of time and a half for all hours worked in excess of forty hours in a week.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Center for the Child Care Workforce, American Federation of Teachers (AFT). 2009. Wage data: Early childhood workforce hourly wage data. 2009 ed. Washington, DC: AFT. http://www.ccw.org/storage/ccworkforce/documents/04-30-09 wwd fact sheet.pdf.

1.4.6.2: Payment for Continuing Education


Directors of centers and large family child care homes should arrange for continuing education that is paid for by the government, by charitable organizations, or by the facility, rather than by the employee. Small family child care home caregivers/teachers should avail themselves of training opportunities offered in their communities or online and claim their educational expenses as a business expense on tax forms.
RATIONALE
Caregivers/teachers often make low wages and may not be able to pay for mandated training. A majority of child care workers earnings are at or near minimum wage (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Center for the Child Care Workforce, American Federation of Teachers. 2009. Wage data: Early childhood workforce hourly wage data. 2009 ed. Washington, DC: AFT. http://www.ccw.org/storage/ccworkforce/documents/04-30-09 wwd fact sheet.pdf.

1.5 Substitutes

1.5.0

1.5.0.1: Employment of Substitutes


Substitutes should be employed to ensure that child:staff ratios and requirements for direct supervision are maintained at all times. Substitutes and volunteers should be at least eighteen years of age and must meet the requirements specified throughout Standards 1.3.2.1-1.3.2.6. Those without licenses/certificates should work under direct supervision and should not be alone with a group of children.

A substitute should complete the same background screening processes as the caregiver/teacher. Obtaining substitutes to provide medical care for children with special health care needs is particularly challenging. A substitute nurse should be experienced in delivering the expected medical services. Decisions should be made on whether a parent/guardian will be allowed to provide needed on-site medical services. Substitutes should be aware of the care plans (including emergency procedures) for children with special health care needs.

RATIONALE
The risk to children from care by unqualified caregivers/teachers is the same whether the caregiver/teacher is a paid substitute or a volunteer (1).
COMMENTS
Substitutes are difficult to find, especially at the last minute. Planning for a competent substitute pool is essential for child care operation. Requiring substitutes for small family child care homes to obtain first aid and CPR certification forces small family child care home caregivers/teachers to close when they cannot be covered by a competent substitute. Since closing a child care home has a negative impact on the families and children they serve, systems should be developed to provide qualified alternative homes or substitutes for family child care home caregivers/teachers.

The lack of back-up for family child care home caregivers/teachers is an inherent liability in this type of care. Parents/guardians who use family child care must be sure they have suitable alternative care, such as family or friends, for situations in which the child’s usual caregiver/teacher cannot provide the service.

Substitutes should have orientation and training on basic health and safety topics. Substitutes should not have an infectious disease when providing care.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.3.2.1 Differentiated Roles
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.6 Additional Qualifications for Caregivers/Teachers Serving School-Age Children
1.3.3.1 General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home
1.3.3.2 Support Networks for Family Child Care
1.5.0.2 Orientation of Substitutes
1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
REFERENCES
  1. National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net.

1.5.0.2: Orientation of Substitutes

Content in the STANDARD was modified on 5/22/2018


The director of any center or large family child care home and the small family child care home caregiver/teacher should provide orientation training to newly hired substitutes, including a review of all the program’s policies and procedures (see sample that follows). This training should include the opportunity for an evaluation and a repeat demonstration of the training lesson. Orientation should be documented in all child care settings. Substitutes should have background screenings.

All substitutes should be oriented to, and demonstrate competence in, the tasks for which they will be responsible.

On the first day a substitute caregiver/teacher should be oriented on the following topics:

  1. Safe infant sleep practices
    1. The practice of putting infants down to sleep positioned on their backs and on a firm surface, along with all safe infant sleep practices, to reduce the risk of sudden infant death syndrome (SIDS), as well as general nap time routines and healthy sleep hygiene for all ages.
  2. Any emergency medical procedure or medication needs of the children
  3. Access to the list of authorized individuals for releasing children
  4. Any special dietary needs of the children

 

During the first week of employment, all substitute caregivers/teachers should be oriented to, and should demonstrate competence in, at least the following items:

  1. The names of the children for whom the caregiver/teacher will be responsible and their specific developmental and special health care needs
  2. The planned program of activities at the facility
  3. Routines and transitions
  4. Acceptable methods of discipline
  5. Meal patterns and safe food-handling policies of the facility (Special attention should be given to life-threatening food allergies.)
  6. Emergency health and safety procedures
  7. General health policies and procedures as appropriate for the ages of the children cared for, including, but not limited to

               1. Hand hygiene techniques, including indications for hand hygiene

               2. Diapering technique, if care is provided to children in diapers, including appropriate diaper disposal and diaper changing techniques and use and wearing of gloves

               3. Preventing shaken baby syndrome/abusive head trauma

               4. Strategies for coping with crying, fussing, or distraught infants and children

               5. Early brain development and its vulnerabilities

               6. Other injury prevention and safety, including the role of a mandatory child abuse reporter to report any suspected abuse/neglect

               7. Correct food preparation and storage techniques, if employee prepares food

               8. Proper handling and storage of human (breast) milk, when applicable, and formula preparation, if formula is handled

               9. Bottle preparation, including guidelines for human milk and formula, if care is provided to infants or children with bottles

               10. Proper use of gloves in compliance with Occupational Safety and Health Administration blood-borne pathogen regulations

      h. Emergency plans and practices

 

On employment, substitutes should be able to carry out the duties assigned to them.

RATIONALE

Because facilities and the children enrolled in them vary, orientation programs for new substitutes can be most productive. Because of frequent staff turnover, comprehensive orientation programs are critical to protecting the health and safety of children and new staff (1,2).  Most SIDS deaths in child care occur on the first day of care or within the first week due to unaccustomed prone (on stomach) sleeping. Unaccustomed prone sleeping increases the risk of SIDS 18 times (3). 

 

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
1.2.0.2 Background Screening
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.2.1.1 Type of Diapers Worn
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.4.3.1 Emergency Procedures
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.5 Chemical Toilets
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning/Training Equipment
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.4 Futons
5.4.5.5 Bunk Beds
9.2.2.3 Exchange of Information at Transitions
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
9.2.4.2 Review of Written Plan for Urgent Care
9.4.1.18 Records of Nutrition Service
Appendix D: Gloving
REFERENCES
  1. Landry SH, Zucker TA, Taylor HB, et al. Enhancing early child care quality and learning for toddlers at risk: the responsive early childhood program. Dev Psychol. 2014;50(2):526–541

  2. Ellenbogen S, Klein B, Wekerle C. Early childhood education as a resilience intervention for maltreated children. Early Child Dev Care. 2014;184:1364–1377
  3. Ball HL, Volpe LE. Sudden infant death syndrome (SIDS) risk reduction and infant sleep location—moving the discussion forward. Soc Sci Med. 2013;79:84–91

NOTES

Content in the STANDARD was modified on 5/22/2018

1.6 Consultants

1.6.0

1.6.0.1: Child Care Health Consultants


A facility should identify and engage/partner with a child care health consultant (CCHC) who is a licensed health professional with education and experience in child and community health and child care and preferably specialized training in child care health consultation.

CCHCs have knowledge of resources and regulations and are comfortable linking health resources with child care facilities.

The child care health consultant should be knowledgeable in the following areas:

  1. Consultation skills both as a child care health consultant as well as a member of an interdisciplinary team of consultants;
  2. National health and safety standards for out-of-home child care;
  3. Indicators of quality early care and education;
  4. Day-to-day operations of child care facilities;
  5. State child care licensing and public health requirements;
  6. State health laws, Federal and State education laws (e.g., ADA, IDEA), and state professional practice acts for licensed professionals (e.g., State Nurse Practice Acts);
  7. Infancy and early childhood development, social and emotional health, and developmentally appropriate practice;
  8. Recognition and reporting requirements for infectious diseases;
  9. American Academy of Pediatrics (AAP) and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening recommendations and immunizations schedules for children;
  10. Importance of medical home and local and state resources to facilitate access to a medical home as well as child health insurance programs including Medicaid and State Children’s Health Insurance Program (SCHIP);
  11. Injury prevention for children;
  12. Oral health for children;
  13. Nutrition and age-appropriate physical activity recommendations for children including feeding of infants and children, the importance of breastfeeding and the prevention of obesity;
  14. Inclusion of children with special health care needs, and developmental disabilities in child care;
  15. Safe medication administration practices;
  16. Health education of children;
  17. Recognition and reporting requirements for child abuse and neglect/child maltreatment;
  18. Safe sleep practices and policies (including reducing the risk of SIDS);
  19. Development and implementation of health and safety policies and practices including poison awareness and poison prevention;
  20. Staff health, including adult health screening, occupational health risks, and immunizations;
  21. Disaster planning resources and collaborations within child care community;
  22. Community health and mental health resources for child, parent/guardian and staff health;
  23. Importance of serving as a healthy role model for children and staff.

The child care health consultant should be able to perform or arrange for performance of the following activities:

  1. Assessing caregivers’/teachers’ knowledge of health, development, and safety and offering training as indicated;
  2. Assessing parents’/guardians’ health, development, and safety knowledge, and offering training as indicated;
  3. Assessing children’s knowledge about health and safety and offering training as indicated;
  4. Conducting a comprehensive indoor and outdoor health and safety assessment and on-going observations of the child care facility;
  5. Consulting collaboratively on-site and/or by telephone or electronic media;
  6. Providing community resources and referral for health, mental health and social needs, including accessing medical homes, children’s health insurance programs (e.g., CHIP), and services for special health care needs;
  7. Developing or updating policies and procedures for child care facilities (see comment section below);
  8. Reviewing health records of children;
  9. Reviewing health records of caregivers/teachers;
  10. Assisting caregivers/teachers and parents/guardians in the management of children with behavioral, social and emotional problems and those with special health care needs;
  11. Consulting a child’s primary care provider about the child’s individualized health care plan and coordinating services in collaboration with parents/guardians, the primary care provider, and other health care professionals (the CCHC shows commitment to communicating with and helping coordinate the child’s care with the child’s medical home, and may assist with the coordination of skilled nursing care services at the child care facility);
  12. Consulting with a child’s primary care provider about medications as needed, in collaboration with parents/guardians;
  13. Teaching staff safe medication administration practices;
  14. Monitoring safe medication administration practices;
  15. Observing children’s behavior, development and health status and making recommendations if needed to staff and parents/guardians for further assessment by a child’s primary care provider;
  16. Interpreting standards, regulations and accreditation requirements related to health and safety, as well as providing technical advice, separate and apart from an enforcement role of a regulation inspector or determining the status of the facility for recognition;
  17. Understanding and observing confidentiality requirements;
  18. Assisting in the development of disaster/emergency medical plans (especially for those children with special health care needs) in collaboration with community resources;
  19. Developing an obesity prevention program in consultation with a nutritionist/registered dietitian (RD) and physical education specialist;
  20. Working with other consultants such as nutritionists/RDs, kinesiologists (physical activity specialists), oral health consultants, social service workers, early childhood mental health consultants, and education consultants.

The role of the CCHC is to promote the health and development of children, families, and staff and to ensure a healthy and safe child care environment (11).

The CCHC is not acting as a primary care provider at the facility but offers critical services to the program and families by sharing health and developmental expertise, assessments of child, staff, and family health needs and community resources. The CCHC assists families in care coordination with the medical home and other health and developmental specialists. In addition, the CCHC should collaborate with an interdisciplinary team of early childhood consultants, such as, early childhood education, mental health, and nutrition consultants.

In order to provide effective consultation and support to programs, the CCHC should avoid conflict of interest related to other roles such as serving as a caregiver/teacher or regulator or a parent/guardian at the site to which child care health consultation is being provided.

The CCHC should have regular contact with the facility’s administrative authority, the staff, and the parents/guardians in the facility. The administrative authority should review, and collaborate with the CCHC in implementing recommended changes in policies and practices. In the case of consulting about children with special health care needs, the CCHC should have contact with the child’s medical home with permission from the child’s parent/guardian.

Programs with a significant number of non-English-speaking families should seek a CCHC who is culturally sensitive and knowledgeable about community health resources for the parents’/guardians’ native culture and languages.

RATIONALE
CCHCs provide consultation, training, information and referral, and technical assistance to caregivers/teachers (10). Growing evidence suggests that CCHCs support healthy and safe early care and education settings and protect and promote the healthy growth and development of children and their families (1-10). Setting health and safety policies in cooperation with the staff, parents/guardians, health professionals, and public health authorities will help ensure successful implementation of a quality program (3). The specific health and safety consultation needs for an individual facility depend on the characteristics of that facility (1-2). All facilities should have an overall child care health consultation plan (1,2,10).

The special circumstances of group care may not be part of the health care professional’s usual education. Therefore, caregivers/teachers should seek child care health consultants who have the necessary specialized training or experience (10). Such training is available from instructors who are graduates of the National Training Institute for Child Care Health Consultants (NTI) and in some states from state-level mentoring of seasoned child care health consultants known to chapter child care contacts networked through the Healthy Child Care America (HCCA) initiatives of the AAP.

Some professionals may not have the full range of knowledge and expertise to serve as a child care health consultant but can provide valuable, specialized expertise. For example, a sanitarian may provide consultation on hygiene and infectious disease control and a Certified Playground Safety Inspector would be able to provide consultation about gross motor play hazards.

COMMENTS
The U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) has supported the development of state systems of child care health consultants through HCCA and State Early Childhood Comprehensive Systems grants. Child care health consultants provide services to centers as well as family child care homes through on-site visits as well as phone or email consultation. Approximately twenty states are funding child care health consultant initiatives through a variety of funding sources, including Child Care Development Block Grants, TANF, and Title V. In some states a wide variety of health consultants, e.g., nutrition, kinesiology (physical activity), mental health, oral health, environmental health, may be available to programs and those consultants may operate through a team approach. Connecticut is an example of one state that has developed interdisciplinary training for early care and education consultants (health, education, mental health, social service, nutrition, and special education) in order to develop a multidisciplinary approach to consultation (8).

Some states offer CCHC training with continuing education units, college credit, and/or a certificate of completion. Credentialing is an umbrella term referring to the various means employed to designate that individuals or organizations have met or exceeded established standards. These may include accreditation of programs or organizations and certification, registration, or licensure of individuals. Accreditation refers to a legitimate state or national organization verifying that an educational program or organization meets standards. Certification is the process by which a non-governmental agency or association grants recognition to an individual who has met predetermined qualifications specified by the agency or association. Certification is applied for by individuals on a voluntary basis and represents a professional status when achieved. Typical qualifications include 1) graduation from an accredited or approved program and 2) acceptable performance on a qualifying examination. While there is no national accreditation of CCHC training programs or individual CCHCs at this time, this is a future goal. 

CCHC services may be provided through the public health system, resource and referral agency, private source, local community action program, health professional organizations, other non-profit organizations, and/or universities. Some professional organizations include child care health consultants in their special interest groups, such as the AAP’s Section on Early Education and Child Care and the National Association of Pediatric Nurse Practitioners (NAPNAP).

CCHCs who are not employees of health, education, family service or child care agencies may be self-employed. Compensating them for their services via fee-for-service, an hourly rate, or a retainer fosters access and accountability.

Listed below is a sample of the policies and procedures child care health consultants should review and approve:

  1. Admission and readmission after illness, including inclusion/exclusion criteria;
  2. Health evaluation and observation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance;
  3. Plans for care and management of children with communicable diseases;
  4. Plans for prevention, surveillance and management of illnesses, injuries, and behavioral and emotional problems that arise in the care of children;
  5. Plans for caregiver/teacher training and for communication with parents/guardians and primary care providers;
  6. Policies regarding nutrition, nutrition education, age-appropriate infant and child feeding, oral health, and physical activity requirements;
  7. Plans for the inclusion of children with special health or mental health care needs as well as oversight of their care and needs;
  8. Emergency/disaster plans;
  9. Safety assessment of facility playground and indoor play equipment;
  10. Policies regarding staff health and safety;
  11. Policy for safe sleep practices and reducing the risk of SIDS;
  12. Policies for preventing shaken baby syndrome/abusive head trauma;
  13. Policies for administration of medication;
  14. Policies for safely transporting children;
  15. Policies on environmental health – handwashing, sanitizing, pest management, lead, etc.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.3 Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants
REFERENCES
  1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.
  2. Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21.
  3. Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
  4. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.
  5. Farrer, J., A. Alkon, K. To. 2007. Child care health consultation programs: Barriers and opportunities. Maternal Child Health J 11:111-18.
  6. Heath, J. M., et al. 2005. Creating a statewide system of multi-disciplinary consultation system for early care and education in Connecticut. Farmington, CT: Child Health and Development Institute of Connecticut. http://nitcci.nccic.acf.hhs.gov/resources/10262005_93815_901828.pdf.
  7. Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
  8. Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health consultation: A conceptual model. J for Specialists in Pediatric Nurs 13:74-88.
  9. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nurs 32:530-37.
  10. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.
  11. Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81.

1.6.0.2: Frequency of Child Care Health Consultation Visits

Content in the STANDARD was modified on 8/22/2013.


The child care health consultant (CCHC) should visit each facility as needed to review and give advice on the facility’s health component and review the overall health status of the children and staff (1-4). Early childhood programs that serve any child younger than three years of age should be visited at least once monthly by a health professional with general knowledge and skills in child health and safety and health consultation. Child care programs that serve children three to five years of age should be visited at least quarterly and programs serving school-age children should be visited at least twice annually. In all cases, the frequency of visits should meet the needs of the composite group of children and be based on the needs of the program for training, support, and monitoring of child health and safety needs, including (but not limited to) infectious disease, injury prevention, safe sleep, nutrition, oral health, physical activity and outdoor learning, emergency preparation, medication administration, and the care of children with special health care needs. Written documentation of CCHC visits should be maintained at the facility.
RATIONALE
Almost everything that goes on in a facility and almost everything about the facility itself affects the health of the children, families, and staff. (1-4). Because infants are developing rapidly, environmental situations can quickly create harm. Their rapid changes in behavior make regular and frequent visits by the CCHC extremely important (2-4). More frequent visits should be arranged for those facilities that care for children with special health care needs and those programs that experience health and safety problems and high turnover rate to ensure that staff have adequate training and ongoing support (2). In one study, 84% of child care directors who were required to have weekly health consultation visits considered the visits critical for children’s health and program health and safety (2). Growing evidence suggests that frequent visits by a trained health consultant improves health policies and health and safety practices  and improves children’s immunization status, access to a medical home, enrollment in health insurance, timely screenings, and potentially reduces the prevalence of obesity with a targeted intervention (5-11). Furthermore, in one state, child care center medication administration regulatory compliance was associated with weekly visits by a trained nurse child care health consultant who delivered a standardized best practice curriculum (12).
COMMENTS
State child care regulations display a wide range of frequency and recommendations in states that require CCHC visits (5,6,13), from as frequently as once a week for programs serving children under three years of age to twice a year for programs serving children three to five years of age (2,5,6,13).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.6.0.1 Child Care Health Consultants
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
4.4.0.1 Food Service Staff by Type of Facility and Food Service
4.6.0.2 Nutritional Quality of Food Brought From Home
9.4.1.17 Documentation of Child Care Health Consultation/Training Visits
10.3.4.3 Support for Consultants to Provide Technical Assistance to Facilities
10.3.4.4 Development of List of Providers of Services to Facilities
REFERENCES
  1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.
  2. Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
  3. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37.
  4. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.
  5. Healthy Child Care Consultant Network Support Center, CHT Resource Group. 2006. The influence of child care health consultants in promoting children’s health and well-being: A report on selected resources. http://hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf.
  6. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.
  7. Crowley, A. A. & Kulikowich, J. Impact of training on child care health consultant knowledge and practice. Pediatric Nursing.,2009, 35 (2): 93-100.
  8. Nurse Consultant Intervention Improves Nutrition and Physical Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care.  A. Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, V. Ngyuen, J. Kotch. Head Start Research Conference, Washington, DC. June 20, 2012.
  9. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. Nutrition and physical activity self-assessment for child care (NAP SACC): Results from a pilot intervention. Journal of Nutrition Education and Behavior 39(3):142-9.
  10. Bryant, D. “Quality Interventions for Early Care and Education.” Early Developments, Spring 2013, http://fpg.unc.edu/sites/default/files/resources/early-developments/FPG_EarlyDevelopments_v14n1.pdf.
  11. Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Improvement of child care programs’ policies, practices, and children’s access to health care linked to child care health consultation. NHSA Dialog: A Research to Practice Journal 2013;16 (2):34-52 (ISSN:1930-1395).
  12. Crowley, A. A. & Rosenthal, M. S. IMPACT: Ensuring the health and safety of Connecticut’s early care and education programs. 2009. Farmington, CT: The Child Health and Development Institute of Connecticut.
  13. National Resource Center for Health and Safety in Child Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/default/assets/File/CCHC%20by%20state%20NOV%202012_FINAL.pdf.
NOTES

Content in the STANDARD was modified on 8/22/2013.

1.6.0.3: Early Childhood Mental Health Consultants


A facility should engage a qualified early childhood mental health consultant who will assist the program with a range of early childhood social-emotional and behavioral issues and who will visit the program at minimum quarterly and more often as needed.

The knowledge base of an early childhood mental health consultant should include:

  1. Training, expertise and/or professional credentials in mental health (e.g., psychiatry, psychology, clinical social work, nursing, developmental-behavioral medicine, etc.);
  2. Early childhood development (typical and atypical) of infants, toddlers, and preschool age children;
  3. Early care and education settings and practices;
  4. Consultation skills and approaches to working as a team with early childhood consultants from other disciplines, especially health and education consultants, to effectively support directors and caregivers/teachers.

The role of the early childhood mental health consultant should be focused on building staff capacity and be both proactive in decreasing the incidence of challenging classroom behaviors and reactive in formulating appropriate responses to challenging classroom behaviors and should include:

  1. Developing and implementing classroom curricula regarding conflict resolution, emotional regulation, and social skills development;
  2. Developing and implementing appropriate screening and referral mechanisms for behavioral and mental health needs;
  3. Forming relationships with mental health providers and special education systems in the community;
  4. Providing mental health services, resources and/or referral systems for families and staff;
  5. Helping staff facilitate and maintain mentally healthy environments within the classroom and overall system;
  6. Helping address mental health needs and reduce job stress within the staff;
  7. Improving management of children with challenging behaviors;
  8. Preventing the development of problem behaviors;
  9. Providing a classroom climate that promotes positive social-emotional development;
  10. Recognizing and appropriately responding to the needs of children with internalizing behaviors, such as persistent sadness, anxiety, and social withdrawal;
  11. Actively teaching developmentally appropriate social skills, conflict resolution, and emotional regulation;
  12. Addressing the mental health needs and daily stresses of those who care for young children, such as families and caregivers/teachers;
  13. Helping the staff to address and handle unforeseen crises or bereavements that may threaten the mental health of staff or children and families, such as the death of a caregiver/teacher or the serious illness of a child.
RATIONALE
As increasing numbers of children are spending longer hours in child care settings, there is an increasing need to build the capacity of caregivers/teachers to attend to the social-emotional and behavioral well-being of children as well as their health and learning needs. Early childhood mental health underlies much of what constitutes school readiness, including emotional and behavioral regulation, social skills (i.e., taking turns, postponing gratification), the ability to inhibit aggressive or anti-social impulses, and the skills to verbally express emotions, such as frustration, anger, anxiety, and sadness. Supporting children’s health, mental health and learning requires a comprehensive approach. Child care programs need to have health, education, and mental health consultants who can help them implement universal, selected and targeted strategies to improve school readiness in young children in their care (1-5). Mental health consultants in collaboration with education and child care health consultants can reduce the risk for children being expelled, can reduce levels of problem behaviors, increase social skills and build staff efficacy and capacity (1-11).
COMMENTS
Access to an early childhood mental health consultant should be in the context of an ongoing relationship, with at least quarterly regular visits to the classroom to consult. However, even an on-call-only relationship is better than no relationship at all. Regardless of the frequency of contact, this relationship should be established before a crisis arises, so that the consultant can establish a useful proactive working relationship with the staff and be quickly mobilized when needs arise. This consultant should be viewed as an important part of the program’s support staff and should collaborate with all regular classroom staff, administration, and other consultants such as child care health consultants and education consultants, and support staff. In most cases, there is no single place in which to look for early childhood mental health consultants. Qualified potential consultants may be identified by contacting mental health and behavioral providers (e.g., child clinical and school psychologists, licensed clinical social workers, child psychiatrists, developmental pediatricians, etc.), as well as training programs at local colleges and universities where these professionals are being trained. Colleges and universities may be a good place to find well-supervised consultants-in-training at a potentially reasonable cost, although consultant turnover may be higher.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
1.6.0.4 Early Childhood Education Consultants
REFERENCES
  1. Brennan, E. M., J. Bradley, M. D. Allen, D. F. Perry. 2008. The evidence base for mental health consultation in early childhood settings: A research synthesis addressing staff and program outcomes. Early Ed Devel 19:982-1022.
  2. National Scientific Council on the Developing Child. 2008. Mental health problems in early childhood can impair learning and behavior for life. Working Paper no. 6. http://developingchild.harvard.edu/library/reports_and_working_papers/working_papers/wp6/.
  3. Perry, D. F., M. D. Allen, E. M. Brennan, J. R. Bradley. 2010. The evidence base for mental health consultation in early childhood settings: A research synthesis addressing children’s behavioral outcomes. Early Ed Devel 21:795-824.
  4. Perry, D. F., R. Kaufmann, J. Knitzer. 2007. Early childhood social and emotional health: Building bridges between services and systems. Baltimore, MD: Paul Brookes Publishing.
  5. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing the risk for preschool expulsion: Mental health consultation for young children with challenging behaviors. J Child Fam Studies 17:44-54.
  6. Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: National Academy Press.
  7. Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development (FCD). Policy Brief Series no. 3. New York: FCD. http://www.challengingbehavior.org/explore/policy_docs/prek
    _expulsion.pdf.
  8. Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.
  9. Gilliam, W. S. 2007. Early Childhood Consultation Partnership: Results of a random-controlled evaluation. New Haven, CT: Yale Universty. http://www.chdi.org/admin/uploads/5468903394946c41768730.pdf.
  10. American Academy of Pediatrics, Committee on School Health. 2003. Policy statement: Out-of-school suspension and expulsion. Pediatrics 112:1206-9.
  11. Duran, F., K. Hepburn, M. Irvine, R. Kaufmann, B. Anthony, N. Horen, D. Perry. 2009. What works?: A study of effective early childhood mental health consultation programs. Washington, DC: Georgetown University Center for Child and Human Development. http://gucchdtacenter.georgetown.edu/publications/ECMHCStudy
    _Report.pdf.

1.6.0.4: Early Childhood Education Consultants


A facility should engage an early childhood education consultant who will visit the program at minimum semi-annually and more often as needed. The consultant must have a minimum of a Baccalaureate degree and preferably a Master’s degree from an accredited institution in early childhood education, administration and supervision, and a minimum of three years in teaching and administration of an early care/education program. The facility should develop a written plan for this consultation which must be signed annually by the consultant. This plan should outline the responsibilities of the consultant and the services the consultant will provide to the program.

The knowledge base of an early childhood education consultant should include:

  1. Working knowledge of theories of child development and learning for children from birth through eight years across domains, including socio-emotional development and family development;
  2. Principles of health and wellness across the domains, including social and emotional wellness and approaches in the promotion of healthy development and resilience;
  3. Current practices and materials available related to screening, assessment, curriculum, and measurement of child outcomes across the domains, including practices that aid in early identification and individualizing for a wide range of needs;
  4. Resources that aid programs to support inclusion of children with diverse health and learning needs and families representing linguistic, cultural, and economic diversity of communities;
  5. Methods of coaching, mentoring, and consulting that meet the unique learning styles of adults;
  6. Familiarity with local, state, and national regulations, standards, and best practices related to early education and care;
  7. Community resources and services to identify and serve families and children at risk, including those related to child abuse and neglect and parent education;
  8. Consultation skills as well as approaches to working as a team with early childhood consultants from other disciplines, especially child care health consultants, to effectively support program directors and their staff.

The role of the early childhood education consultant should include:

  1. Review of the curriculum and written policies, plans and procedures of the program;
  2. Observations of the program and meetings with the director, caregivers/teachers, and parents/guardians;
  3. Review of the professional needs of staff and program and provision of recommendations of current resources;
  4. Reviewing and assisting directors in implementing and monitoring evidence based approaches to classroom management;
  5. Maintaining confidences and following all Family Educational Rights and Privacy Act (FERPA) regulations regarding disclosures;
  6. Keeping records of all meetings, consultations, recommendations and action plans and offering/providing summary reports to all parties involved;
  7. Seeking and supporting a multidisciplinary approach to services for the program, children and families;
  8. Following the National Association for the Education of Young Children (NAEYC) Code of Ethics;
  9. Availability by telecommunication to advise regarding practices and problems;
  10. Availability for on-site visit to consult to the program;
  11. Familiarity with tools to evaluate program quality, such as the Early Childhood Environment Rating Scale–Revised (ECERS–R), Infant/Toddler Environment Rating Scale–Revised (ITERS–R), Family Child Care Environment Rating Scale–Revised (FCCERS–R), School-Age Care Environment Rating Scale (SACERS), Classroom Assessment Scoring System (CLASS), as well as tools used to support various curricular approaches.
RATIONALE
The early childhood education consultant provides an objective assessment of a program and essential knowledge about implementation of child development principles through curriculum which supports the social and emotional health and learning of infants, toddlers and preschool age children (1-5). Furthermore, utilization of an early childhood education consultant can reduce the need for mental health consultation when challenging behaviors are the result of developmentally inappropriate curriculum (6,7). Together with the child care health consultant, the early childhood education consultant offers core knowledge for addressing children’s healthy development.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
1.6.0.3 Early Childhood Mental Health Consultants
REFERENCES
  1. Dunn, L., K. Susan. 1997. What have we learned about developmentally appropriate practice? Young Children 52:4-13.
  2. Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics Early Childhood Special Ed 26:131-41.
  3. Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53.
  4. Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. Baltimore, MD: Brookes Publishing.
  5. Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Rev ed. National Association for the Education of Young Children (NAEYC). Publication no. 234. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
  6. The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org.
  7. Connecticut Department of Public Health. Child day care licensing program. http://www.ct.gov/dph/cwp/view
    .asp?a=3141&Q=387158&dphNav_GID=1823/.

1.6.0.5: Specialized Consultation for Facilities Serving Children with Disabilities


When children at the facility include those with special health care needs, developmental delay or disabilities, and mental health or behavior problems, the staff or documented consultants should involve any of the following consultants in the child’s care, with prior informed, written parental consent and as appropriate to each child’s needs:

  1. A registered nurse, nurse practitioner with pediatric experience, or child care health consultant;
  2. A physician with pediatric experience, especially those with developmental-behavioral training;
  3. A registered dietitian;
  4. A psychologist;
  5. A psychiatrist;
  6. A physical therapist;
  7. An adaptive equipment technician;
  8. An occupational therapist;
  9. A speech pathologist;
  10. An audiologist for hearing screenings conducted on-site at child care;
  11. A vision screener;
  12. A respiratory therapist;
  13. A social worker;
  14. A parent/guardian of a child with special health care needs;
  15. Part C representative/service coordinator;
  16. A mental health consultant;
  17. Special learning consultant/teacher (e.g., teacher specializing in work with visually impaired child or sign language interpreters);
  18. A teacher with special education expertise;
  19. The caregiver/teacher;
  20. Individuals identified by the parent/guardian;
  21. Certified child passenger safety technician with training in safe transportation of children with special needs.
RATIONALE
The range of professionals needed may vary with the facility, but the listed professionals should be available as consultants when needed. These professionals need not be on staff at the facility, but may simply be available when needed through a variety of arrangements, including contracts, agreements, and affiliations. The parent’s participation and written consent in the native language of the parent, including Braille/sign language, is required to include outside consultants (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Cohen, A. J. 2002. Liability exposure and child care health consultation. http://www.ucsfchildcarehealth.org/pdfs/forms/CCHCLiability.pdf.

1.7 Staff Health

1.7.0

1.7.0.1: Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

Frequently Asked Questions/CFOC3 Clarifications

Reference: 1.7.0.1

Date: 2/17/2012

Topic & Location:
Chapter 1
Staffing
1.7.0.1: Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

Question:
This standard title suggests that something will be said about ongoing adult health appraisals and immunization, but the standard only addresses prechild contact requirements. Further, isn’t a “pre-employment” health appraisal not permitted before a job offer is made per the Equal Employment Opportunity Commission regulations? Shouldn’t there be a requirement for a health appraisal whenever someone has a change in position or role that has physical requirements and at least at the intervals recommended by whoever makes credentialed recommendations for such services for adults?

Answer:
The intention of this standard is that a pre-employment health appraisal of all paid and volunteer staff should be conducted and that ongoing health appraisals should be required based on the employee’s primary health care provider’s recommendation and/or if there is a change in the physical requirements of the position or role. "Pre-employment" does not mean pre-hire. Often a job offer is issued and a pre-employment screening is then required prior to the assigned employment date.


All paid and volunteer staff members should have a health appraisal before their first involvement in child care work. The appraisal should identify any accommodations required of the facility for the staff person to function in his or her assigned position.

Health appraisals for paid and volunteer staff members should include:

  1. Physical exam;
  2. Dental exam;
  3. Vision and hearing screening;
  4. The results and appropriate follow up of a tuberculosis (TB) screening, using the Tuberculin Skin Test (TST) or IGRA (interferon gamma release assay), once upon entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter;
  5. A review and certification of up-to-date immune status per the current Recommended Adult Immunization Schedule found in Appendix H, including annual influenza vaccination and up to date Tdap;
  6. A review of occupational health concerns based on the performance of the essential functions of the job.

All adults who reside in a family child care home who are considered to be at high risk for TB, should have completed TB screening (1) as specified in Standard 7.3.10.1. Adults who are considered at high risk for TB include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active TB.

Testing for TB of staff members with previously negative skin tests should not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation should be on file in the facility.

RATIONALE
Caregivers/teachers need to be physically and emotionally healthy to perform the tasks of providing care to children. Performing their work while ill can spread infectious disease and illness to other staff and the children in their care (2). Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis. Accommodation requires knowledge of conditions that must be accommodated to ensure competent function of staff and the well-being of children in care (3).

Since detection of tuberculosis using screening of healthy individuals has a low yield compared with screening of contacts of known cases of tuberculosis, public health authorities have determined that routine repeated screening of healthy individuals with previously negative skin tests is not a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be subject to modification by local or state health authorities.

COMMENTS
Child care facilities should provide the job description or list of activities that the staff person is expected to perform. Unless the job description defines the duties of the role specifically, under federal law the facility may be required to adjust the activities of that person. For example, child care facilities typically require the following activities of caregivers:
  1. Moving quickly to supervise and assist young children;
  2. Lifting children, equipment, and supplies;
  3. Sitting on the floor and on child-sized furniture;
  4. Washing hands frequently;
  5. Responding quickly in case of an emergency;
  6. Eating the same food as is served to the children (unless the staff member has dietary restrictions);
  7. Hearing and seeing at a distance required for playground supervision or driving;
  8. Being absent from work for illness no more often than the typical adult, to provide continuity of caregiving relationships for children in child care.

Healthy Young Children: A Manual for Programs, from the National Association for the Education of Young Children (NAEYC), provides a model form for an assessment by a health professional. See also Model Child Care Health Policies, from NAEYC and from the American Academy of Pediatrics (AAP).

Concern about the cost of health exams (particularly when many caregivers/teachers do not receive health benefits and earn minimum wage) is a barrier to meeting this standard. When staff members need hepatitis B immunization to meet Occupational Safety and Health Administration (OSHA) requirements (4), the cost of this immunization may or may not be covered under a managed care contract. If not, the cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee’s preparation for work in the child care setting by the prospective employee or the employer. Child care workers are among those for whom annual influenza vaccination is strongly recommended.

Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the country. These centers can be reached by calling 1-800-949-4232 (callers are routed to the appropriate region) or by accessing regional center’s contacts directly at http://adata
.org/Static/Home.aspx.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.7.0.3 Health Limitations of Staff
1.7.0.4 Occupational Hazards
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
7.3.10.1 Measures for Detection, Control, and Reporting of Tuberculosis
7.3.10.2 Attendance of Children with Latent Tuberculosis Infection or Active Tuberculosis Disease
Appendix E: Child Care Staff Health Assessment
REFERENCES
  1. Baldwin, D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female child care providers: Implications for quality of care. J Comm Health Nurs 24:1-7.
  2. Keyes, C. R. 2008. Adults with disabilities in early childhood settings. Child Care Info Exchange 179:82-85.
  3. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p _id=10051.
  4. Centers for Disease Control and Prevention. 2015. Recommended adult immunization schedule – United States, 2015. http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html.

1.7.0.2: Daily Staff Health Check


On a daily basis, the administrator of the facility or caregiver/teacher should observe staff members, substitutes, and volunteers for obvious signs of ill health. When ill, staff members, substitutes and volunteers may be directed to go home. Staff members, substitutes, and volunteers should be responsible for reporting immediately to their supervisor any injuries or illnesses they experience at the facility or elsewhere, especially those that might affect their health or the health and safety of the children. It is the responsibility of the administration, not the staff member who is ill or injured, to arrange for a substitute caregiver/teacher.
RATIONALE
Sometimes adults report to work when feeling ill or become ill during the day but believe it is their responsibility to stay. The administrator’s or caregiver’s/teacher’s observation of illness followed by sending the staff member home may prevent the spread of illness. Arranging for a substitute caregiver/teacher ensures that the children receive competent care (1,2).
COMMENTS
Administrators and caregivers/teachers need guidelines to ensure proper application of this standard. For a demonstration of how to implement this standard, see the video series, Caring for Our Children, available from National Association for the Education of Young Children (NAEYC) and the American Academy of Pediatrics (AAP) (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Baldwin D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female child care providers: Implications for quality of care. J Comm Health Nurs 24:1-7.
  2. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

1.7.0.3: Health Limitations of Staff


Staff and volunteers must have a primary care provider’s release to return to work in the following situations:

  1. When they have experienced conditions that may affect their ability to do their job or require an accommodation to prevent illness or injury in child care work related to their conditions (such as pregnancy, specific injuries, or infectious diseases);
  2. After serious or prolonged illness;
  3. When their condition or health could affect promotion or reassignment to another role;
  4. Before return from a job-related injury;
  5. If there are workers’ compensation issues or if the facility is at risk of liability related to the employee’s or volunteer’s health problem.

If a staff member is found to be unable to perform the activities required for the job because of health limitations, the staff person’s duties should be limited or modified until the health condition resolves or employment is terminated because the facility can prove that it would be an undue hardship to accommodate the staff member with the disability.

RATIONALE
Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation (1). Undue hardship is defined also on a case by case basis (1).
COMMENTS
Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers throughout the country. These centers can be reached by calling 1-800-949-4232 and callers are routed to the appropriate region or accessing contacts directly at http://adata.org/Static/
Home.aspx.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
7.6.1.4 Informing Public Health Authorities of Hepatitis B Virus (HBV) Cases
7.6.3.4 Ability of Caregivers/Teachers with HIV Infection to Care for Children
REFERENCES
  1. ADA National Network. The Americans with Disabilities Act (ADA) from a civil rights perspective. http://adaanniversary.org/2010/ap03_ada_civilrights/03_ada_civilrights_09_natl.pdf.

1.7.0.4: Occupational Hazards


Written personnel policies of centers and large family child care homes should address the major occupational health hazards for workers in child care settings. Special health concerns of pregnant caregivers/teachers should be carefully evaluated, and up-to-date information regarding occupational hazards for pregnant caregivers/teachers should be made available to them and other workers. The occupational hazards including those regarding pregnant workers listed in Appendix B: Major Occupational Health Hazards, should be referenced and used in evaluations by caregivers/teachers and supervisors.
RATIONALE
Early care and education employees need to learn about and practice ways to minimize risk of illness and injury and promote wellness for themselves (1). As a workforce composed primarily of women of childbearing age, pregnancy is common among caregivers/teachers in child care settings. All female staff members of childbearing age should be encouraged to discuss the potential exposure to risks that could cause harm to their unborn child with their primary health care provider (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

1.7.0.5: Stress


Caregivers/teachers should be able to:

  1. Identify risks associated with stress;
  2. Identify stressors specific to child caregiving;
  3. Identify specific ways to manage stress in the child care environment.

The following measures to lessen stress for the staff should be implemented to the maximum extent possible:

  1. Wages and benefits (including health care insurance) that fairly compensate the skills, knowledge, and performance required of caregivers/teachers, at the levels of wages and benefits paid for other jobs that require comparable skills, knowledge, and performance;
  2. Job security;
  3. Training to improve skills and hazard recognition;
  4. Stress management and reduction training;
  5. Written plan/policy in place for the situation in which a caregiver/teacher recognizes that s/he or a colleague is stressed and needs help immediately (the plan should allow for caregivers/teachers who feel they may lose control to have a short, but relatively immediate break away from the children at times of high stress);
  6. Regular work breaks and paid time-off;
  7. Appropriate child:staff ratios;
  8. Liability insurance for caregivers/teachers;
  9. Staff lounge separate from child care area with adult size furniture;
  10. The use of sound-absorbing materials in the workspace;
  11. Regular performance reviews which, in addition to addressing any areas requiring improvement, provide constructive feedback, individualized encouragement and appreciation for aspects of the job well performed;
  12. Stated provisions for back-up staff, for example, to allow caregivers/teachers to take necessary time off when ill without compromising the function of the center or incurring personal negative consequences from the employer (this back-up should also include a stated plan to be implemented in the event a staff member needs to have a short, but relatively immediate break away from the children);
  13. Adult size furniture in the classroom for the staff;
  14. Access to experts in child development and behavior to help problem solve child specific issues.
RATIONALE
One of the best indicators of quality child care is consistent staff with low turnover rates (5,6).

According to the Bureau of Labor Statistics’ Website, “in 2007, hourly earnings of nonsupervisory workers in the child day care services industry averaged $10.53” (1). About 42% of all child care workers have a high school degree or less, reflecting the minimal training requirements for most jobs. Many child care workers leave the industry due to stressful working conditions and dissatisfaction with benefits and pay (1).

Stress reduction measures (particularly adequate wages and reasonable health care benefits) contribute to decreased staff turnover and thereby promote quality care (2). The health, welfare, and safety of adult workers in child care determine their ability to provide care for the children.

Serious physical abuse sometimes occurs when the caregiver/teacher is under high stress. Too much stress can not only affect the caregiver’s/teacher’s health, but also the quality of the care that the adult is able to give. A caregiver/teacher who is feeling too much stress may not be able to offer the praise, nurturing, and direction that children need for good development (3). Regular breaks with substitutes when the caregiver/teacher cannot continue to provide safe care can help ensure quality child care.

Sound-absorbing materials in the work area, break times, and a separate lounge allow for respite from noise and from non-auditory stress. Unwanted sound, or noise, can be damaging to hearing as well as to psychosocial well-being. The stress effects of noise will aggravate other stress factors present in the facility. Lack of adequate sound reduction measures in the facility can force the caregiver/teacher to speak at levels above those normally used for conversation, and thus may increase the risk of throat irritation. When caregivers/teachers raise their voices to be heard, the children tend to raise theirs, escalating the problem.

COMMENTS
Documentation of implementation of stress reduction measures should be on file in the facility.

Rest breaks of twenty minutes or less are customary in industry and are customarily paid for as working time. Meal periods (typically thirty minutes or more) generally need not be compensated as work time as long as the employee is completely relieved from duty for the entire meal period (4). For resources on respite or crisis care, contact the ARCH National Respite Network at http://archrespite.org.

Caregivers/teachers who use tobacco can experience stress related to nicotine withdrawals. For help dealing with stress from tobacco addiction, see the Tobacco Research and Intervention Program’s Forever Free booklet on smoking, stress, and mood at http://www.smokefree.gov/pubs/FFree6.pdf. Or, for help quitting smoking, visit the Smoke Free Website at http://www.smokefree.gov.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
REFERENCES
  1. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Career guide to industries: Child day care services, 2010-11 Edition. http://www.bls.gov/oco/cg/cgs032.htm.
  2. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Occupational employment statistics: occupational employment and wages, May 2009. http://www.bls.gov/oes/current/oes399011.htm.
  3. Healthy Childcare Consultants (HCCI). Stress management for child caregivers. Pelham, AL: HCCI.
  4. U.S. Department of Labor, Wage and Hour Division. 2009. Fact sheet #46: Daycare centers and preschools under the Fair Labor Standards Act (FLSA). Rev. ed. http://www.dol.gov/whd/regs/compliance/whdfs46.pdf.
  5. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  6. National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD.

1.8 Human Resource Management

1.8.1 Benefits

1.8.1.1: Basic Benefits


The following basic benefits should be offered to staff:

  1. Affordable health insurance;
  2. Paid time-off (vacation, sick time, personal leave, holidays, family, parental and medical leave, etc.);
  3. Social Security or other retirement plan;
  4. Workers’ compensation;
  5. Educational benefits.

Centers and large family child care homes should have written policies that detail these benefits of employees at the facility.

RATIONALE
The quality and continuity of the child care workforce is the main determining factor of the quality of care. Nurturing the nurturers is essential to prevent burnout and promote retention. Fair labor practices should apply to child care as well as other work settings. Child care workers should be considered as worthy of benefits as workers in other careers.

Medical coverage should include the cost of the health appraisals and immunizations required of child care workers, and care for the increased incidence of communicable disease and stress-related conditions in this work setting.

The potential for acquiring injuries and infections when caring for young children is a health and safety hazard for child care workers. Information abounds about the risk of infectious disease for children in child care settings. Children are reservoirs for many infectious agents. Staff members come into close and frequent contact with children and their excretions and secretions and are vulnerable to these illnesses. In addition, many child care workers are women who are planning a pregnancy or who are pregnant, and they may be vulnerable to potentially serious effects of infection on the outcome of pregnancy (2).

Sick leave is important to minimize the spread of communicable diseases and maintain the health of staff members. Sick leave promotes recovery from illness and thereby decreases the further spread or recurrence of illness.

Workplace benefits contribute to higher morale and less staff turnover, and thus promote quality child care. Lack of benefits is a major reason reported for high turnover of child care staff (1).

COMMENTS
Staff benefits may be appropriately addressed in center personnel policies and in state and federal labor standards. Not all the material that has to be addressed in these policies is appropriate for state child care licensing requirements. Having facilities acknowledge which benefits they do provide will help enhance the general awareness of staff benefits among child care workers and other concerned parties. Currently, this standard is difficult for many facilities to achieve, but new federal programs and shared access to small business benefit packages will help. Many options are available for providing leave benefits and education reimbursements, ranging from partial to full employer contribution, based on time employed with the facility.

Caregivers/teachers should be encouraged to have health insurance. Health benefits can include full coverage, partial coverage (at least 75% employer paid), or merely access to group rates. Some local or state child care associations offer reduced group rates for health insurance for child care facilities and individual caregivers/teachers.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
9.3.0.1 Written Human Resource Management Policies for Centers and Large Family Child Care Homes
REFERENCES
  1. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The national child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
  2. National Association for the Education of Young Children (NAEYC). 2008. Leadership and management: A guide to the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC.

1.8.2 Evaluation

1.8.2.1: Staff Familiarity with Facility Policies, Plans and Procedures


All caregivers/teachers should be familiar with the provisions of the facility’s policies, plans, and procedures, as described in Chapter 9: Administration. The compliance with these policies, plans, and procedures should be used in staff performance evaluations and documented in the personnel file.
RATIONALE
Written policies, plans and procedures provide a means of staff orientation and evaluation essential to the operation of any organization (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Boone, L. E., D. L. Kurtz. 2010. Contemporary business. Hoboken, NJ: John Wiley and Sons.

1.8.2.2: Annual Staff Competency Evaluation


For each employee, there should be a written annual self-evaluation, a performance review from the personnel supervisor, and a continuing education/professional development plan based on the needs assessment, described in Standard 1.4.4.1 through Standard 1.4.5.4.
RATIONALE
A system for evaluation of employees is a basic component of any personnel policy (1). Staff members who are well trained are better able to prevent, recognize, and correct health and safety problems (2).
COMMENTS
Formal evaluation is not a substitute for continuing feedback on day-to-day performance. Performance appraisals should include a customer satisfaction component and/or a peer review component. Compliance with this standard may be determined by licensing requirements set by the state and local regulatory processes, and by state and local funding requirements, or by accrediting bodies (1). In some states, a central Child Development Personnel Registry may track and certify the qualifications of staff.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
1.8.2.2 Annual Staff Competency Evaluation
REFERENCES
  1. National Association for the Education of Young Children (NAEYC). 2008. Leadership and management: A guide to the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC.
  2. Owens, C. 1997. Rights in the workplace: A guide for child care teachers. Washington, DC: Worker Option Resource Center.

1.8.2.3: Staff Improvement Plan


When a staff member of a center or a large family child care home does not meet the minimum competency level, that employee should work with the employer to develop a plan to assist the person in achieving the necessary skills. The plan should include a timeline for completion and consequences if it is not achieved.
RATIONALE
Children must be protected from incompetent caregiving. A system for evaluation and a plan to promote continued development are essential to assist staff to meet performance requirements (1).
COMMENTS
Whether the caregiver/teacher meets the minimum competency level is related to the director’s assessment of the caregiver’s/teacher’s performance.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.1.1 Pre-service Training
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
9.4.3.1 Maintenance and Content of Staff and Volunteer Records
REFERENCES
  1. University of California Berkeley Human Resources. Guide to managing human resources. Chapter 7: Performance management. http://hrweb.berkeley.edu/guides/managing-hr/managing
    -successfully/performance-management/introduction/.

1.8.2.4: Observation of Staff


Observation of staff by a designee of the program director should include an assessment of each member’s adherence to the policies and procedures of the facility with respect to sanitation, hygiene, and management of infectious diseases. Routine, direct observation of employees is the best way to evaluate hygiene and safety practices. The observation should be followed by positive and constructive feedback to staff. Staff will be informed in their job description and/or employee handbook that observations will be made.
RATIONALE
Ongoing observation is an effective tool to evaluate consistency of staff adherence to program policies and procedures (1). It also serves to identify areas for additional orientation and training.
COMMENTS
Videotaping of these assessments may be a useful way to provide feedback to staff around their adherence to policies and procedures regarding hygiene and safety practices. If videotaping includes interactions with children, parent/guardian permission must be obtained before taping occurs. Desirable interactions can be encouraged and discussing methods of improvement can be facilitated through videotaping. Videotaped interactions can also prove useful to caregivers/teachers when informing, illustrating and discussing an issue with the parents/guardians. It gives the parents/guardians a chance to interpret the observations and begin a healthy, respectful dialogue with caregivers/teachers in developing a consistent approach to supporting their child’s healthy development. Sharing videotaping must have participant approval to avoid privacy issues.

If the staff follows the National Association for the Education of Young Children (NAEYC) Code of Ethical Conduct, peers are expected to observe, support and guide peers. In addition within the role of the child care health consultant and the education consultant are guidelines for observation of staff within the classroom. It should be within the role of the director and assistant director guidelines for direct observation of staff for health, safety, developmentally appropriate practice, and curriculum. For more information on the NAEYC Code of Ethical Conduct, go to http://www.naeyc.org/files/naeyc/file/positions/PSETH05.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Nolan, Jr., J. F., L. A. Hoover. 2010. Teacher supervision and evaluation. Hoboken, NJ: John Wiley and Sons.

1.8.2.5: Handling Complaints About Caregivers/Teachers


When complaints are made to licensing or referral agencies about caregivers/teachers, the caregivers/teachers should receive formal notice of the complaint and the resulting action, if any. Caregivers/teachers should maintain records of such complaints, post substantiated complaints with correction action, make them available to parents/guardians on request, and post a notice of how to contact the state agency responsible for maintaining complaint records.
RATIONALE
Parents/guardians seeking child care should know if previous complaints have been made, particularly if the complaint is substantiated. This information should be easily accessible to the parents/guardians. Parents/guardians can then evaluate whether or not the complaint is valid, and whether the complaint has been adequately addressed and necessary changes have been made.
COMMENTS
This policy requires program development by licensing agencies.
TYPE OF FACILITY
Center, Large Family Child Care Home

Chapter 2: Program Activities for Healthy Development

2.1 Program of Developmental Activities

2.1.1 General Program Activities

2.1.1.1: Written Daily Activity Program and Statement of Principles

Content in the STANDARD was modified on 5/30/2018


Facilities should have a written comprehensive and coordinated planned program of daily activities appropriate for groups of children at each stage of early childhood. This plan should be based on a statement of principles for the facility and each child’s individual development.The objective of the program of daily activities should be to foster incremental developmental progress in a healthy and safe environment, and the program should be flexible to capture the interests and individual abilities of the children.

Infants and toddlers learn through healthy and ongoing relationships with primary caregivers/teachers, and a relationship-based plan should be shared with parents/guardians that includes opportunities for parents/guardians to be an integral partner and member of this relationship system.

Centers and all family child care homes should develop a written statement of principles that set out the basic elements from which the daily indoor/outdoor program is to be built.

These principles should address the following elements:

  1. Overall child health and safety
  2. Physical development, which facilitates small and large motor skills
  3. Family partnership, which acknowledges the essential role of the family, and reflects their culture and language
  4. Social development, which leads to cooperative play with other children and the ability to make relationships with other children, including those  of diverse backgrounds and ability levels and adults 
  5. Emotional development, which facilitates self-awareness and self-confidence
  6. Cognitive development, which includes an understanding of the world and environment in which children live and leads to understanding science, math, and literacy concepts, as well as increasing the use and understanding of language to express feelings and ideas

 

All the principles should be developed with play being the foundation of the planned curriculum. Material such as blocks, clay, paints, books, puzzles, and/or other manipulatives should be available indoors and outdoors to children to further the planned curriculum.

 

The program plan should provide for the incorporation of specific health education topics on a daily basis throughout the year. Topics of health education should include health promotion and disease prevention topics (e.g., handwashing, oral health, nutrition, physical activity, healthy sleep habits) (1-3).

Health and safety behaviors should be modeled by staff to foster healthy habits for children during their time in child care.

Staff should ensure that children and parents/guardians understand the need for a safe indoor and outdoor learning/play environment and feel comfortable when playing indoors and outdoors.

Continuity and consistency by a caring staff are vital so that children and parents/guardians know what to expect.

RATIONALE

Children attending early care and education programs with well-developed curricula are more likely to achieve appropriate levels of development (4).

Early childhood specialists agree on the

  1. Inseparability and interdependence of cognitive, physical, emotional, communication, and social development. Social-emotional capacities do not develop or function separately.
  2. Influence of the child’s health and safety on cognitive, physical, emotional, communication, and social development.
  3. Central importance of continuity and consistent relationships with affectionate care that is the formation of strong, nurturing relationships between caregivers/teachers and children.
  4. Relevance of the development phase or stage of the child.
  5. Importance of action (including play) as a mode of learning and to express self (5).

Those who provide early care and education must be able to articulate the components of the curriculum they are implementing and the related values/principles on which the curriculum is based. In centers and large family child care homes, because more than 2 caregivers/teachers are involved in operating the facility, a written statement of principles helps achieve consensus about the basic elements from which all staff will plan the daily program (4).

A written description of the planned program of daily activities allows staff and parents/guardians to have a common understanding and gives them the ability to compare the program’s actual performance to the stated intent. Early care and education is a “delivery of service” involving a contractual relationship between the caregiver/teacher and the consumer. A written plan helps to define the service and contributes to specific and responsible operations that are conducive to sound child development and safety practices and to positive consumer relations (4).

Professional development is often required to enable staff to develop proficiency in the development and implementation of a curriculum that they use to carry out daily activities appropriately (1).

Planning ensures that some thought goes into indoor and outdoor programming for children. The plan is a tool for monitoring and accountability. Also, a written plan is a tool for staff and parent/guardian orientation.

COMMENTS

The National Association for the Education of Young Children (NAEYC) accreditation criteria and procedures, the National Association for Family Child Care accreditation standards, and the National Child Care Association standards can serve as resources for planning program activities.

Parents/guardians and staff can experience mutual learning in an open, supportive early care and education setting. Suggestions for topics and methods of presentation are widely available. For example, the publication catalogs of the NAEYC and the American Academy of Pediatrics contain many materials for child, parent/guardian, and staff education on child development and physical and mental health development, covering topics such as the importance of attachment and temperament. A certified health education specialist, a child care health consultant, or an early childhood mental health consultant can also be a source of assistance.

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.8 Diversity in Enrollment and Curriculum
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.2.2 Interactions with Infants and Toddlers
2.1.2.3 Space and Activity to Support Learning of Infants and Toddlers
2.1.2.4 Separation of Infants and Toddlers from Older Children
2.1.2.5 Toilet Learning/Training
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.1.3.2 Opportunities for Learning for Three- to Five-Year-Olds
2.1.3.3 Selection of Equipment for Three- to Five-Year-Olds
2.1.3.4 Expressive Activities for Three- to Five-Year-Olds
2.1.3.5 Fostering Cooperation of Three- to Five-Year-Olds
2.1.3.6 Fostering Language Development of Three- to Five-Year-Olds
2.1.3.7 Body Mastery for Three- to Five-Year-Olds
2.1.4.1 Supervised School-Age Activities
2.1.4.2 Space for School-Age Activity
2.1.4.3 Developing Relationships for School-Age Children
2.1.4.4 Planning Activities for School-Age Children
2.1.4.5 Community Outreach for School-Age Children
2.1.4.6 Communication Between Child Care and School
2.4.1.1 Health and Safety Education Topics for Children
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
2.4.1.3 Gender and Body Awareness
2.4.2.1 Health and Safety Education Topics for Staff
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians
2.4.3.2 Parent/Guardian Education Plan
REFERENCES
  1. Rosenthal MS, Crowley AA, Curry L. Family child care providers’ self-perceived role in obesity prevention: working with children, parents, and external influences. J Nutr Educ Behav. 2013;45(6):595–601

  2. Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24
  3. Policy on oral health in child care centers. Pediatr Dent. 2016;38(6):34–36

  4. Modigliani K. Quality Standards for NAFCC Accreditation. 4th ed. The National Foundation for Family Child Care Foundation, Family Child Care Project - Wheelock College. Salt Lake City, UT: The National Association for Family Child Care Foundation; 2013
  5. Pinkham AM, Kaefer T, Neuman SB, eds. Knowledge Development in Early Childhood: Sources of Learning and Classroom Implications. New York, NY: The Guilford Press; 2012
NOTES

Content in the STANDARD was modified on 5/30/2018

2.1.1.2: Health, Nutrition, Physical Activity, and Safety Awareness

Content in the STANDARD was modified on 5/30/2018


Early care and education programs should create and implement written program plans addressing the physical, oral, mental, nutritional, and social and emotional health, physical activity, and safety aspects of each formally structured activity documented in the written curriculum. These plans should include daily opportunities to learn health habits that prevent infection and significant injuries and health habits that support healthful eating, nutrition education, physical activity, and sleep. Awareness of healthy and safe behaviors, including good nutrition, physical activity, and sleep habits, should be an integral part of the overall program.

RATIONALE

Young children learn better through experiencing an activity and observing behavior than through didactic methods (1). There may be a reciprocal relationship between learning and play so that play experiences are closely related to learning (2). Children can accept and follow rules, routines, and guidelines about health and safety when their personal experience helps them to understand why these rules were created. National guidelines for children birth to age 5 years encourage their engagement in daily physical activity that promotes movement, motor skills, and the foundations of health-related fitness (3). Physical activity is important to overall health and to overweight and obesity prevention (4). Healthy sleep habits (e.g., a bedtime routine, an adequate amount of sleep) (5,6) helps children get the amount of uninterrupted sleep their brains and bodies need, which is associated with lower rates of overweight and obesity later in life (7-11).

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.1.1.3 Coordinated Child Care Health Program Model
3.1.3.1 Active Opportunities for Physical Activity
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
4.5.0.4 Socialization During Meals
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
4.9.0.8 Supply of Food and Water for Disasters
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. Stirrup J, Evans J, Davies B. Learning one’s place and position through play: social class and educational opportunity in early years education. Int J Early Years Educ. 2017;1–18

  2. Weisberg D, Hirsh-Pasek K, Golinkoff R, Kittredge A, Klahr D. Guided play: principles and practices. Curr Dir Psychol Sci. 2016;25(3):177–182

  3. Roth K, Kriemler S, Lehmacher W, Ruf KC, Graf C, Hebestreit H. Effects of a physical activity intervention in preschool children. Med Sci Sports Exerc. 2015;47(12):2542–2551

  4. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Government Printing Office; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Published December 2015. Accessed November 14, 2017

  5. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, Hysing M. Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study. JAMA Pediatr. 2015;169(6):575–582

  6. Kelly Y, Kelly J, Sacker A. Time for bed: associations with cognitive performance in 7-year-old children: a longitudinal population-based study. J Epidemiol Community Health. 2013;67(11):926–931

  7. Institute of Medicine. Early Childhood Obesity Prevention Policies: Goals, Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention-Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017

  8. Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149

  9. Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a systematic review and meta-analysis of prospective cohort studies. J Paediatr Child Health. 2017;53(4):378–385

  10. Anderson SE, Andridge R, Whitaker RC. Bedtime in preschool-aged children and risk for adolescent obesity. J Pediatr. 2016;176:17–22

  11. Lumeng JC, Somashekar D, Appugliese D, Kaciroti N, Corwyn RF, Bradley RH. Shorter sleep duration is associated with increased risk for being overweight at ages 9 to 12 years. Pediatrics. 2007;120(5):1020–1029

NOTES

Content in the STANDARD was modified on 5/30/2018

2.1.1.3: Coordinated Child Care Health Program Model


Caregivers/teachers should follow these guidelines for implementing coordinated health programs in all early care and education settings. These coordinated health programs should consist of health and safety education, physical activity and education, health services and child care health consultation, nutrition services, mental health services, healthy and safe indoor and outdoor learning environment, health and safety promotion for the staff, and family and community involvement. The guidelines consist of the following eight interactive components:

1. Health Education: A planned, sequential, curriculum that addresses the physical, mental, emotional, and social dimensions of health. The curriculum is designed to motivate and assist children in maintaining and improving their health, preventing disease and injury, and reducing health-related risk behaviors (1,2).

2. Physical Activity and Education: A planned, sequential curriculum that provides learning experiences in a variety of activity areas such as basic movement skills, physical fitness, rhythms and dance, games, sports, tumbling, outdoor learning and gymnastics. Quality physical activity and education should promote, through a variety of planned physical activities indoors and outdoors, each child’s optimum physical, mental, emotional, and social development, and should promote activities and sports that all children enjoy and can pursue throughout their lives (1,2,6).

3. Health Services and Child Care Health Consultants: Services provided for child care settings to assess, protect, and promote health. These services are designed to ensure access or referral to primary health care services or both, foster appropriate use of primary health care services, prevent and control communicable disease and other health problems, provide emergency care for illness or injury, promote and provide optimum sanitary conditions for a safe child care facility and child care environment, and provide educational opportunities for promoting and maintaining individual, family, and community health. Qualified professionals such as child care health consultants may provide these services (1,2,4,5).

4. Nutrition Services: Access to a variety of nutritious and appealing meals that accommodate the health and nutrition needs of all children. School nutrition programs reflect the U.S. Dietary Guidelines for Americans and other criteria to achieve nutrition integrity. The school nutrition services offer children a learning laboratory for nutrition and health education and serve as a resource for linkages with nutrition-related community services (1,2).

5. Mental Health Services: Services provided to improve children’s mental, emotional, and social health. These services include individual and group assessments, interventions, and referrals. Organizational assessment and consultation skills of mental health professionals contribute not only to the health of students but also to the health of the staff and child care environment (1,2).

6. Healthy Child Care Environment: The physical and aesthetic surroundings and the psychosocial climate and culture of the child care setting. Factors that influence the physical environment include the building and the area surrounding it, natural spaces for outdoor learning, any biological or chemical agents that are detrimental to health, indoor and outdoor air quality, and physical conditions such as temperature, noise, and lighting. Unsafe physical environments include those such as where bookcases are not attached to walls and doors that could pinch children’s fingers. The psychological environment includes the physical, emotional, and social conditions that affect the well-being of children and staff (1,2).

7. Health Promotion for the Staff: Opportunities for caregivers/teachers to improve their own health status through activities such as health assessments, health education, help in accessing immunizations, health-related fitness activities, and time for staff to be outdoors. These opportunities encourage caregivers/teachers to pursue a healthy lifestyle that contributes to their improved health status, improved morale, and a greater personal commitment to the child care’s overall coordinated health program. This personal commitment often transfers into greater commitment to the health of children and creates positive role modeling. Health promotion activities have improved productivity, decreased absenteeism, and reduced health insurance costs (1,2).

8. Family and Community Involvement: An integrated child care, parent/guardian, and community approach for enhancing the health and safety, and well-being of children. Parent/guardian-teacher health advisory councils, coalitions, and broadly based constituencies for child care health can build support for child care health program efforts. Early care and education settings should actively solicit parent/guardian involvement and engage community resources and services to respond more effectively to the health-related needs of children (1,2).

RATIONALE
Early care and education settings provide a structure by which families, caregivers/teachers, administrators, primary care providers, and communities can promote optimal health and well-being of children (3,4). The coordinated child care health program model was adapted from the Center for Disease Control and Prevention (CDC) Division of Adolescent and School Health’s (DASH) Coordinated School Health Program (CSHP) model (2).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Centers for Disease Control and Prevention. 2008. Healthy youth! Coordinates school health programs. http://www.cdc.gov/healthyyouth/CSHP/.
  2. Cory, A. C. 2007. The role of the child care health consultant in promoting health literacy for children, families, and educators in early care and education settings. Paper presented at the annual meeting of the American School Health Association.
  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  4. U.S. Department of health and Human Services, Office of Child Care. 2010. Coordinating child care consultants: Combining multiple disciplines and improving quality in infant/toddler care settings. http://nitcci.nccic.acf.hhs.gov/resources/consultation
    _brief.pdf.
  5. Coordinated Health/Care. Maximize your benefits: FAQs about care coordination. https://www.cchcare.com/router
    .php?action=about.
  6. Friedman, H. S., L. R. Martin, J. S. Tucker, M. H. Criqui, M. L. Kern, C. A. Reynolds. 2008. Stability of physical activity across the lifespan. J Health Psychol 13:1092-1104.

2.1.1.4: Monitoring Children’s Development/Obtaining Consent for Screening


Child care settings provide daily indoor and outdoor opportunities for promoting and monitoring children’s development. Caregivers/teachers should monitor the children’s development, share observations with parents/guardians, and provide resource information as needed for screenings, evaluations, and early intervention and treatment. Caregivers/teachers should work in collaboration to monitor a child’s development with parents/guardians and in conjunction with the child’s primary care provider and health, education, mental health, and early intervention consultants. Caregivers/teachers should utilize the services of health and safety, education, mental health, and early intervention consultants to strengthen their observation skills, collaborate with families, and be knowledgeable of community resources.

Programs should have a formalized system of developmental screening with all children that can be used near the beginning of a child’s placement in the program, at least yearly thereafter, and as developmental concerns become apparent to staff and/or parents/guardians. The use of authentic assessment and curricular-based assessments should be an ongoing part of the services provided to all children (5-9). The facility’s formalized system should include a process for determining when a health or developmental screening or evaluation for a child is necessary. This process should include parental/guardian consent and participation.

Parents/guardians should be explicitly invited to:

  1. Discuss reasons for a health or developmental assessment;
  2. Participate in discussions of the results of their child’s evaluations and the relationship of their child’s needs to the caregivers’/teachers’ ability to serve that child appropriately;
  3. Give alternative perspectives;
  4. Share their expectations and goals for their child and have these expectations and goals integrated with any plan for their child;
  5. Explore community resources and supports that might assist in meeting any identified needs that child care centers and family child care homes can provide;
  6. Give written permission to share health information with primary health care professionals (medical home), child care health consultants and other professionals as appropriate;

The facility should document parents’/guardians’ presence at these meetings and invitations to attend.

If the parents/guardians do not attend the screening, the caregiver/teacher should inform the parents/guardians of the results, and offer an opportunity for discussion. Efforts should be made to provide notification of meetings in the primary language of the parents/guardians. Formal evaluations of a child’s health or development should also be shared with the child’s medical home with parent/guardian consent.

Programs are encouraged to utilize validated screening tools to monitor children’s development, as well as various measures that may inform their work facilitating children’s development and providing an enriching indoor and outdoor environment, such as authentic-based assessment, work sampling methods, observational assessments, and assessments intended to support curricular implementation (5,9). Programs should have clear policies for using reliable and valid methods of developmental screening with all children and for making referrals for diagnostic assessment and possible intervention for children who screen positive. All programs should use methods of ongoing developmental assessment that inform the curricular approaches used by the staff. Care must be taken in communicating the results. Screening is a way to identify a child at risk of a developmental delay or disorder. It is not a diagnosis.

If the screening or any observation of the child results in any concern about the child’s development, after consultation with the parents/guardians, the child should be referred to his or her primary care provider (medical home), or to an appropriate specialist or clinic for further evaluation. In some situations, a direct referral to the Early Intervention System in the respective state may also be required.

RATIONALE
Seventy percent of children with developmental disabilities and mental health problems are not identified until school entry (10). Daily interaction with children and families in early care and education settings offers an important opportunity for promoting children’s development as well as monitoring developmental milestones and early signs of delay (1-3). Caregivers/teachers play an essential role in the early identification and treatment of children with developmental concerns and disabilities (6-8) because of their knowledge in child development principles and milestones and relationship with families (4). Coordination of observation findings and services with children’s primary care providers in collaboration with families will enhance children’s outcomes (6).
COMMENTS
Parents/guardians need to be included in the process of considering, identifying and shaping decisions about their children, (e.g., adding, deleting, or changing a service). To provide services effectively, facilities must recognize parents’/guardians’ observations and reports about the child and their expectations for the child, as well as the family’s need of child care services. A marked discrepancy between professional and parent/guardian observations of, or expectations for, a child necessitates further discussion and development of a consensus on a plan of action.

Consideration should be given to utilizing parent/guardian-completed screening tools, such as the Ages and Stages Questionnaire (ASQ) (for a list of validated developmental screening tools, see the American Academy of Pediatric’s [AAP] list of developmental screening tools at http://www
.medicalhomeinfo.org/downloads/pdfs/DPIPscreeningtool
grid.pdf). The caregiver/teacher should explain the results to parents/guardians honestly, with sensitivity, and without using technical jargon (11).

Resources for implementing a program that involves a formalized system of developmental screening are available at the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncbddd/actearly/ and the AAP at http://www.healthychildcare.org.

Scheduling meetings at times convenient for parent/guardian participation is optimal. Those conducting an evaluation, and when subsequently discussing the findings with the family, should consider parents’/guardians’ input. Parents/guardians have both the motive and the legal right to be included in decision-making and to seek other opinions.

A second, independent opinion could be provided by the program’s child care health consultant or the child’s primary care provider.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.7 Qualifications and Responsibilities for Health Advocates
3.1.4.5 Unscheduled Access to Rest Areas
9.4.1.3 Written Policy on Confidentiality of Records
REFERENCES
  1. Copple, C., S. Bredekamp. 2009. Developmentally appropriate practice in early childhood programs serving children at birth through age 8. 3rd ed. Washington, DC: National Association for the Education of Young Children.
  2. Dworkin, P. H. 1989. British and American recommendations for developmental monitoring: The role of surveillance. Pediatrics 84:1000-1010.
  3. Brothers, K. l., F. Glascoe, N. Robertshaw. 2008. PEDS: Developmental milestones - An accurate brief tool for surveillance and screening. Clinical Pediatrics 47:271-79.
  4. Kostelnik, M. J., A. K. Soderman, A. P. Whiren. 2006. Developmentally appropriate curriculum best practices in early childhood education. Upper Saddle River, NJ: Prentice Hall.
  5. Squires, J., D. Bricker. 2009. Ages and stages questionnaires. Baltimore: Brookes Publishing.
  6. Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.
  7. American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. 2006. Identifying infants and young children with developmental disorders in the medical home: An alogorithm for developmental surveillance and screening. Pediatrics 118:405-20.
  8. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  9. Gilliam, W. S., S. Meisels, L. Mayes. 2005. Screening and surveillance in early intervention systems. In A developmental systems approach to early intervention: National and international perspectives, ed. M. J. Guralnick, 73-98. Baltimore, MD: Brookes Publishing.
  10. Glascoe, F. P. 2005. Screening for developmental and behavioral problems. Mental Retardation Develop Disabilities 11:173-79.
  11. O’Connor, S., et al. 1996. ASQ: Assessing school age child care quality. Wellesly, MA: Center for Research on Women.

2.1.1.5: Helping Families Cope with Separation


The staff of the facility should engage strategies to help a child and parents/guardians cope with the experience of separation and reunion, such as death of family members, divorce, or placement in foster care.

For the child, this should be accomplished by:

  1. Encouraging parents/guardians to spend time in the facility with the child and supporting the separation transition;
  2. Providing a comfortable setting both indoors and outdoors for parents/guardians to be with their children to transition or to have conversation with staff;
  3. Having established routines for drop-off and pick-up times to assist with transition;
  4. Enabling the child to bring to child care tangible reminders of home/family (such as a favorite toy or a picture of self and parent/guardian);
  5. Encouraging parents/guardians to reassure the child of their return and to calmly say “goodbye”;
  6. Helping the child play out themes of separation and reunion;
  7. Frequently exchanging information between the child’s parents/guardians and caregivers/teachers, including activities and routine care information particularly during greeting and departing;
  8. Reassuring the child about the parent’s/guardian’s return;
  9. Ensuring the caregivers/teachers are consistent both within the parts of a day and across days;
  10. Requesting assistance from early childhood mental health consultants, mental health professionals, developmental-behavioral pediatricians, parent/guardian counselors, etc. when a child’s adjustment continues to be problematic over time;
  11. When a family is experiencing separation due to a military deployment, explore changes in children’s behavior that may be related to feelings of anger, fear, sadness, or uncertainty related to changes in family structure as a result of deployment. Work with the parent/guardian at home to help the child adjust to these changes, including providing activities that help the child remain connected to the deployed parent/guardian and manage their emotions throughout the deployment cycle.

For the parents/guardians, this should be accomplished by:

  1. Validating their feelings as a universal human experience;
  2. Providing parents/guardians with information about the positive effects for children of high quality facilities with strong parent/guardian participation;
  3. Encouraging parents/guardians to discuss their feelings;
  4. Providing parents/guardians with evidence, such as photographs, that their child is being cared for and is enjoying the activities of the facility;
  5. Ask parents/guardians to bring pictures from home that may be placed in the room or cubby and displayed throughout the indoor and outdoor learning/play environment at the child’s eye level;
  6. Where a family is experiencing separation due to a military deployment, collaborate with the parent/guardian at home to address changes in children’s behavior that may be related to the deployment, providing parents/guardians with information about activities in care and at home may help promote their child’s positive adjustment throughout the deployment cycle (connect parents/guardians with services/resources in the community that can help to support them);
  7. Requesting assistance from early childhood mental health consultants, mental health professionals, developmental-behavioral pediatricians, parent/guardian counselors, etc. when a child’s adjustment continues to be problematic over time.
RATIONALE
In childhood, some separation experiences facilitate psychological growth by mobilizing new approaches for learning and adaptation. Other separations are painful and traumatic. The way in which influential adults provide support and understanding, or fail to do so, will shape the child’s experience (1).

Many parents/guardians who prefer to care for their young children only at home may have no other option than to place their children in out-of-home child care before three months of age. Some parents/guardians prefer combining out-of-home child care with parental/guardian care to provide good experiences for their children and support for other family members to function most effectively. Whether parents/guardians view out-of-home child care as a necessary accommodation to undesired circumstances or a benefit for their family, parents/guardians and their children need help from the caregivers/teachers to accommodate the transitions between home and out-of-home settings (2).

Many parents/guardians experience distress at separation. For most parents/guardians, the younger their child and the less experience they have had with sharing the care of their children with others, the more intense their distress at separation (3).

Although children’s responses to deployment separation will vary depending on age, personality, and support received, children will be aware of a parent’s/guardian’s long-term absence and may mourn. Children may feel uncertain, sad, afraid, or angry. These feelings can manifest as increased clinginess, aggression, withdrawal, changes in sleeping or eating patterns, regression or other behaviors. Young children don’t often have the vocabulary to express their emotions, and may need support to express their feelings in healthy and safe ways (2). Additionally, the parent/guardian at home may be experiencing stress, anxiety, depression, or fear. These parents/guardians may benefit from additional outreach from caregivers/teachers, who are part of their community support system, and can help them with strategies to promote children’s adjustment and connect them with resources in the community (3).

COMMENTS
Depending on the child’s developmental stage, the impact of separation on the child and parent/guardian will vary. Child care facilities should understand and communicate this variation to parents/guardians and work with parents/guardians to plan developmentally appropriate coping strategies for use at home and in the child care setting. For example, a child at eighteen to twenty-four months of age is particularly vulnerable to separation issues and may show visible distress when experiencing separation from parents/guardians. Entry into child care at this age may trigger behavior problems, such as difficulty sleeping. Even for the child who has adapted well to a child care arrangement before this developmental stage, such difficulties can occur as the child continues in care and enters this developmental stage. For younger children, who are working on understanding object permanence (usually around nine to twelve months of age), parents/guardians who sneak out after bringing their children to the child care facility may create some level of anxiety in the child throughout the day. Sneaking away leaves the child unable to discern when someone the child trusts will leave without warning. Parents/guardians and caregivers/teachers reminding a child that the parent/guardian returned as promised reinforces truthfulness and trust. Parents/guardians of children of any age should be encouraged to visit the facility together before the child care officially begins. Parents/guardians of infants may benefit from feeling assured by the caregivers/teachers themselves. Depending on the child’s temperament and prior care experience, several visits may be recommended before enrolling as well opportunities to practice the process and consistency of a separation experience in the first weeks of entering the child care. Using a phasing-in period can also be helpful (e.g., spend only a part of the day with parents/guardians on the first day, half-day on the second day, and parents/guardians leave earlier, etc.)
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.2.1 Minimum Age to Enter Child Care
1.6.0.3 Early Childhood Mental Health Consultants
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
REFERENCES
  1. Blecher-Sass, H. 1997. Good-byes can build trust. Young Child 52:12-14.
  2. Kim, A. M., J. Yeary. 2008. Making long-term separations easier for children and families. Young Children 63:32-37.
  3. Gonzalez-Mena, J. 2007. Separation: Helping children and families. In 50 Early childhood strategies for working and communicating with diverse families, 96-97. Upper Saddle River, NJ: Prentice Hall.

2.1.1.6: Transitioning within Programs and Indoor and Outdoor Learning/Play Environments


Caregivers/teachers should take into consideration the individual needs of children when transitioning them to a new indoor and outdoor learning/play environment. The transitioning child/children should be offered the opportunity to visit the new space with a familiar caregiver/teacher with enough time to allow them to display comfort in the new space. The program should allow time for communication with the families regarding the process and for each child to follow through a comfortable time line of adaptation to the new indoor and outdoor learning/play environment, caregiver/teachers, and peers.

Children need time to manipulate, explore and familiarize themselves with the new space and caregivers/teachers. This should be done before they are part of a new group to allow them time to explore to their personal satisfaction. Eating is a primary reinforcer and need. The opportunity to share food within the new space will help reassure a child and help adults assess how the transition is going. Toileting involves another level of trust. Diapering/toileting should be introduced in the new space with a familiar teacher.

New routines should be introduced by the new staff with a familiar caregiver/teacher present to support the child/children. Transitions to the indoor and outdoor learning/play environment, especially if the space is different than the one from which they are familiar, should follow similar procedures as moving to another indoor space. Parents/guardians should be part of the transition as they too are in the process of learning to trust a new indoor and outdoor learning/play environment for their child. Primary needs need to be met to support a smooth transition.

Transitions should be planned in advance, based on the child’s readiness. A written plan should be developed and shared with parents/guardians, describing how and when the transition will occur. Children should not be moved to a new indoor and outdoor learning/play environment for the sole purpose of maintaining child: staff ratios.

RATIONALE
Supporting the achievement of developmental tasks for young children is essential for their social and emotional health. Establishing trust with caregivers/teachers and successful adaptation to a new indoor and outdoor learning/play environment is a critical component of quality care. Young children need predictability and routine. They need to feel secure and to understand the expectations of their environment. By taking time to allow them to familiarize themselves with their new caregivers/teachers and environment, they are better able to handle the emotional, cognitive, and social requirements of their new space (1-5).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.2.5 Toilet Learning/Training
REFERENCES
  1. Erikson, E. H. 1950. Childhood and society. New York: W.W. Norton and Co.
  2. Gorski, P. A., S. P. Berger. 2005. Emotional health in child care. In Health in child care: A manual for health professionals, ed. J. R. Murph, S. D. Palmer, D. Glassy, 173-86. Elk Grove Village, IL: American Academy of Pediatrics.
  3. Lally, R. L., L. Y. Torres, P. C. Phelps. 1994. Caring for infants and toddlers in groups: Necessary considerations for emotional, social, and cognitive development. Zero to Three 14:1-8.
  4. Mahler, M., F. Pine, A. Bergman. 1975. The Psychological birth of the human infant. New York: Basic Books.
  5. Maslow, A. 1943. A theory of human motivation. Psychological Review 50:370-96

2.1.1.7: Communication in Native Language Other Than English


At least one member of the staff should be able to communicate with the parents/guardians and children in the family’s native language (sign or spoken), or the facility should work with parents/guardians to arrange for a translator to communicate with parents/guardians and children. Efforts should be made to support a child’s and family’s native language while providing resources and opportunities for learning English (2). Children should not be used as translators. They are not developmentally able to understand the meaning of all words as used by adults, nor should they participate in all conversations that may be regarding the child.
RATIONALE
The future development of the child depends on his/her command of language (1). Richness of language increases as a result of experiences as well as through the child’s verbal interaction with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. Learning English while maintaining a family’s native language enriches child development and strengthens family cultural traditions.
COMMENTS
For resources on bilingual and dual language learning, see the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics (SODBP) at http://www.aap.org/sections/dbpeds/.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances Applied Dev Psychol 20:248.
  2. Olsen, L. 2006. Ensuring academic success of English learners. 2006. U.C. Linguistic Minority Research Institute 15:1-7.

2.1.1.8: Diversity in Enrollment and Curriculum


Programs should work to increase understanding of cultural, ethnic, and other similarities and differences by enrolling children who reflect the cultural and ethnic diversity of the community. Programs should provide cultural curricula that engage children and families and teach multicultural learning activities. Indoor and outdoor learning/play environments should have an array of toys, materials, posters, etc. that reflect diverse cultures and ethnicities. Stereotyping of any culture must be avoided.
RATIONALE
Children who participate in programs that reflect and show respect for the cultural diversity of their communities learn to understand and value cultural diversity. This learning in early childhood enables their healthy participation in a democratic pluralistic society (peaceful coexistence of different interests, convictions, and lifestyles) throughout life (1-3,11,12). By facilitating the expression of cultural development or ethnic identity and by encouraging familiarity with different groups and practices through ordinary interaction and activities integrated into a developmentally appropriate curriculum, a facility can foster children’s ability to relate to people who are different from themselves, their sense of possibility, and their ability to succeed in a diverse society, while also promoting feelings of belonging and identification with a tradition.
COMMENTS
Sharing information about the child on a daily basis with the children’s families shows respect for the children’s cultures by creating an opportunity to learn more about the families’ background, beliefs, and traditions (5-9). Materials, displays, and learning activities must represent the cultural heritage of the children and the staff to instill a sense of pride and positive feelings of identification in all children and staff members (4). In order to enroll a diverse group, the facility should market its services in a culturally sensitive way and should make sincere efforts to employ staff members that represent the culture of the children and their families (10). Children need to see members of their own community in positions of influence in the services they use. Scholarships and tuition assistance can be used to increase the diversity among enrolled children.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Wardle, F. 1998. Meeting the needs of multicultural and multiethnic children in early childhood settings. Early Child Education J 26:7-11.
  2. Ramsey, P. G. 1998. Teaching and learning in a diverse world: Multicultural education for young children. 2nd ed. New York: Teachers College Press.
  3. Ramsey, P. G. 1995. Growing up with the contradictions of race and class. Young Child 50:18-22.
  4. Maschinot, B. 2008. The changing face of the United States: The influence of culture on early child development. Washington, DC: Zero to Three. http://www.zerotothree.org/site/DocServer/Culture_book.pdf?docID=6921.
  5. Williams, K. C., M. H. Cooney. 2006. Young children and social justice. Young Children 61:75-82.
  6. Gonzalex-Mena, J. 2008. Diversity in early care and education: Honoring differences. 5th ed. Boston: McGraw-Hill.
  7. Gonzalez-Mena, J. 2007. 50 early childhood strategies for working and communicating with diverse families. Upper Saddle River, NJ: Pearson Merrill Prentice Hall.
  8. Bradely, J., P. Kibera. 2006. Closing the gap: Culture and promotion of inclusion in child care. Young Children 61:34-40.
  9. Romero, M. 2008. Promoting tolerance and respect for diversity in early childhood: Toward a research and practice agenda. Report of the Promoting Tolerance and Respect for Diversity in Early Childhood Meeting, Brooklyn, NY, June 25, 2007. http://www.nccp
    .org/publications/pdf/text_812.pdf.
  10. Matthews, H. 2008. Supporting a diverse and culturally competent workforce: Charting progress for babies in child care. Charting Progress for Babies in Child Care: A CLASP Child Care and Early Education Project, Washington, DC. http://www.clasp.org/babiesinchildcare/recommendations?id=0005.
  11. Parent Services Project (PSP). Making room in the circle. Training Curriculum, PSP, San Rafael, CA.
  12. Fox, R. K. 2007. One of the hidden diversities in schools: Families with parents who are Lesbian or Gay. Childhood Education 83:277-81.

2.1.1.9: Verbal Interaction


The child care facility should assure that a rich environment of spoken language by caregivers/teachers surrounds and includes all children with opportunities to expand their language communication skills. Each child should have at least one speaking adult person who engages the child in frequent verbal exchanges linked to daily events and experiences. To encourage the development of language, the caregiver/teacher should demonstrate skillful verbal communication and interaction with the child.

  1. For infants, these interactions should include responses to, and encouragement of, soft infant sounds, as well as identifying objects, feelings, and desires by the caregiver/teacher.
  2. For toddlers, the interactions should include naming of objects, feelings, listening to the child and responding, along with actions and supporting, but not forcing, the child to do the same.
  3. For preschool and school-age children, interactions should include respectful listening and responses to what the child has to say, amplifying and clarifying the child’s intent, and not reinforcing mispronunciations (e.g., Wambulance instead of Ambulance).
  4. Frequent interchange of questions, comments, and responses to children, including extending children’s utterances with a longer statement, by teaching staff.
  5. For children with special needs, alternative methods of communication should be available, including but not limited to: sign language, assistive technology, picture boards, picture exchange communication systems (PECS), FM systems for hearing aids, etc. Communication through methods other than verbal communication can result in the same desired outcomes.
  6. Profanity should not be used at any time.
RATIONALE
Conversation with adults is one of the main channels through which children learn about themselves, others, and the world in which they live. While adults speaking to children teaches the children facts and relays information, the social and emotional communications and the atmosphere of the exchange are equally important. Reciprocity of expression, response, and the initiation and enrichment of dialogue are hallmarks of the social function and significance of the conversations (1-4).

The future development of the child depends on his/her command of language (5). Research suggests that language experiences in a child’s early years have a profound influence on that child’s language and vocabulary development, which in turn has an impact on future school success (6). Richness of the child’s language increases as it is nurtured by verbal interactions and learning experiences with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. Discussing the impact of actions on feelings for the child and others helps to develop empathy.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Education 7:229-39.
  2. Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, IL: Learning Seed.
  3. Szanton, E. S., ed. 1997. Creating child-centered programs for infants and toddlers, birth to 3 year olds, step by step: A Program for children and families. New York: Children’s Resources International, Inc.
  4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: Why are they so important? Young Child 52:4-12.
  5. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances in Applied Dev Psychol 20:248.
  6. Pikulski, J. J., Templeton, S. 2004. Teaching and developing vocabulary: Key to long-term reading success. Geneva, IL: Houghton Mifflin Company. http://www.eduplace.com/state/author/pik_temp.pdf.

2.1.2 Program Activities for Infants and Toddlers from Three Months to Less Than Thirty-Six Months

2.1.2.1: Personal Caregiver/Teacher Relationships for Infants and Toddlers

Content in the STANDARD was modified on 05/30/2018.


The facility should practice a relationship-based philosophy that promotes consistency and continuity of caregivers/teachers for infants and toddlers (1-3). Facilities should implement continuity of care practices into established policies and procedures as a means to foster strong, positive relationships that will act as a secure basis for exploration and learning in the classroom (1-4). Child–caregiver relationships based on high-quality care are central to brain development, emotional regulation, and overall learning (5). The facility should encourage practices of continuity of care that give infants and toddlers the added benefit of the same caregiver for the first three years of life of the child or during the time of enrollment (6). The facility should limit the number of caregivers/teachers who interact with any one infant or toddler (1).

The caregiver/teacher should:

  1. Use a variety of safe and appropriate individualized soothing methods of holding and comforting infants and toddlers who are upset (7).
  2. Engage in frequent, multiple, and rich social interchanges, such as smiling, talking, appropriate forms of touch, singing, and eating.
  3. Be play partners as well as protectors.
  4. Be attuned to infants’ and toddlers’ feelings and reflect them back.
  5. Communicate consistently with parents/guardians.
  6. Interact with infants and toddlers and develop a relationship in the context of everyday routines (eg, diapering, feeding).

Opportunities should be provided for each infant and toddler to develop meaningful relationships with caregivers.


The facility’s touch policy should be direct in addressing that children may be touched when it is appropriate for, respectful to, and safe for the child. Caregivers/teachers should respect the wishes of children, regardless of their age, for physical contact and their comfort or discomfort with it. Caregivers/teachers should avoid even “friendly” contact (eg, touching the shoulder or arm) with a child if the child expresses that he or she is uncomfortable.

RATIONALE

When children trust caregivers and are comfortable in the environment that surrounds them, they are allowed to focus on educational discoveries in their physical, social, and emotional development.

Holding, and hugging, in a positive, respectful, and safe manner is an essential part of providing care for infants and toddlers.

Quality caregivers/teachers provide care and learning experiences that play a key role in a child’s development as an active, self-knowing, self-respecting, thinking, feeling, and loving person (8). Limiting the number of adults with whom an infant or a toddler interacts fosters reciprocal understanding of communication cues that are unique to each infant or toddler. This leads to a sense of trust of the adult by the infant or toddler that the infant’s or toddler’s needs will be understood and met promptly (5,6). Studies of infant behavior show that infants have difficulty forming trusting relationships in settings where many adults interact with infants (eg, in hospitalization of infants when shifts of adults provide care) (9).

Sexual abuse in the form of inappropriate touching is an act that induces or coerces children in a sexually suggestive manner or for the sexual gratification of the adult, such as sexual penetration and/or overall inappropriate touching or kissing (10).

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect
REFERENCES
  1. Zero to Three. Primary caregiving and continuity of care. https://www.zerotothree.org/resources/85-primary-caregiving-and-continuity-of-care. Published February 8, 2010. Accessed January 11, 2018

  2. National Scientific Council on the Developing Child. The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper 12. https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2012/05/The-Science-of-Neglect-The-Persistent-Absence-of-Responsive-Care-Disrupts-the-Developing-Brain.pdf. Published December 2012. Accessed January 11, 2018

  3. Harvard University Center on the Developing Child. Three principles to improve outcomes for children and families. https://developingchild.harvard.edu/resources/three-early-childhood-development-principles-improve-child-family-outcomes. Accessed January 11, 2018

  4. Recchia SL. Caregiver–child relationships as a context for continuity in child care. Early Years. 2012;32(2):143–157

  5. US Department of Health and Human Services, Child Care State Capacity Building Center. Six essential program practices. Program for infant/toddler care. https://childcareta.acf.hhs.gov/sites/default/files/public/pitc_rationale_-_continuity_of_care_508_0.pdf. Published January 2017. Accessed January 11, 2018

  6. Ruprecht K, Elicker J, Choi J. Continuity of care, caregiver–child interactions, toddler social competence and problem behaviors. Early Educ Dev. 2015;27:221–239

  7. Kim Y. Relationship-based developmentally supportive approach to infant childcare practice. Early Child Dev Care. 2015:734-749

  8. Understanding children’s behavior. In: Miller DF. Positive Child Guidance. 8th ed. Boston, MA: Cengage Learning; 2016

  9. Sandstrom H, Huerta S. The negative effects of instability on child development: a research synthesis. Urban Institute Web site. https://www.urban.org/research/publication/negative-effects-instability-child-development-research-synthesis. Published September 18, 2013. Accessed January 11, 2018

  10. Al Odhayani A, Watson WJ, Watson L. Behavioural consequences of child abuse. Can Fam Physician. 2013;59(8):831–836

NOTES

Content in the STANDARD was modified on 05/30/2018.

2.1.2.2: Interactions with Infants and Toddlers


Caregivers/teachers should provide consistent, continuous and inviting opportunities to talk, listen to, and otherwise interact with young infants throughout the day (indoors and outdoors) including feeding, changing, playing with, and cuddling them.
RATIONALE
Richness of language increases by nurturing it through verbal interactions between the child and adults and peers. Adults’ speech is one of the main channels through which children learn about themselves, others, and the world in which they live. While adults speaking to children teach the children facts, the social and emotional communications and the atmosphere of the exchange are equally important. Reciprocity of expression, response, the initiation and enrichment of dialogue are hallmarks of the social function and significance of the conversations (2-5). Infants and toddlers learn through meaningful relationships and interaction with consistent adults and peers.

The future development of the child depends on his/her command of language (1). Richness of language increases as it is nurtured by verbal interactions of the child with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. A language-rich environment and warm, responsive interactions between staff and children are among the elements that produce positive impacts (6).

COMMENTS
Live, real-time interaction with caregivers/teachers is preferred. For example, caregivers/teachers naming objects in the indoor and outdoor learning/play environment or singing rhymes to all children supports language development. Children’s stories and poems presented on recordings with a fixed speed for sing-along can actually interfere with a child’s ability to participate in the singing or recitation. With fixed-speed activities, the pace may be too fast for some children, and the activity may have to be repeated for some children or the caregiver/teacher will need to try a different method for learning.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.3 Screen Time/Digital Media Use
REFERENCES
  1. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances Applied Dev Psychol 20:248.
  2. Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, Ill: Learning Seed.
  3. Szanton, E. S., ed. 1997. Creating child-centered programs for infants and toddlers, birth to 3 year olds, step by step: A Program for children and families. New York: Children’s Resources International.
  4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: Why are they so important? Young Child 52:4-12.
  5. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. ERIC Digest (January).
  6. National Forum on Early Childhood Program Evaluation, National Scientific Council on the Developing Child. 2007. A science-based framework for early childhood policy: Using evidence to improve outcomes in learning, behavior, and health for vulnerable children. Cambridge, MA: Center on the Developing Child, Harvard University. http://developingchild.harvard.edu/index.php/library/reports_and_working_papers/policy_framework/.

2.1.2.3: Space and Activity to Support Learning of Infants and Toddlers


The facility should provide a safe and clean learning environment, both indoors and outdoors, colorful materials and equipment arranged to support learning. The indoor and outdoor learning/play environment should encourage and be comfortable with staff on the floor level when interacting with active infant crawlers and toddlers. The indoor and outdoor play and learning settings should provide opportunities for the child to act upon the environment by experiencing age-appropriate obstacles, frustrations, and risks in order to learn to negotiate environmental challenges. The facility should provide opportunities for play that:

  1. Lessen the child’s anxiety and help the child adapt to reality and resolve conflicts;
  2. Enable the child to explore and experience the natural world;
  3. Help the child practice resolving conflicts;
  4. Use symbols (words, numbers, etc.);
  5. Manipulate objects;
  6. Exercise physical skills;
  7. Encourage language development;
  8. Foster self-expression;
  9. Strengthen the child’s identity as a member of a family and a cultural community;
  10. Promote sensory exploration.

For infants and toddlers the curriculum should be based on the child’s development at the time and connected to a sound understanding as to where they are in their developmental course.

RATIONALE
Opportunities to be an active learner are vitally important for the development of motor competence and awareness of one’s own body and person, the development of sensory motor skills, the ability to demonstrate initiative through active outdoor and indoor play, and feelings of mastery and successful coping. Coping involves original, imaginative, and innovative behavior as well as previously learned strategies.

Learning to resolve conflicts constructively in childhood is essential in preventing violence later in life (1,2). A physical and social environment that offers opportunities for active mastery and coping enhances the child’s adaptive abilities (3,4,9). The importance of play for developing cognitive skills, for maintaining an affective and intellectual equilibrium, and for creating and testing new capacities is well recognized (8). Play involves a balance of action and symbolization, and of feeling and thinking (5-7). Children need access to age-appropriate toys and safe household objects.

COMMENTS
For more information regarding appropriate play materials for young children, see “Which Toy for Which Child: A Consumer’s Guide for Selecting Suitable Toys” from the U.S. Consumer Product Safety Commission (CPSC) and “The Right Stuff for Children Birth to 8: Selecting Play Materials to Support Development” from the National Association for the Education of Young Children (NAEYC). For information regarding appropriate materials for outdoor play, see POEMS: Preschool Outdoor Environment Measurement Scale (10).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
5.1.2.1 Space Required per Child
5.2.9.14 Shoes in Infant Play Areas
5.3.1.1 Safety of Equipment, Materials, and Furnishings
5.3.1.5 Placement of Equipment and Furnishings
REFERENCES
  1. Massey, M. S. 1998. Early childhood violence prevention. ERIC Digest (October).
  2. Levin, D. E. 1994. Teaching young children in violent times: Building a peaceable classroom, A preschool-grade 3 violence prevention and conflict resolution guide. Cambridge, MA: Educators for Social Responsibility.
  3. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Education 7:229-39.
  4. Cartwright, S. 1998. Group trips: An invitation to cooperative learning. Child Care Infor Exch 124:95-97.
  5. Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer cultures of preschool and preadolescent children: An interpretative approach. Childhood 5:377-402.
  6. Petersen, E. A. 1998. The amazing benefits of play. Child Family 17:7-8.
  7. Pica, R. 1997. Beyond physical development: Why young children need to move. Young Child 52:4-11.
  8. Tepperman, J., ed. 2007. Play in the early years: Key to school success, a policy brief. El Cerrito, CA: Early Childhood Funders. http://www.4children.org/images/pdf/play07.pdf.
  9. Torelli, L., C. Durrett. 1996. Landscape for learning: The impact of classroom design on infants and toddlers. Early Childhood News 8 (March-April): 12-17. http://www.spacesforchildren.com/landc1.pdf.
  10. DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. 2005. Preschool outdoor environment measurement scale. Lewisville, NC: Kaplan Early Learning Co.

2.1.2.4: Separation of Infants and Toddlers from Older Children


Infants and toddlers younger than three years of age should be cared for in a closed room(s) that separates them from older children, except in small family child care homes with closed groups of mixed aged children.

In facilities caring for three or more children younger than three years of age, activities that bring children younger than three years of age in contact with older children should be prohibited, unless the younger children already have regular contact with the older children as part of a group.

Pooling, as a practice in larger settings where the infants/toddlers are not part of the group all day – as in home care – should be avoided for the following reasons:

  1. Unfamiliarity with caregivers/teachers if not the primary one during the day;
  2. Concerns of noise levels, space ratios, social-emotional well-being, etc.;
  3. Occurs at times when children are least able to handle transitions;
  4. Increases the number of transitions for children,
  5. Increases the number of adults caring for infants and toddlers, a practice to be avoided if possible.

Caregivers/teachers of infants should not be responsible for the care of older children who are not a part of the infants’ closed child care group.

Groups of younger infants should receive care in closed room(s) that separates them from other groups of toddlers and older children.

When partitions are used, they must control interaction between groups, provide separated ventilation of the spaces and control sound transmission. The acoustic controls should limit significant transmission of sound from one group’s activity into other group environments.

RATIONALE
Infants need quiet, calm environments, away from the stimulation of older children. Younger infants should be cared for in rooms separate from the more boisterous toddlers. In addition to these developmental needs of infants, separation is important for reasons of disease prevention. Rates of hospitalization for all forms of acute infectious respiratory tract diseases are highest during the first year of life, indicating that respiratory tract illness becomes less severe as the child gets older (1). Therefore, infants should be a focus for interventions to reduce the incidence of respiratory tract diseases. Handwashing and sanitizing practices are key.

Depending on the temperament of the child, an increase in transitions can increase anxiety in young children by reducing the opportunity for routine and predictability (2), and it increases basic health and safety concerns of cross contamination with older children who have more contact with the environment.

COMMENTS
This separation of younger children from older children ideally should be implemented in all facilities, but may be less feasible in small or large family child care homes.

Separation of groups of children by low partitions that divide a single common space is not acceptable. Without sound attenuation, limitation of shared air pollutants including airborne infectious disease agents, or control of interactions among the caregivers/teachers who are working with different groups, the separate smaller groups are essentially one large group.

TYPE OF FACILITY
Center
RELATED STANDARDS
3.2.2.2 Handwashing Procedure
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Izurieta, H. S., W. W. Thompson, P. Kramarz, et al. 2000. Influenza and the rates of hospitalization for respiratory disease among infants and young children. New England J Med 342:232-39.
  2. Poole, C. 1998. Routine matters. Scholastic Parent Child (August/September).

2.1.2.5: Toilet Learning/Training


The facility should develop and implement a plan that teaches each child how and when to use the toilet. Toilet learning/training, when initiated, should follow a prescribed, sequential plan that is developed and coordinated with the parent’s/guardian’s plan for implementation in the home environment. Toilet learning/training should be based on the child’s developmental level rather than chronological age.

To help children achieve bowel and bladder control, caregivers/teachers should enable children to take an active role in using the toilet when they are physically able to do so and when parents/guardians support their children’s learning to use the toilet.

Diapering/toilet training should not be used as rationale for not spending time outdoors. Practices and policies should be offered to address diapering/toileting needs outdoors such as providing staff who can address children’s needs, or provide outdoor diapering and toileting that meets all sanitation requirements.

Caregivers/teachers should take into account the preferences and customs of the child’s family.

For children who have not yet learned to use the toilet, the facility should defer toilet learning/training until the child’s family is ready to support this learning and the child demonstrates:

  1. An understanding of the concept of cause and effect;
  2. An ability to communicate, including sign language;
  3. The physical ability to remain dry for up to two hours;
  4. An ability to sit on the toilet, to feel/understand the sense of elimination;
  5. A demonstrated interest in autonomous behavior.

For preschool and school-age children, an emphasis should be placed on appropriate handwashing after using the toilet and they should be provided frequent and unrestricted opportunities to use the toilet.

Children with special health care needs may require specific instructions, training techniques, adapted toilets, and/or supports or precautions. Some children will need to be taught special techniques like catheterization or care of ostomies. This can be provided by trained staff or older children can sometimes learn self-care techniques. Any special techniques should be documented in a written care plan. The child care health consultant can provide training or coordinate resources necessary to accommodate special toileting techniques while in child care.

Cultural expectations of toilet learning/training need to be recognized and respected.

RATIONALE
A child’s achievements of motor and cognitive or developmental skills assist in determining when s/he is ready for toilet learning/training (1). Physical ability/neurological function also includes the ability to sit on the toilet and to feel/understand the sense of elimination.

Toilet learning/training is achieved more rapidly once expectations from adults across environments are consistent (3). The family may not be prepared, at the time, to extend this learning/training into the home environment (2).

School-age and preschool children may not respond when their bodies signal a need to use the toilet because they are involved in activities or embarrassed about needing to use the toilet. Holding back stool or urine can lead to constipation and urinary tract problems (4). Also, unless reminded, many children forget to correctly wash their hands after toileting.

COMMENTS
The area of toilet learning/training for children with special health care needs is difficult because there are no age-related, disability-specific rules to follow. As a result, support and counseling for parents/guardians and caregivers/teachers are required to help them deal with this issue. Some children with multiple disabilities do not demonstrate any requisite skills other than being dry for a few hours. Establishing a toilet routine may be the first step toward learning to use the toilet, and at the same time, improving hygiene and skin care. The child care health consultant should be considered a resource to assist is supporting special health care needs.

Sometimes children need to increase their fluid intake to help a medical condition and this can lead to increased urination. Other conditions can lead to loose stools. Children should be given unrestricted access to toileting facilities, especially in these situations. Children who are recovering from gastrointestinal illness might temporarily lose continence, especially if they are recently toilet trained, and may need to revert to diapers or training pants for a short period of time. Children who are experiencing stress (e.g., a new infant in the family) may regress and also return to using diapers for a period of time.

For more information on toilet learning/training, see “Toilet Training: Guidelines for Parents,” available from the American Academy of Pediatrics (AAP) at http://www.aap.org and the AAP Section on Developmental and Behavioral Pediatrics at http://www.aap.org/sections/dbpeds/.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.5 Chemical Toilets
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning/Training Equipment
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)
REFERENCES
  1. Mayo Clinic. 2009. Potty training: How to get the job done. http://www.mayoclinic.com/health/potty-training/CC00060/.
  2. American Academy of Pediatrics. 2009. When is the right time to start toilet training? http://www.aap.org/publiced/BR_ToiletTrain.htm.
  3. Anthony-Pillai, R. 2007. What’s potty about early toilet training? British Med J 334:1166.
  4. Schmitt, B. D. 2004. Toilet training problems: Underachievers, refusers, and stool holders. Contemporary Pediatrics 21:71-77.

2.1.3 Program Activities for Three- to Five-Year-Olds

2.1.3.1: Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds


Facilities should provide opportunities for each child to build long-term, trusting relationships with a few caring caregivers/teachers by limiting the number of adults the facility permits to care for any one child in child care to a maximum of eight adults in a given year and no more than three primary caregivers/teachers in a day. Children with special health care needs may require additional specialists to promote health and safety and to support learning; however, relationships with primary caregivers/teachers should be supported.
RATIONALE
Children learn best from adults who know and respect them; who act as guides, facilitators, and supporters within a rich learning environment; and with whom they have established a trusting relationship (1,2). When the facility allows too many adults to be involved in the child’s care, the child does not develop a reciprocal, sustained, responsive, and trusting relationship with any of them.

Children should have continuous friendly and trusting relationships with several caregivers/teachers who are reasonably consistent within the child care facility. Young children can extract from these relationships a sense of themselves with a capacity for forming trusting relationships and self-esteem. Relationships are fragmented by rapid staff turnover, staffing reassignment, or if the child is frequently moved from one room to another or one child care facility to another.

COMMENTS
Compliance should be measured by staff and parent/guardian interviews. Turnover of staff lowers the quality of the facility. High quality facilities maintain low turnover through their wage policies, training and support for staff (3).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Rodd, J. 1996. Understanding young children’s behavior: A guide for early childhood professionals. New York: Teacher’s College Press.
  2. Greenberg, P. 1991. Character development: Encouraging self-esteem and self-discipline in infants, toddlers, and two-year-olds. Washington, DC: National Association for the Education of Young Children.
  3. Whitebook, M., D. Bellm. 1998. Taking on turnover: An action guide for child care center teachers and directors. Washington, DC: Center for the Child Care Workforce.

2.1.3.2: Opportunities for Learning for Three- to Five-Year-Olds


Programs should provide children a balance of guided and self-initiated play and learning indoors and outdoors. These should include opportunities to observe, explore, order and reorder, to make mistakes and find solutions, and to move from the concrete to the abstract in learning.
RATIONALE
The most meaningful learning has its source in the child’s self-initiated activities. The learning environment that supports individual differences, learning styles, abilities, and cultural values fosters confidence and curiosity in learners (1,2).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Rodd, J. 1996. Understanding young children’s behavior: A guide for early childhood professionals. New York: Teacher’s College Press.
  2. Ritchie, S., B. Willer. 2008. Teaching: A guide to the NAEYC early childhood standard and related accreditation criteria. Washington, DC: National Association for the Education of Young Children.

2.1.3.3: Selection of Equipment for Three- to Five-Year-Olds


The program should select, for both indoor and outdoor play and learning, developmentally appropriate equipment and materials, for safety, for its ability to provide large and small motor experiences, and for its adaptability to serve many different ideas, functions, and forms of creative expression.
RATIONALE
An aesthetic, orderly, appropriately stimulating, child-oriented indoor and outdoor learning/play environment contributes to the preschooler’s sense of well-being and control (1,2,4,5).
COMMENTS
“Play and learning settings that motivate children to be physically active include pathways, trails, lawns, loose parts, anchored playground equipment, and layouts that stimulate all forms of active play” (3). If traditional playground equipment is used, caregivers/teachers may want to consult with an early childhood specialist or a certified playground inspector for recommendations on developmentally appropriate play equipment. For more information on play equipment also contact the National Program for Playground Safety (http://www.uni.edu/playground/).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.9 Plastic Containers and Toys
5.2.9.12 Treatment of CCA Pressure-Treated Wood
REFERENCES
  1. Torelli, L., C. Durrett. 1996. Landscape for learning: The impact of classroom design on infants and toddlers. Early Child News 8:12-17.
  2. Center for Environmental Health. The safe playgrounds project. http://www.safe2play.org.
  3. DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. 2005. Preschool outdoor environment measurement scale. Lewisville, NC: Kaplan Early Learning Co.
  4. Banning, W., G. Sullivan. 2009. Lens on outdoor learning. St. Paul, MN: Red Leaf Press.
  5. Keeler, R. 2008. Natural playscapes: Creating outdoor play environments for the soul. Redmond, WA: Exchange Press.

2.1.3.4: Expressive Activities for Three- to Five-Year-Olds


Caregivers/teachers should encourage and enhance expressive activities that include play, painting, drawing, storytelling, sensory play, music, singing, dancing, and dramatic play.
RATIONALE
Expressive activities are vehicles for socialization, conflict resolution, and language development. They are vital energizers and organizers for cognitive development (2). Stifling the preschooler’s need to play damages a natural integration of thinking and feeling (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Cooney, M., L. Hutchinson, V. Costigan. 1996. From hitting to tattling to communication and negotiation: The young child’s stages of socialization. Early Child Education J 24:23-27.
  2. Tepperman, J., ed. 2007. Play in the early years: Key to school success, a policy brief. El Cerrito, CA: Early Childhood Funders. http://www.4children.org/images/pdf/play07.pdf.

2.1.3.5: Fostering Cooperation of Three- to Five-Year-Olds


Programs should foster a cooperative rather than a competitive indoor and outdoor learning/play environment.
RATIONALE
As three-, four-, and five-year-olds play and work together, they shift from almost total dependence on the adult to seeking social opportunities with peers that still require adult monitoring and guidance. The rules and responsibilities of a well-functioning group help children of this age to internalize impulse control and to become increasingly responsible for managing their behavior. A dynamic curriculum designed to include the ideas and values of a broad socioeconomic group of children will promote socialization. The inevitable clashes and disagreements are more easily resolved when there is a positive influence of the group on each child (1).
COMMENTS
Encouraging communication skills and attentiveness to the needs of individuals and the group as a whole supports a cooperative atmosphere. Adults need to model cooperation.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Pica, R. 1997. Beyond physical development: Why young children need to move. Young Child 52:4-11.

2.1.3.6: Fostering Language Development of Three- to Five-Year-Olds


The indoor and outdoor learning/play environment should be rich in first-hand experiences that offer opportunities for language development. They should also have an abundance of books of fantasy, fiction, and nonfiction, and provide chances for the children to relate stories. Caregivers/teachers should foster language development by:

  1. Speaking with children rather than at them;
  2. Encouraging children to talk with each other by helping them to listen and respond;
  3. Giving children models of verbal expression;
  4. Reading books about the child’s culture and history, which would serve to help the child develop a sense of self;
  5. Reading to children and re-reading their favorite books;
  6. Listening respectfully when children speak;
  7. Encouraging interactive storytelling;
  8. Using open-ended questions;
  9. Provide opportunities during indoor and outdoor learning/play to use writing supplies and printed materials;
  10. Provide and read books relevant to their natural environment outdoors (for example, books about the current season, local wildlife, etc.);
  11. Provide settings that encourage children to observe nature, such as a butterfly garden, bird watching station, etc.;
  12. Providing opportunities to explore writing, such as through a writing area or individual journals.
RATIONALE
Language reflects and shapes thinking. A curriculum created to match preschoolers’ needs and interests enhances language skills. First-hand experiences encourage children to talk with each other and with adults, to seek, develop, and use increasingly more complex vocabulary, and to use language to express thinking, feeling, and curiosity (1-3).
COMMENTS
Compliance with development should be measured by structured observation. Examples of verbal encouragement of verbal expression are: “ask Johnny if you may play with him”; “tell him you don’t like being hit”; “tell Sara what you saw downtown yesterday;” “can you tell Mommy about what you and Johnny played this morning?” These encouraging statements should be followed by respectful listening, without pressuring the child to speak.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.3.2.3 Support Services for Parents/Guardians
REFERENCES
  1. Szanton, E. S., ed. 1997. Creating child-centered programs for infants and toddlers, birth to 3 year olds, step by step: A Program for children and families. New York: Children’s Resources International.
  2. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. ERIC Digest (January).
  3. Maschinot, B. 2008. The changing face of the United States: The influence of culture on early child development. Washington, DC: Zero to Three. http://www.zerotothree.org/site/DocServer/Culture_book.pdf?docID=6921.

2.1.3.7: Body Mastery for Three- to Five-Year-Olds


The caregivers/teachers should offer children opportunities, indoors and outdoors, to learn about their bodies and how their bodies function in the context of socializing with others. Caregivers/teachers should support the children in their curiosity and body mastery, consistent with parental/guardian expectations and cultural preferences. Body mastery includes feeding oneself, learning how to use the toilet, running, skipping, climbing, balancing, playing with peers, displaying affection, and using and manipulating objects.
RATIONALE
Achieving the pleasure and gratification of feeling physically competent on a voluntary basis is a basic component of developing self-esteem and the ability to socialize with adults and other children inside and outside the family (1-5).
COMMENTS
Self-stimulatory behaviors, such as thumb sucking or masturbation, should be ignored. If the masturbation is excessive, interferes with other activities, or is noticed by other children, the caregiver/teacher should make a brief non-judgmental comment that touching of private body parts is normal, but is usually done in a private place (7,8). After making such a comment, the caregiver/teacher should offer friendly assistance in going on to other activities. These behaviors may be signs of stress in the child’s life, or simply a habit. If the child’s sexual play is more explicit or forceful toward other children or the child witnessed or was exposed to adult sexuality, the caregiver/teacher may need to consider that abuse is possible (6).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Botkin, D., et al. 1991. Children’s affectionate behavior: Gender differences. Early Education Dev 2:270-86.
  2. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Education 7:229-39.
  3. Cartwright, S. 1998. Group trips: An invitation to cooperative learning. Child Care Infor Exch 124:95-97.
  4. Rodd, J. 1996. Understanding young children’s behavior: A guide for early childhood professionals. New York: Teacher’s College Press.
  5. Cooney, M., L. Hutchinson, V. Costigan. 1996. From hitting to tattling to communication and negotiation: The young child’s stages of socialization. Early Child Education J 24:23-27.
  6. Kellogg, N., American Academy of Pediatrics Committee on Child Abuse and Neglect. 2005. Clinical report: The evaluation of sexual abuse in children. Pediatrics 116:506-12.
  7. Johnson, T. C. 2007. Understanding children’s sexual behaviors: What’s natural and healthy. San Diego: Institute on Violence, Abuse and Trauma.
  8. Friedrich, W. N., J. Fisher, D. Broughton, M. Houston, C. R. Shafran. 1998. Normative sexual behavior in children: A contemporary sample. Pediatrics 101: e9.

2.1.4 Program Activities for School-Age Children

2.1.4.1: Supervised School-Age Activities


The facility should have a program of supervised activities designed especially for school-age children, to include:

  1. Free choice of play;
  2. Opportunities, both indoors and outdoors, for vigorous physical activity which engages each child daily for at least sixty minutes and are not limited to opportunities to develop physical fitness through a program of focused activity that only engages some of the children in the group;
  3. Opportunities for concentration, alone or in a group, indoors and/or outdoors;
  4. Time to read or do homework, indoors and/or outdoors;
  5. Opportunities to be creative, to explore the arts, sciences, and social studies, and to solve problems, indoors and/or outdoors;
  6. Opportunities for community service experience (museums, library, leadership development, elderly citizen homes, etc.);
  7. Opportunities for adult-supervised skill-building and self-development groups, such as scouts, team sports, and club activities (as transportation, distance, and parental permission allow);
  8. Opportunities to rest;
  9. Opportunities to seek comfort, consolation, and understanding from adult caregivers/teachers;
  10. Opportunities for exercise and exploration out of doors.
RATIONALE
Programs organized for older children after school or during vacation time should provide indoor and outdoor learning/play environments that meet the needs of these children for physical activity, recreation, responsible completion of school work, expanding their interests, learning cultural sensitivity, exploring community resources, and practicing pro-social skills (1,2).
COMMENTS
For more information on school-age standards, see [The NAA Standards for Quality School-Age Care,] available from the National AfterSchool Association (NAA).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
REFERENCES
  1. Coltin, L. 1999. Enriching children’s out-of-school time. ERIC Digest (May).
  2. Fashola, O. S. 1999. Implementing effective after-school programs. Here’s How 17:1-4

2.1.4.2: Space for School-Age Activity


The facility should provide a space for indoor and outdoor activities for children in school-age child care.
RATIONALE
A safe and secure environment that fosters the growing independence of school-age children is essential for their development (1,2). Active connection with nature promotes children’s sensitivity, confidence, exploration, and self-regulation.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Greenspan, S. L. 1997. Building children’s minds: Early childhood development for a better future. Our Child 23:6-10.
  2. Maxwell, L. E. 1996. Designing early childhood education environments: A partnership between architect and educator. Education Facility Planner 33:15-17.

2.1.4.3: Developing Relationships for School-Age Children


The facility should offer opportunities to school-age children for developing trusting, supportive relationships with the staff and with peers.
RATIONALE
Although school-age children need more independent experiences, they continue to need the guidance and support of adults. Peer relationships take on increasing importance for this age group. Community service opportunities can be valuable for this age group.
TYPE OF FACILITY
Center, Large Family Child Care Home

2.1.4.4: Planning Activities for School-Age Children


The facility should offer a program based on the needs and interests of the age group, as well as of the individuals within it. Children should participate in planning the program activities. Parents/guardians should be engaged and their work commitments should be honored when planning program activities.
RATIONALE
A child care facility for school-age children should provide an enriching contrast to the formal school program, but also offer time for children to complete homework assignments. Programs that offer a wide range of activities (such as team sports, cooking, dramatics, art, music, crafts, games, open time, quiet time, outdoor play and learning, and use of community resources) allow children to explore new interests and relationships.
TYPE OF FACILITY
Center, Large Family Child Care Home

2.1.4.5: Community Outreach for School-Age Children


The facility should provide opportunities for school-age children to participate in community outreach and involvement, such as field trips and community improvement projects.
RATIONALE
As the world of the school-age child encompasses the larger community, facility activities should reflect this stage of development. Field trips and other opportunities to explore the community should enrich the child’s experience (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Taras, H. L. 2005. School-aged child care. In Health in child care: A manual for health professionals, ed. J. R. Murph, S. D. Palmer, D. Glassy, 411-21. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2.1.4.6: Communication Between Child Care and School


Facilities that accept school-age children directly from school should arrange a system of communication with the child’s school teacher. Families should be included in this communication loop.
RATIONALE
This communication may be facilitated by phone or email between the child’s teacher and the school-age child care facility. School-age child care programs should include parent/guardian permissions which allow school teachers to communicate relevant information to caregivers/teachers. Parents/guardians should also be notified of any significant event so that a system of communication is established between and among family, school, and caregivers/teachers. The child’s school teacher and a staff member from the facility should meet at least once to exchange telephone numbers and to offer a contact in the event relevant information needs to be shared.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.4.1.3 Written Policy on Confidentiality of Records
REFERENCES
  1. National Association of Elementary School Principals, National AfterSchool Association. Leading a new day for learning. http://www.naaweb.org/downloads/Principal Documents/leading_joint_statement-r3_.pdf.

2.2 Supervision and Discipline

2.2.0

2.2.0.1: Methods of Supervision of Children


Caregivers/teachers should directly supervise infants, toddlers, and preschoolers by sight and hearing at all times, even when the children are going to sleep, napping or sleeping, are beginning to wake up, or are indoors or outdoors. School-age children should be within sight or hearing at all times. Caregivers/teachers should not be on one floor level of the building, while children are on another floor or room. Ratios should remain the same whether inside or outside.

School-age children should be permitted to participate in activities off the premises with appropriate adult supervision and with written approval by a parent/guardian and by the caregiver. If parents/guardians give written permission for the school-age child to participate in off-premises activities, the facility would no longer be responsible for the child during the off-premises activity and not need to provide staff for the off-premises activity.

Caregivers/teachers should regularly count children (name to face on a scheduled basis, at every transition, and whenever leaving one area and arriving at another), going indoors or outdoors, to confirm the safe whereabouts of every child at all times. Additionally, they must be able to state how many children are in their care at all times.

Developmentally appropriate child:staff ratios should be met during all hours of operation, including indoor and outdoor play and field trips, and safety precautions for specific areas and equipment should be followed. No center-based facility or large family child care home should operate with fewer than two staff members if more than six children are in care, even if the group otherwise meets the child:staff ratio. Although centers often downsize the number of staff for the early arrival and late departure times, another adult must be present to help in the event of an emergency. The supervision policies of centers and large family child care homes should be written policies.

RATIONALE
Supervision is basic to safety and the prevention of injury and maintaining quality child care. Parents/guardians have a contract with caregivers/teachers to supervise their children. To be available for supervision or rescue in an emergency, an adult must be able to hear and see the children. In case of fire, a supervising adult should not need to climb stairs or use a ramp or an elevator to reach the children. Stairs, ramps, and elevators may become unstable because they can be pathways for fire and smoke.

Children who are presumed to be sleeping might be awake and in need of adult attention. A child’s risk-taking behavior must be detected and illness, fear, or other stressful behaviors must be noticed and managed.

The importance of supervision is not only to protect children from physical injury, but from harm that can occur from topics discussed by children or by teasing/bullying/inappropriate behavior. It is the responsibility of caregivers/teachers to monitor what children are talking about and intervene when necessary.

Children like to test their skills and abilities. This is particularly noticeable around playground equipment. Even if the highest safety standards for playground layout, design and surfacing are met, serious injuries can happen if children are left unsupervised. Adults who are involved, aware, and appreciative of young childrens’ behaviors are in the best position to safeguard their well-being. Active and positive supervision involves:

  1. Knowing each child’s abilities;
  2. Establishing clear and simple safety rules;
  3. Being aware of and scanning for potential safety hazards;
  4. Placing yourself in a strategic position so you are able to adapt to the needs of the child;
  5. Scanning play activities and circulating around the area;
  6. Focusing on the positive rather than the negative to teach a child what is safe for the child and other children;
  7. Teaching children the developmentally appropriate and safe use of each piece of equipment (e.g., using a slide correctly – feet first only – and teaching why climbing up a slide can cause injury, possibly a head injury).

Primary caregiving systems, small group sizes, and low child:staff ratios unique to infant/toddler settings support staff in properly supervising infants and toddlers. These practices encourage responsive interactions and understanding each child's strengths and challenges. When staff connect deeply with the children in their care, they are more in tune to children’s needs and whereabouts.  Ultimately, carefully planned environments; staffing that supports nurturing, individualized, and engaged caregiving; and well-planned, responsive care routines support active supervision in infant and toddler environments.

Children are going to be more active in the outdoor learning/play environment and need more supervision rather than less outside. Playground supervisors need to be designated and trained to supervise children in play areas (1). Supervision of the playground is a strategy of watching all the children within a specific territory and not engaging in prolonged dialog with any one child or group of children (or other staff). Other adults not designated to supervise may facilitate outdoor learning/play activities and engage in conversations with children about their exploration and discoveries. Facilitated play is where the adult is engaged in helping children learn a skill or achieve specific outcome of an activity. Facilitated play is not supervision (2).

Children need spaces, indoors and out, in which they can withdraw for alone-time or quiet play in small groups. However, program spaces should be designed with visibility that allows constant unobtrusive adult supervision. To protect children from maltreatment, including sexual abuse, the environment layout should limit situations in which an adult or older child is left alone with a child without another adult present (3,4).

Many instances have been reported where a child has hidden when the group was moving to another location, or where the child wandered off when a door was opened for another purpose. Regular counting of children (name to face) will alert the staff to begin a search before the child gets too far, into trouble, or slips into an unobserved location.

Caregivers/teachers should record the count on an attendance sheet or on a pocket card, along with notations of any children joining or leaving the group. Caregivers/teachers should do the counts before the group leaves an area and when the group enters a new area. The facility should assign and reassign counting responsibility as needed to maintain a counting routine. Facilities might consider counting systems such as using a reminder tone on a watch or musical clock that sounds at timed intervals (about every fifteen minutes) to help the staff remember to count.

Caregivers/teachers should be ready to provide help and guidance when children are ready to use the toilet correctly and independently. Caregivers/teachers should make sure children correctly wash their hands after every use of the toilet, as well as monitor the bathroom to make sure that the toilet is flushed, the toilet seat and floor are free from stool or urine, and supplies (toilet paper, soap, and paper towels) are available.

Older preschool children and school-age children may use toilet facilities without direct visual observation but must remain within hearing range in case children need assistance and to prevent inappropriate behavior. If toilets are not on the same floor as the child care area or within sight or hearing of a caregiver/teacher, an adult should accompany children younger than five years of age to and from the toilet area. Younger children who request privacy and have shown capability to use toilet facilities properly should be given permission to use separate and private toilet facilities.

Planning must include advance assignments, monitoring, and contingency plans to maintain appropriate staffing. During times when children are typically being dropped off and picked up, the number of children present can vary. There should be a plan in place to monitor and address unanticipated changes, allowing for caregivers/teachers to receive additional help when needed. Sufficient staff must be maintained to evacuate the children safely in case of emergency. Compliance with proper child:staff ratios should be measured by structured observation, by counting caregivers/teachers and children in each group at varied times of the day, and by reviewing written policies.

COMMENTS

ADDITIONAL READINGS:

Harms, T., R. M. Clifford, D. Cryer. 2005. Early childhood environment rating scale, revised ed. Frank Porter Graham Child Development Institute, University of North Carolina. http://ers.fpg
.unc.edu/node/82/.

Harms, T., D. Cryer, R. M. Clifford. 2005. Infant/toddler environment rating scale, revised ed. Frank Porter Graham Child Development Institute, University of North Carolina. http://ers.fpg.unc.edu/node/84/.

Chen, X., M. Beran, R. Altkorn, S. Milkovich, K. Gruaz, G. Rider, A. Kanti, J. Ochsenhirt. 2006. Frequency of caregiver supervision of young children during play. Intl J Injury Control and Safety Promotion 14:122-24.

Schwebel, D. C., A. L. Summerlin, M. L. Bounds, B. A. Morrongiello. 2006. The stamp-in-safety program: A behavioral intervention to reduce behaviors that can lead to unintentional playground injury in a preschool setting. J Pediatric Psychology 31:152-62.

U.S. Consumer Product Safety Commission (CPSC). 2010. Public playground safety handbook. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
5.4.1.2 Location of Toilets and Privacy Issues
REFERENCES
  1. National Program for Playground Safety. 2006. Playground supervision training for childcare providers. University of Northern Iowa. http://www.playgroundsafety.org/training/online/childcare/course_supervision.htm.
  2. National Program for Playground Safety. 2006. NPPS Website. http://www.playgroundsafety.org.
  3. National Association for the Education of Young Children. 1996. Position Statement. Prevention of child abuse in early childhood programs and the responsibilities of early childhood professionals to prevent child abuse.
  4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

2.2.0.2: Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.

Frequently Asked Questions/CFOC3 Clarifications

Reference: 2.2.0.2

Date: 10/13/2011

Topic & Location:
Chapter 2
Program Activities
Standard 2.2.0.2: Limiting In-fant/Toddler Time in Crib, High Chair, Care Seat, Etc.

Question:
Please provide more contexts surrounding the research that informed the recommendation that “children should not be left to sleep in equipment, such as car seats, swings, or infants seats that do not meet the ASTM International (ASTM) product safety standards for sleep equipment.”

Is part of the intent regarding this standard to educate parents about safe infant sleep practices or is it actually dangerous for infants to sleep sitting up, or both?

Answer:
Both. Extended periods of time in the crib, high chair, car seat, or other confined space limits infants’ physical growth (gross motor development) and also affects their social interactions. Injuries and Sudden Infant Death Syndrome (SIDS) have occurred when children have been left to sleep in car seats or infants seats.

Please see the Standard’s rationale and references for information on related injuries and SIDS.


A child should not sit in a high chair or other equipment that constrains his/her movement (1,2) indoors or outdoors for longer than fifteen minutes, other than at meals or snack time. Children should never be left out of the view and attention of adult caregivers/teachers while in these types of equipment/furniture. A least restrictive environment should be encouraged at all times. Children should not be left to sleep in equipment, such as car seats, swings, or infant seats that does not meet ASTM International (ASTM) product safety standards for sleep equipment.
RATIONALE
Children are continually developing their physical skills. They need opportunities to use and build on their physical abilities. This is especially true for infants and toddlers who are eagerly using their bodies to explore their environment. Extended periods of time in the crib, high chair, car seat, or other confined space limits their physical growth and also affects their social interactions. Injuries and Sudden Infant Death Syndrome (SIDS) have occurred when children have been left to sleep in car seats or infant seats when the straps have entrapped body parts, or the children have turned the seats over while in them. Sleeping in a seated position can restrict breathing and cause oxygen desaturation in young infants (3). Sleeping should occur in equipment manufactured for this activity. When children are awake, restricting them to a seat may limit social interactions. These social interactions are essential for children to gain language skills, develop self-esteem, and build relationships (4).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.3.1.10 Restrictive Infant Equipment Requirements
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
REFERENCES
  1. Kornhauser Cerar, L., C.V. Scirica, I. Stucin Gantar, D. Osredkar, D. Neubauer, T.B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in care safety seats and beds. Pediatrics 124:e396-e402.
  2. Benjamin, S.E., S.L. Rifas-Shiman, E.M. Taveras, J. Haines, J. Finkelstein, K. Kleinman, M.W. Gillman. 2009. Early child care and adiposity at ages 1 and 3 years. Pediatrics 124:555-62.
  3. Bass, J. L., M. Bull. 2008. Oxygen desaturation in term infants in car safety seats. Pediatrics 110:401-2.
  4. New York State Office of Children and Family Services. Website. http://www.ocfs.state.ny.us/main/.

2.2.0.3: Screen Time/Digital Media Use

Frequently Asked Questions/CFOC3 Clarifications

Reference: 2.2.0.3

Date: 3/8/2012

Topic & Location:
Chapter 2
Program Activities
Standard 2.2.0.3: Limiting Screen Time - Media, Computer Time

Question:
This standard states that children two years and older in early care and education settings should not be exposed to more than thirty minutes per week of screen time and that computer use should be limited to no more than fifteen minute increments.

Is the fifteen minute increment for computer use included in the total screen time of thirty minutes per week?

Answer:
Yes.

Content in the STANDARD was modified on 10/12/2017.


Please note: For the purposes of this standard “screen time/digital media” refers to media content viewed on cell/mobile phone, tablet, computer, television (TV), video, film, and DVD. It does not include video-chatting with family.
 
Screen time/digital media should not be used with children ages 2 and younger in early care and education settings. For children ages 2 to 5 years, total exposure (in early care and education and at home combined) to digital media should be limited to 1 hour per day of high-quality programming [1], and viewed with an adult who can help them apply what they are learning to the world around them (1).
 
Children ages 5 and older may need to use digital media in early care and education to complete homework. However, caregivers/teachers should ensure that entertainment media time does not displace healthy activities such as exercise, refreshing sleep, and family time, including meals.
 
For children of all ages, digital media and devices should not be used during meal or snack time, or during nap/rest times and in bed. Devices should be turned off at least one hour before bedtime. When offered, digital media should be free of advertising and brand placement, violence, and sounds that tempt children to overuse the product. 
 
Caregivers/teachers should communicate with parents/guardians about their guidelines for home media use. Caregivers/teachers should take this information into consideration when planning the amount of media use at the child care program to help in meeting daily recommendations (1).
 
Programs should prioritize physical activity and increased personal social interactions and engagement during the program day. It is important for young children to have active social interactions with adults and children. Media use can distract children (and adults), limit conversations and play, and reduce healthy physical activity, increasing the risk for overweight and obesity. Media should be turned off when not in use since background media can be distracting, and reduce social engagement and learning. Overuse of media can also be associated with problems with behavior, limit-setting, and emotional and behavioral self-regulation; therefore, caregivers/teachers should avoid using media to calm a child down (1).
 
Note: The guidance above should not limit digital media use for children with special health care needs who require and consistently use assistive and adaptive computer technology (2). However, the same guidelines apply for entertainment media use. Consultation with an expert in assistive communication may be necessary. 
 


[1] designed with child psychologists and educators to meet specific educational goals

RATIONALE
The first two years of life are critical periods of growth and development for children’s brains and bodies, and rapid brain development continues through the early childhood years. To best develop their cognitive, language, motor, and social-emotional skills, infants and toddlers need hands-on exploration and social interaction with trusted caregivers (1). Digital media viewing do not promote such skills development as well as “real life”.
 
Excessive media use has been associated with lags in achievement of knowledge and skills, as well as negative impacts on sleep, weight, and social/emotional health. (1). For example, among 2-year-olds, research has shown that body mass index (BMI) increases for every hour per week of media consumed (3).
 
COMMENTS

Digital media is not without benefits, including learning from high-quality content, creative engagement, and social interactions. However, especially in young children, real-life social interactions promote greater learning and retention of knowledge and skills.  When limited digital media are used, co-viewing and co-teaching with an engaged adult promotes more effective learning and development. 

Because children may use digital media before and after attending early care and education settings, limiting digital media use in early care and education settings and substituting developmentally appropriate play and other hands-on activities can better promote learning and skills development. Such an activity is reading. Caregivers/teachers should begin reading to children at infancy (4) and facilities should make age-appropriate books available for each cognitive stage of development that can be co-read and discussed with an adult. See the American Academy of Pediatrics’ “Books Build Connections Toolkit” at https://littoolkit.aap.org/forprofessionals/Pages/home.aspx for more information.
The American Academy of Pediatrics has developed a Family Media Use Plan tool, available at https://www.healthychildren.org/English/media/Pages/default.aspx, which can help parents/guardians, caregivers, and families identify healthy activities for each child, and prioritize them ahead of limited digital media use (5). 

Caregivers/teachers serve as role models for children in early care and education settings by not using or being distracted by digital media during care hours. In addition, if adults view media such as news in the presence of children, children may be exposed to inappropriate language or violent or frightening images that can cause emotional upset or increase aggressive thoughts and behavior. Caregivers/teachers should be discouraged from using digital media for personal use while actively engaging with and supervising the children in their care. Instead, opportunities for collaborative activities are preferred.

It is important to safeguard privacy for children on the internet and digital media.  Pictures and videos of children should never be posted on social media without parent/guardian consent. Caregivers/teachers should know and follow their program’s policy for taking, sharing, or posting pictures and videos. 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.1.4.3 Developing Relationships for School-Age Children
2.2.0.1 Methods of Supervision of Children
3.1.3.1 Active Opportunities for Physical Activity
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591. http://pediatrics.aappublications.org/content/pediatrics/138/5/e20162591.full.pdf 
  2. Reid CY, Radesky J, Christakis D, et al., American Academy of Pediatrics Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5):e2016593. 
    http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593
  3. Wen LM, Baur LA, Rissel C, Xu H, Simpson, JM. Correlates of body mass index and overweight and obesity of children aged 2 years: finding from the healthy beginnings trial. Obesity. 2014;22(7):1723-1730.
  4. American Academy of Pediatrics. Council on Early Childhood. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134(2):1-6. http://pediatrics.aappublications.org/content/early/2014/06/19/peds.2014-1384
  5. American Academy of Pediatrics Council on Communications and Media. Media use in school-aged children and adolescents. Pediatrics. 2016;138(5):e20162592. http://pediatrics.aappublications.org/content/138/5/e20162592
  6. ADDITIONAL REFERENCES:
     
    American Academy of Pediatrics Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5): e20162593. http://pediatrics.aappublications.org/content/pediatrics/early/2016/10/19/peds.2016-2593.full.pdf.
     
    American Academy of Pediatrics. Media and children communication toolkit. Aap.org Web site. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/pages/media-and-children.aspx. Accessed October 12, 2017. 
     
    Campaign for a Commercial-Free Childhood. Screenfree.org Web site. http://www.screenfree.org/. Accessed October 12, 2017. 
     
    Common Sense Education. Commonsense.org Web site.  https://www.commonsense.org/education/toolkit/audience/device-free-dinner-educator-resources. Accessed October 12, 2017. 
     
    Fred Rogers Center for Early Learning and Children’s Media at Saint Vincent College. How am I doing? A checklist for identifying exemplary uses of technology and interactive media for early learning. Fredrogerscenter.org Web site. http://www.fredrogerscenter.org/2014/02/25/how-am-i-doing-checklist-exemplary-uses-of-technology-early-learning/. Updated February 25, 2014. Accessed October 12, 2017. 
     
    National Association for the Education of Young Children. Technology and interactive media as tools in early childhood programs serving children from birth through age 8. Position Statement. NAEYC.org Web site. http://www.naeyc.org/files/naeyc/PS_technology_WEB.pdf. January 2012. Accessed October 12, 2017.  
NOTES

Content in the STANDARD was modified on 10/12/2017.

2.2.0.4: Supervision Near Bodies of Water


Constant and active supervision should be maintained when any child is in or around water (1). During any swimming/wading/water play activities where either an infant or a toddler is present, the ratio should always be one adult to one infant/toddler. Children ages thirteen months to five years of age should not be permitted to play in areas where there is any body of water, including swimming pools, ponds and irrigation ditches, built-in wading pools, tubs, pails, sinks, or toilets unless the supervising adult is within an arm’s length providing “touch supervision”.

Caregivers/teachers should ensure that all pools meet the Virginia Graeme Baker Pool and Spa Safety Act, requiring the retrofitting of safe suction-type devices for pools and spas to prevent underwater entrapment of children in such locations with strong suction devices that have led to deaths of children of varying ages (2).

RATIONALE
Small children can drown within thirty seconds, in as little as two inches of liquid (3).

In a comprehensive study of drowning and submersion incidents involving children under five years of age in Arizona, California, and Florida, the U.S. Consumer Product Safety Commission (CPSC) found that:

  1. Submersion incidents involving children usually happen in familiar surroundings;
  2. Pool submersions involving children happen quickly, 77% of the victims had been missing from sight for five minutes or less;
  3. Child drowning is a silent death, and splashing may not occur to alert someone that the child is in trouble (4).

Drowning is the second leading cause of unintentional injury-related death for children ages one to fourteen (5).

In 2006, approximately 1,100 children under the age of twenty in the U.S died from drowning (11). A national study that examined where drowning most commonly takes place concluded that infants are most likely to drown in bathtubs, toddlers are most likely to drown in swimming pools and older children and adolescents are most likely to drown in freshwater (rivers, lakes, ponds) (11).

While swimming pools pose the greatest risk for toddlers, about one-quarter of drowning among toddlers are in freshwater sites, such as ponds or lakes.

The American Academy of Pediatrics (AAP) recommends:

  1. Swimming lessons for children based on the child’s frequency of exposure to water, emotional maturity, physical limitations, and health concerns related to swimming pools;
  2. “Touch supervision” of infants and young children through age four when they are in the bathtub or around other bodies of water;
  3. Installation of four-sided fencing that completely separates homes from residential pools;
  4. Use of approved personal flotation devices (PFDs) when riding on a boat or playing near a river, lake, pond, or ocean;
  5. Teaching children never to swim alone or without adult supervision;
  6. Stressing the need for parents/guardians and teens to learn first aid and cardiopulmonary resuscitation (CPR) (3).

Deaths and nonfatal injuries have been associated with infant bathtub “supporting ring” devices that are supposed to keep an infant safe in the tub. These rings usually contain three or four legs with suction cups that attach to the bottom of the tub. The suction cups, however, may release suddenly, allowing the bath ring and infant to tip over. An infant also may slip between the legs of the bath ring and become trapped under it. Caregivers/teachers must not rely on these devices to keep an infant safe in the bath and must never leave an infant alone in these bath support rings (1,6,7).

Thirty children under five years of age died from drowning in buckets, pails, and containers from 2003-2005 (10). Of all buckets, the five-gallon size presents the greatest hazard to young children because of its tall straight sides and its weight with even just a small amount of liquid. It is nearly impossible for top-heavy (their heads) infants and toddlers to free themselves when they fall into a five-gallon bucket head first (8).

The Centers for Disease Control (CDC) National Center for Injury Prevention and Control recommends that whenever young children are swimming, playing, or bathing in water, an adult should be watching them constantly. The supervising adult should not read, play cards, talk on the telephone, mow the lawn, or do any other distracting activity while watching children (1,9).

COMMENTS
“Touch supervision” means keeping swimming children within arm’s reach and in sight at all times. Flotation devices should never be used as a substitute for supervision. Knowing how to swim does not make a child drown-proof.

The need for constant supervision is of particular concern in dealing with very young children and children with significant motor dysfunction or developmental delays. Supervising adults should be CPR-trained and should have a telephone accessible to the pool and water area at all times should emergency services be required.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.4.3.3 CPR Training for Swimming and Water Play
6.3.1.1 Enclosure of Bodies of Water
6.3.1.7 Pool Safety Rules
REFERENCES
  1. U.S. Consumer Product Safety Commission. 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
  2. U.S. Congress. 2007. Virginia Graeme Baker Pool and Spa Safety Act. 15 USC 8001. http://www.cpsc.gov/businfo/vgb/pssa.pdf.
  3. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement-prevention of drowning. Pediatrics 126: 178-85.
  4. U.S. Consumer Product Safety Commission. 2002. How to plan for the unexpected: Preventing child drownings. Publication #359. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/PUBS/359.pdf.
  5. Centers for Disease Control and Prevention (CDC). 2010. Unintentional drowning: Fact sheet. http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries
    -factsheet.html.
  6. U.S. Consumer Product Safety Commission. 1994. Drowning hazard with baby “supporting ring” devices. Document #5084. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/
    5084.html.
  7. Rauchschwalbe, R., R. A. Brenner, S. Gordon. 1997. The role of bathtub seats and rings in infant drowning deaths. Pediatrics 100:e1.
  8. U.S. Consumer Product Safety Commission. 1994. Infants and toddlers can drown in 5-gallon buckets: A hidden hazard in the home. Document #5006. Washington, DC: CPSC. http://www.cpsc
    .gov/cpscpub/pubs/5006.html.
  9. U.S. Consumer Product Safety Commission. 1997. CPSC reminds pool owners that barriers, supervision prevent drowning. Release #97-152. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/PREREL/PRHTML97/97152.html.
  10. Gipson, K. 2008. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.
  11. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.

2.2.0.5: Behavior Around a Pool


When children are in or around a pool, caregivers/teachers should teach age-appropriate behavior and safety skills including not pushing each other, holding each other under water, or running at the poolside. Children should be shown the depth of the water at different part of the pool. They should be taught that when going into a body of water, they should go in feet first the first time to check the depth. Children should be instructed what an emergency would be and to only call for help only in a real/genuine emergency. They should be taught to never dive in shallow water.
RATIONALE
Caregivers/teachers should take the opportunities to explain how certain behaviors could injure other children. Also such behavior can distract caregivers/teachers from supervising other children, thereby placing the other children at risk (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Department of Health and Human Services, Maternal and Child Health Bureau. 1999. Basic emergency lifesaving skills (BELS): A framework for teaching emergency lifesaving skills to children and adolescents. Newton, MA: Children’s Safety Network, Education Development Center. http://bolivia.hrsa.gov/emsc/Downloads/BELS/BELS.htm.

2.2.0.6: Discipline Measures


Reader’s Note: The word discipline means to teach and guide. Discipline is not punishment. The discipline standard therefore reflects an approach that focuses on preventing behavior problems by supporting children in learning appropriate social skills and emotional responses.

Caregivers/teachers should guide children to develop self-control and appropriate behaviors in the context of relationships with peers and adults. Caregivers/teachers should care for children without ever resorting to physical punishment or abusive language. When a child needs assistance to resolve a conflict, manage a transition, engage in a challenging situation, or express feelings, needs, and wants, the adult should help the child learn strategies for dealing with the situation. Discipline should be an ongoing process to help children learn to manage their own behavior in a socially acceptable manner, and should not just occur in response to a problem behavior. Rather, the adult’s guidance helps children respond to difficult situations using socially appropriate strategies. To develop self-control, children should receive adult support that is individual to the child and adapts as the child develops internal controls. This process should include:

  1. Forming a positive relationship with the child. When children have a positive relationship with the adult, they are more likely to follow that person’s directions. This positive relationship occurs when the adult spends time talking to the child, listening to the child, following the child’s lead, playing with the child, and responding to the child’s needs;
  2. Basing expectations on children’s developmental level;
  3. Establishing simple rules children can understand (e.g., you can’t hurt others, our things, or yourself) and being proactive in teaching and supporting children in learning the rules;
  4. Adapting the physical indoor and outdoor learning/play environment or family child care home to encourage positive behavior and self regulation by providing engaging materials based on children’s interests and ensuring that the learning environment promotes active participation of each child. Well-designed child care environments are ones that are supportive of appropriate behavior in children, and are designed to help children learn about what to expect in that environment and to promote positive interactions and engagement with others;
  5. Modifying the learning/play environment (e.g., schedule, routine, activities, transitions) to support the child’s appropriate behavior;
  6. Creating a predictable daily routine and schedule. When a routine is predictable, children are more likely to know what to do and what is expected of them. This may decrease anxiety in the child. When there is less anxiety, there may be less acting out. Reminders need to be given to the children so they can anticipate and prepare themselves for transitions within the schedule. Reminders should be individualized such that each child understands and anticipates the transition;
  7. Using encouragement and descriptive praise. When clear encouragement and descriptive praise are used to give attention to appropriate behaviors, those behaviors are likely to be repeated. Encouragement and praise should be stated positively and descriptively. Encouragement and praise should provide information that the behavior the child engaged in was appropriate. Examples: “I can tell you are ready for circle time because you are sitting on your name and looking at me.” “Your friend looked so happy when you helped him clean up his toys.” “You must be so proud of yourself for putting on your coat all by yourself.” Encouragement and praise should label the behaviors, not the child (e.g., good listening, good eating, instead of good boy);
  8. Using clear, direct, and simple commands. When clear commands are used with children, they are more likely to follow them. The caregiver/teacher should tell the child what to do rather than what NOT to do. The caregiver/teacher should limit the number of commands. The caregiver/teacher should use if/then and when/then statements with logical and natural consequences. These practices help children understand they can make choices and that choices have consequences;
  9. Showing children positive alternatives rather than just telling children “no”;
  10. Modeling desired behavior;
  11. Using planned ignoring and redirection. Certain behaviors can be ignored while at the same time the adult is able to redirect the children to another activity. If the behavior cannot be ignored, the adult should prompt the child to use a more appropriate behavior and provide positive feedback when the child engages in the behavior;
  12. Individualizing discipline based on the individual needs of children. For example, if a child has a hard time transitioning, the caregiver/teacher can identify strategies to help the child with the transition (individualized warning, job during transition, individual schedule, peer buddy to help, etc.) If a child has a difficult time during a large group activity, the child might be taught to ask for a break;
  13. Using time-out for behaviors that are persistent and unacceptable. Time-out should only be used in combination with instructional approaches that teach children what to do in place of the behavior problem. (See guidance for time-outs below.)

Expectations for children’s behavior and the facility’s policies regarding their response to behaviors should be written and shared with families and children of appropriate age. Further, the policies should address proactive as well as reactive strategies. Programs should work with families to support their children’s appropriate behaviors before it becomes a problem.

RATIONALE
Common usage of the word “discipline” has corrupted the word so that many consider discipline as synonymous with punishment, most particularly corporal punishment (2,3). Discipline is most effective when it is consistent, reinforces desired behaviors, and offers natural and logical consequences for negative behaviors. Research studies find that corporal punishment has limited effectiveness and potentially harmful side effects (4-9). Children have to be taught expectations for their behavior if they are to develop internal control of their actions. The goal is to help children learn to control their own behavior.
COMMENTS
Children respond well when they receive descriptive praise/attention for behaviors that the caregiver/teacher wants to see again. It is best if caregivers/teachers are sincere and enthusiastic when using descriptive praise. On the contrary, children should not receive praise for undesirable behaviors, but instead be praised for honest efforts towards the behaviors the caregivers/teachers want to see repeated (1). Discipline is best received when it includes positive guidance, redirection, and setting clear-cut limits that foster the child’s ability to become self-disciplined. In order to respond effectively when children display challenging behavior, it is beneficial for caregivers/teachers to understand typical social and emotional development and behaviors. Discipline is an ongoing process to help children develop inner control so they can manage their own behavior in a socially approved manner. A comprehensive behavior plan is often based first on a positive, affectionate relationship between the child and the caregiver/teacher. Measures that prevent behavior problems often include developmentally appropriate environments, supervision, routines, and transitions. Children can benefit from receiving guidance and repeated instructions for navigating the various social interactions that take place in the child care setting such as friendship development, problem-solving, and conflict-resolution.

Time-out (also known as temporary separation) is one strategy to help children change their behavior and should be used in the context of a positive behavioral support approach which works to understand undesired behaviors and teach new skills to replace the behavior. Listed below are guidelines when using time-out (8):

  1. Time-outs should be used for behaviors that are persistent and unacceptable, used infrequently and used only for children who are at least two years of age. Time-outs can be considered an extended ignore or a time-out from positive enforcement;
  2. The caregiver/teacher should explain how time-out works to the child BEFORE s/he uses it the first time. The adult should be clear about the behavior that will lead to time-out;
  3. When placing the child in time-out, the caregiver/teacher should stay calm;
  4. While the child is in time-out, the caregiver/teacher should not talk to or look at the child (as an extended ignore). However, the adult should keep the child in sight. The child could 1) remain sitting quietly in a chair or on a pillow within the room or 2) participate in some activity that requires solitary pursuit (painting, coloring, puzzle, etc.) If the child cannot remain in the room, s/he will spend time in an alternate space, with supervision;
  5. Time-outs do not need to be long. The caregiver/teacher should use the one minute of time-out for each year of the child’s age (e.g., three-years-old = three minutes of time-out);
  6. The caregiver/teacher should end the time-out on a positive note and allow the child to feel good again. Discussions with the child to “explain WHY you were in time-out” are not usually effective;
  7. If the child is unable to be distracted or consoled, parents/guardians should be contacted.

How to respond to failure to cooperate during time-out:

Caregivers/teachers should expect resistance from children who are new to the time-out procedure. If a child has never experienced time-out, s/he may respond by becoming very emotional. Time-out should not turn into a power struggle with the child. If the child is refusing to stay on time-out, the caregiver/teacher should give the child an if/then statement. For example, “if you cannot take your time-out, then you cannot join story time.” If the child continues to refuse the time-out, then the child cannot join story time. Note that children should not be restrained to keep them in time-out.

More resources for caregivers/teachers on discipline can be found at the following organizations’ Websites: a) Center on the Social and Emotional Foundations for Early Learning (CSEFEL) at http://csefel.vanderbilt.edu and b) Technical Assistance Center on Social Emotional Intervention (TACSEI) at http://challengingbehavior.fmhi.usf.edu/.

 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.1.6 Written Discipline Policies
9.4.1.6 Availability of Documents to Parents/Guardians
REFERENCES
  1. Henderlong, J., M. Lepper. 2002 The effects of praise on children’s intrinsic motivation: A review and synthesis. Psychological Bulletin 128:774-95.
  2. Hodgkin, R. 1997. Why the “gentle smack” should go: Policy review. Child Soc 11:201-4.
  3. Fraiberg, S. H. 1959. The Magic Years. New York: Charles Scribner’s Sons.
  4. Straus, M. A., et al. 1997. Spanking by parents and subsequent antisocial behavior of children. Arch Pediatric Adolescent Medicine 151:761-67.
  5. Deater-Deckard, K., et al. 1996. Physical discipline among African American and European American mothers: Links to children’s externalizing behaviors. Dev Psychol 32:1065-72.
  6. Weiss, B., et al. 1992. Some consequences of early harsh discipline: Child aggression and a maladaptive social information processing style. Child Dev 63:1321-35.
  7. American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in schools. Pediatrics 118:1266.
  8. Dunlap, S., L. Fox, M. L. Hemmeter, P. Strain. 2004. The role of time-out in a comprehensive approach for addressing challenging behaviors of preschool children. CSEFEL What Works Series. http://csefel.vanderbilt.edu/briefs/wwb14.pdf.
  9. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  10. ADDITIONAL REFERENCES:

    Gross, D., C. Garvey, W. Julion, L. Fogg, S. Tucker, H. Mokos. 2009. Efficacy of the Chicago Parent Program with low-income multi-ethnic parents of young children. Preventions Science 10:54-65.

    Breitenstein, S., D. Gross, I. Ordaz, W. Julion, C. Garvey, A. Ridge. 2007. Promoting mental health in early childhood programs serving families from low income neighborhoods. J Am Psychiatric Nurses Assoc 13:313-20.

    Gross, D., C. Garvey, W. Julion, L. Fogg. 2007. Preventive parent training with low-income ethnic minority parents of preschoolers. In Handbook of parent training: Helping parents prevent and solve problem behaviors. Ed. J. M. Briesmeister, C. E. Schaefer. 3rd ed. Hoboken, NJ: Wiley.

    Gartrell, D. 2007. He did it on purpose! Young Children 62:62-64.

    Gartrell, D. 2004. The power of guidance: Teaching social-emotional skills in early childhood classrooms. Clifton Park, NY: Thomson Delmar Learning; Washington, DC: NAEYC.

    Gartrell, D., K. Sonsteng. 2008. Promoting physical activity: It’s pro-active guidance. Young Children 63:51-53.

    Shiller, V. M., J. C. O’Flynn. 2008. Using rewards in the early childhood classroom: A reexamination of the issues. Young Children 63:88, 90-93.

    Reineke, J., K. Sonsteng, D. Gartrell. 2008. Nurturing mastery motivation: No need for rewards. Young Children 63:89, 93-97.

    Ryan, R. M., E. L. Deci. 2000. When rewards compete with nature: The undermining of intrinsic motivation and self-regulation. In Intrinsic and extrinsic motivation: The search for optimal motivation and performance, ed. C. Sanstone, J. M. Harackiewicz, 13-54. San Diego, CA: Academic Press.

2.2.0.7: Handling Physical Aggression, Biting, and Hitting


Caregivers/teachers should intervene immediately when a child’s behavior is aggressive and endangers the safety of others. It is important that the child be clearly told verbally, “no hitting” or “no biting.” The caregiver/teacher should use age–appropriate interventions. For example, a toddler can be picked up and moved to another location in the room if s/he bites other children or adults. A preschool child can be invited to walk with you first but, if not compliant, taken by the hand and walked to another location in the room. The caregiver/teacher should remain calm and make eye contact with the child telling him/her the behavior is unacceptable. If the behavior persists, parents/guardians, caregivers/teachers, the child care health consultant and the early childhood mental health consultant should be involved to create a plan targeting this behavior. For example, a plan may be developed to recognize non-aggressive behavior. Children who might not have the social skills or language to communicate appropriately may use physical aggression to express themselves and the reason for and antecedents of the behavior must be considered when developing a plan for addressing the behavior.
RATIONALE
Caregiver/teacher intervention protects children and encourages children to exhibit more acceptable behavior (1).
COMMENTS
Biting is a phase. Here are some specific steps to deal with biting:

Step 1: If a child bites another child, the caregiver/teacher should comfort the child who was bitten and remind the biter that biting hurts and we do not bite. Children should be given some space from each other for an appropriate amount of time.

Step 2: The caregiver/teacher should follow first aid instructions (available from the American Academy of Pediatrics [AAP] and the American Red Cross) and use the Center for Disease Control and Prevention’s (CDC’s) Standard Precautions to handle potential exposure to blood.

Step 3: The caregiver/teacher should allow for “dignity of risk,” and let the children back in the same space with increased supervision. Interactions should be structured between children such that the child learns to use more appropriate social skills or language rather than biting. If there is another incident, caregivers/teachers should repeat step one. The biter can play with children they have not bitten.

Step 4: The adult needs to shadow the biter to ensure safety of the other children. This can be challenging but imperative for the biter.

Step 5: For all transitions when the biter would be in close contact, the caregiver/teacher should hold him/her on her/his hip or if possible hold hands, keep a close watch, and keep the biter from close proximity with peers.

Step 6: The child (biter) should play with one or two other children whom they have not bitten with a favored adult in a section separate from the other children. Sometimes, until a phase (biting is a phase) passes, the caregiver/teacher needs to extinguish the behavior by not allowing it to happen and thereby reducing the attention given to the behavior.

Step 7: Parents/guardians of both children of the incident should be informed.

Step 8: The caregiver/teacher should determine whether the incident necessitates documentation (see Standard 9.4.1.9). If so, s/he should complete a report form.

Caregivers/teachers need to consider why the child is biting and teach the child a more appropriate way to communicate the same need. Possible reasons why a child would bite include:

  1. Lack of words (desire to stop the behavior of another child);
  2. Teething;
  3. Tired (is nap time too late?);
  4. Hungry (is lunch time too late?);
  5. Lack of toys – consider buying duplicates of popular items;
  6. Lack of supervision – more staff should be added, staff are near children during transitions, and room is set up to ensure visibility;
  7. Child is bored – too much sitting, activities are too frustrating;
  8. Child has oral motor needs – teethers are offered;
  9. Child is avoiding something, and biting gets him/her out of it;
  10. Lack of attention – child receives attention when biting.

Other important strategies to consider:

  1. The caregiver/teacher should point out the effect of the child’s biting on the victim: “Emma is crying. Biting hurts. Look at her face. See how sad she is?” Label feelings and give victims the words to respond. “Emma, you can say ‘No biting!’ to Josh”;
  2. The child should help the victim feel better. He can get a wet paper towel, a blankie or favorite toy for the victim and sit near them until the other child is feeling better. This encourages children to take responsibility for their actions, briefly removes the child from other activities and also lets the child experience success as a helper.

Discussing aggressive behavior in group time with the children can be an effective way to gain and share understanding among the children about how it feels when aggressive behavior occurs. Although bullying has not been studied in the preschool population, it is a form of aggression (2). Here are some helpful Websites: http://stopbullying.gov and http://www.eyesonbullying.org/preschool.html.

For more helpful strategies for handling aggression, see Center on the Social and Emotional Foundations for Early Learning Website at http://csefel.vanderbilt.edu. In addition, a child care health consultant or child care mental health consultant can help when the biting behavior continues.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.6 Discipline Measures
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
3.2.3.3 Cuts and Scrapes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
9.4.1.9 Records of Injury
REFERENCES
  1. Rush, K. L. 1999. Caregiver-child interactions and early literacy development of preschool children from low-income environments. Topics Early Child Special Education 19:3-14.
  2. Ross, Scott W., Horner, Robert H. 2009. Bully prevention in positive behavior support. J Applied Behavior Analysis 42:747-59.

2.2.0.8: Preventing Expulsions, Suspensions, and Other Limitations in Services


Child care programs should not expel, suspend, or otherwise limit the amount of services (including denying outdoor time, withholding food, or using food as a reward/punishment) provided to a child or family on the basis of challenging behaviors or a health/safety condition or situation unless the condition or situation meets one of the two exceptions listed in this standard.

Expulsion refers to terminating the enrollment of a child or family in the regular group setting because of a challenging behavior or a health condition. Suspension and other limitations in services include all other reductions in the amount of time a child may be in attendance of the regular group setting, either by requiring the child to cease attendance for a particular period of time or reducing the number of days or amount of time that a child may attend. Requiring a child to attend the program in a special place away from the other children in the regular group setting is included in this definition.

Child care programs should have a comprehensive discipline policy that includes an explicit description of alternatives to expulsion for children exhibiting extreme levels of challenging behaviors, and should include the program’s protocol for preventing challenging behaviors. These policies should be in writing and clearly articulated and communicated to parents/guardians, staff and others. These policies should also explicitly state how the program plans to use any available internal mental health and other support staff during behavioral crises to eliminate to the degree possible any need for external supports (e.g., local police departments) during crises.

Staff should have access to in-service training on both a proactive and as-needed basis on how to reduce the likelihood of problem behaviors escalating to the level of risk for expulsion and how to more effectively manage behaviors throughout the entire class/group. Staff should also have access to in-service training, resources, and child care health consultation to manage children’s health conditions in collaboration with parents/guardians and the child’s primary care provider. Programs should attempt to obtain access to behavioral or mental health consultation to help establish and maintain environments that will support children’s mental well-being and social-emotional health, and have access to such a consultant when more targeted child-specific interventions are needed. Mental health consultation may be obtained from a variety of sources, as described in Standard 1.6.0.3.

When children exhibit or engage in challenging behaviors that cannot be resolved easily, as above, staff should:

  1. Assess the health of the child and the adequacy of the curriculum in meeting the developmental and educational needs of the child;
  2. Immediately engage the parents/guardians/family in a spirit of collaboration regarding how the child’s behaviors may be best handled, including appropriate solutions that have worked at home or in other settings;
  3. Access an early childhood mental health consultant to assist in developing an effective plan to address the child’s challenging behaviors and to assist the child in developing age-appropriate, pro-social skills;
  4. Facilitate, with the family’s assistance, a referral for an evaluation for either Part C (early intervention) or Part B (preschool special education), as well as any other appropriate community-based services (e.g., child mental health clinic);
  5. Facilitate with the family communication with the child’s primary care provider (e.g., pediatrician, family medicine provider, etc.), so that the primary care provider can assess for any related health concerns and help facilitate appropriate referrals.

The only possible reasons for considering expelling, suspending or otherwise limiting services to a child on the basis of challenging behaviors are:

  1. Continued placement in the class and/or program clearly jeopardizes the physical safety of the child and/or his/her classmates as assessed by a qualified early childhood mental health consultant AND all possible interventions and supports recommended by a qualified early childhood mental health consultant aimed at providing a physically safe environment have been exhausted; or
  2. The family is unwilling to participate in mental health consultation that has been provided through the child care program or independently obtain and participate in child mental health assistance available in the community; or
  3. Continued placement in this class and/or program clearly fails to meet the mental health and/or social-emotional needs of the child as agreed by both the staff and the family AND a different program that is better able to meet these needs has been identified and can immediately provide services to the child.

In either of the above three cases, a qualified early childhood mental health consultant, qualified special education staff, and/or qualified community-based mental health care provider should be consulted, referrals for special education services and other community-based services should be facilitated, and a detailed transition plan from this program to a more appropriate setting should be developed with the family and followed. This transition could include a different private or public-funded child care or early education program in the community that is better equipped to address the behavioral concerns (e.g., therapeutic preschool programs, Head Start or Early Head Start, prekindergarten programs in the public schools that have access to additional support staff, etc.), or public-funded special education services for infants and toddlers (i.e., Part C early intervention) or preschoolers (i.e., Part B preschool special education).

To the degree that safety can be maintained, the child should be transitioned directly to the receiving program. The program should assist parents/guardians in securing the more appropriate placement, perhaps using the services of a local child care resource and referral agency. With parent/guardian permission, the child’s primary care provider should be consulted and a referral for a comprehensive assessment by qualified mental health provider and the appropriate special education system should be initiated. If abuse or neglect is suspected, then appropriate child protection services should be informed. Finally, no child should ever be expelled or suspended from care without first conducting an assessment of the safety of alternative arrangements (e.g., Who will care for the child? Will the child be adequately and safely supervised at all times?) (1).

RATIONALE
The rate of expulsion in child care programs has been estimated to be as high as one in every thirty-six children enrolled, with 39% of all child care classes per year expelling at least one child. In state-funded prekindergarten programs, the rate has been estimated as one in every 149 children enrolled, with 10% of prekindergarten classes per year expelling at least one child. These expulsions prevent children from receiving potentially beneficial mental health services and deny the child the benefit of continuity of quality early education and child care services. Mental health consultation has been shown in rigorous research to help reduce the likelihood of behaviors leading to expulsion decisions. Also, research suggests that expulsion decisions may be related to teacher job stress and depression, large group sizes, and high child:staff ratios (1-6).

Mental health services should be available to staff to help address challenging behaviors in the program, to help improve the mental health climate of indoor and outdoor learning/play environments and child care systems, to better provide mental health services to families, and to address job stress and mental health needs of staff.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
1.6.0.3 Early Childhood Mental Health Consultants
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.2.0.10 Using Physical Restraint
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies
REFERENCES
  1. American Academy of Pediatrics, Committee on School Health. 2008. Policy statement: Out-of-school suspension and expulsion. Pediatrics 122:450.
  2. Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development, Policy Brief Series no. 3. http://medicine.yale.edu/childstudy/zigler/Images/National Prek Study_expulsion brief_tcm350-34775.pdf.
  3. Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.
  4. Gilliam, W. S. 2008. Implementing policies to reduce the likelihood of preschool expulsion. Foundation for Child Development, Policy Brief Series no. 7. http://medicine.yale.edu/childstudy/zigler/Images/PreKExpulsionBrief2_tcm350-34772.pdf.
  5. National Scientific Council on the Developing Child. 2008. Mental health problems in early childhood can impair learning and behavior for life. Working paper #6. http://developingchild.harvard.edu/library/reports_and_working_papers/working_papers/wp6/.
  6. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing the risk for preschool expulsion: Mental health consultation for young children with challenging behaviors. J Child Family Studies 17:44-54.

2.2.0.9: Prohibited Caregiver/Teacher Behaviors

Content in the STANDARD was modified on 5/22/2018


Child care programs must not tolerate, or in any manner condone, an act of abuse or neglect of a child. The following behaviors by an older child, caregiver/teacher, substitute or any other person employed by the facility, volunteer, or visitor should be prohibited in all child care settings:

  1. The use of corporal punishment/physical abuse (1) (punishment inflicted directly on the body), including, but not limited to
    1. Hitting, spanking (striking a child with an open hand or instrument on the buttocks or extremities with the intention of modifying behavior without causing physical injury), shaking, slapping, twisting, pulling, squeezing, or biting
    2. Demanding excessive physical exercise, excessive rest, or strenuous or bizarre postures
    3. Forcing and/or demanding physical touch from the child
    4. Compelling a child to eat or have soap, food, spices, or foreign substances in his or her mouth
    5. Exposing a child to extreme temperatures
  2. Isolating a child in an adjacent room, hallway, closet, darkened area, play area, or any other area where the child cannot be seen or supervised
  3. Binding or tying to restrict movement, such as in a car seat (except when traveling) or taping the mouth
  4. Using or withholding food as a punishment or reward
  5. Toilet learning/training methods that punish, demean, or humiliate a child
  6. Any form of emotional abuse, including rejecting, terrorizing, extended ignoring, isolating, or corrupting a child
  7. Any form of sexual abuse (Sexual abuse in the form of inappropriate touching is an act that induces or coerces children in a sexually suggestive manner or for the sexual gratification of the adult, such as sexual penetration and/or overall inappropriate touching or kissing.)
  8. Abusive, profane, or sarcastic language or verbal abuse, threats, or derogatory remarks about the child or child’s family
  9. Any form of public or private humiliation, including threats of physical punishment (2)
  10. Physical activity/outdoor time taken away as punishment

Children should not see hitting, ridicule, and/or similar types of behavior among staff members.

RATIONALE

The behaviors mentioned in the standard threaten the safety and security of children. This would include behaviors that occur among or between staff. Even though adults may state that the behaviors are “playful,” children cannot distinguish this. Corporal punishment may be physical abuse or may easily become abusive. Corporal punishment is clearly prohibited in family child care homes and centers in most states (3). Research links corporal punishment with negative effects such as later aggression, behavior problems in school, antisocial and criminal behavior, and learning impairment (3-6).

 The American Academy of Pediatrics is opposed to the use of corporal punishment (7). Factors supporting prohibition of certain methods of discipline include current child development theory and practice, legal aspects (namely, that a caregiver/teacher does not foster a relationship with the child in place of the parents/guardians to prevent the development of an inappropriate adult-child relationship), and increasing liability suits.

Appropriate alternatives to corporal punishment vary as children grow and develop. As infants become more mobile, the caregiver/teacher must create a safe space and redirect children’s difficult or emotional outbursts when necessary. Recognizing a child’s desires and offering a brief explanation of the rules to support infants and toddlers in developing increased understanding over time as developmentally appropriate. Preschoolers can beginning to develop an understanding of rules; therefore brief verbal expressions help prepare reasoning skills in infants and toddlers. School-aged children begin to develop a sense of personal responsibility and self-control and can learn using healthy and safe incentives (8).  In the wake of well-publicized allegations of child abuse in out-of-home settings and increased concerns about liability, some programs have instituted no-touch policies, either explicitly or implicitly. No-touch policies are misguided efforts that fail to recognize the importance of touch to children’s healthy development. Touch is especially important for infants and toddlers. Warm, responsive, safe, and appropriate touches convey regard and concern for children of any age. Adults should be sensitive to ensure their touches (eg, pats on the back, hugs, ruffling a child’s hair) are welcomed by the children and appropriate to their individual characteristics and cultural experience. Careful, open communication between the program and families about the value of touch in children’s development can help to achieve consensus on the acceptable ways for adults to show their respect and support for children in the program (5).

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.10 Using Physical Restraint
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies
REFERENCES
  1. Gershoff ET, Purtell KM, Holas I. Education and advocacy efforts to reduce school corporal punishment. In: Corporal Punishment in U.S. Public Schools: Legal Precedents, Current Practices, and Future Policy. New York, NY: Springer International Publishing; 2015:87–98

  2. Centers for Disease Control and Prevention. Violence prevention. Child abuse and neglect: definitions. https://www.cdc.gov/violenceprevention/childmaltreatment/definitions.html. Updated April 5, 2016. Accessed January 11, 2018

  3. Fréchette S, Zoratti M, Romano E. What is the link between corporal punishment and child physical abuse? J Fam Violence. 2015;30(2):135–148

  4. Zolotor AJ. Corporal punishment. Pediatr Clin North Am. 2014;61(5):971–978

  5. Hornor G, Bretl D, Chapman E, et al. Corporal punishment: evaluation of an intervention by PNPs. J Pediatr Health Care. 2015;29(6):526–535

  6. Afifi TO, Ford D, Gershoff ET, et al. Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse Negl. 2017;(71):24-31  

  7. American Academy of Pediatrics Councils on Early Childhood and School Health. The pediatrician’s role in school readiness. Pediatrics. 2016;138(3):1-7

  8. Carr A. The Handbook of Child and Adolescent Clinical Psychology. 3rd ed. New York, NY: Routledge; 2016

  9. Ferguson CJ. Spanking, corporal punishment and negative long-term outcomes: a meta-analytic review of longitudinal studies. Clin Psychol Rev. 2013;33(1):196–208

NOTES

Content in the STANDARD was modified on 5/22/2018

2.2.0.10: Using Physical Restraint


Reader’s Note: It should never be necessary to physically restrain a typically developing child unless his/her safety and/or that of others are at risk.

When a child with special behavioral or mental health issues is enrolled who may frequently need the cautious use of restraint in the event of behavior that endangers his or her safety or the safety of others, a behavioral care plan should be developed with input from the child’s primary care provider, mental health provider, parents/guardians, center director/family child care home caregiver/teacher, child care health consultant, and possibly early childhood mental health consultant in order to address underlying issues and reduce the need for physical restraint.

That behavioral care plan should include:

  1. An indication and documentation of the use of other behavioral strategies before the use of restraint and a precise definition of when the child could be restrained;
  2. That the restraint be limited to holding the child as gently as possible to accomplish the restraint;
  3. That such child restraint techniques do not violate the state’s mental health code;
  4. That the amount of time the child is physically restrained should be the minimum necessary to control the situation and be age-appropriate; reevaluation and change of strategy should be used every few minutes;
  5. That no bonds, ties, blankets, straps, car seats, heavy weights (such as adult body sitting on child), or abusive words should be used;
  6. That a designated and trained staff person, who should be on the premises whenever this specific child is present, would be the only person to carry out the restraint.
RATIONALE
A child could be harmed if not restrained properly (1). Therefore, staff who are doing the restraining must be trained. A clear behavioral care plan needs to be in place. And, clear documentation with parent/guardian notification needs to be done after a restraining incident occurs in order to conform with the mental health code.
COMMENTS
If all strategies described in Standard 2.2.0.6 are followed and a child continues to behave in an unsafe manner, staff need to physically remove the child from the situation to a less stimulating environment. Physical removal of a child is defined according the development of the child. If the child is able to walk, staff should hold the child’s hand and walk him/her away from the situation. If the child is not ambulatory, staff should pick the child up and remove him/her to a quiet place where s/he cannot hurt themselves or others. Staff need to remain calm and use a calm voice when directing the child. Certain procedures described in Standard 2.2.0.6 can be used at this time, including not giving a lot of attention to the behavior, distracting the child and/or giving a time-out to the child. If the behavior persists, a plan needs to be made with parental/guardian involvement. This plan could include rewards or a sticker chart and/or praise and attention for appropriate behavior. Or, loss of privileges for inappropriate behavior can be implemented, if age-appropriate. Staff should request or agree to step out of the situation if they sense a loss of their own self-control and concern for the child.

The use of safe physical restraint should occur rarely and only for brief periods to protect the child and others. Staff should be alert to repeated instances of restraint for individual children or within a indoor and outdoor learning/play environment and seek consultation from health and mental health consultants in collaboration with families to develop more appropriate strategies.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.6 Discipline Measures
REFERENCES
  1. Safe and Responsive Schools. 2003. Effective responses: Physical restraint. http://www.unl.edu/srs/pdfs/physrest.pdf.

2.3 Parent/Guardian Relationships

2.3.1 General

2.3.1.1: Mutual Responsibility of Parents/Guardians and Staff


The quality of the relationship between parents/guardians and caregivers/teachers has an influence on the child. There should be a reciprocal responsibility of the family and caregivers/teachers to observe, participate, and be trained in the care that each child requires, and they should be encouraged to work together as partners in providing care.

During the enrollment process, caregivers/teachers should clarify who is/are the legal guardian(s) of the child. All relevant legal documents, court orders, etc., should also be collected and filed during the enrollment process (1). Caregivers/teachers should comply with court orders and written consent from the parent/guardian with legal authority, and not try to make the determination themselves regarding the best interests of the child.

All aspects of child care programs should be designed to facilitate parent/guardian input and involvement. Non-custodial parents should have access to the same developmental and behavioral information given to the custodial parent/guardian, if they have joint legal custody, permission by court order, or written consent from the custodial parent/guardian.

Caregivers/teachers should also clarify with whom the child spends significant time and with whom the child has primary relationships as they will be key informants for the caregivers/teachers about the child and his/her needs.

Parent/guardian involvement is needed at all levels of the program, including program planning for indoors and outdoors, provision of quality care, screening for children who are ill, and support for other parents/guardians. Communication between the administrator, caregiver/teacher and parent/guardian are essential to facilitate the involvement and commitment of parents/guardians. Parents/guardians should be invited to participate on the program board or planning meetings for the program. Parents/guardians should meet with their child’s caregiver/teacher or the director annually to discuss how their child is doing in the program. On a daily basis, parents/guardians and caregivers/teachers should share information about the child’s health, changes in drop-off or pick-up times, and changes in family routines or family events. Caregivers/teachers should communicate regularly with parents/guardians by providing injury report forms if their child sustains an injury, posting notices of exposures to infectious diseases, and greeting the parent/guardian at drop-off each day. Parents/guardians should receive a copy of the child care programs’ written policies, including health and safety policies.

Caregivers/teachers should informally share with parents/guardians daily information about their child’s needs and activities.

Transition reports on any symptoms that the child developed, differences in patterns of appetite or urinating, and activity level should be exchanged to keep parents/guardians informed.

RATIONALE
This plan will help achieve the important goal of carryover of facility components from the child care setting to the child’s home environment. The child’s learning of new skills is a continuous process occurring both at home and in child care.

Research, practice, and accumulated wisdom attest to the crucially important influence of children’s relationships with those closest to them. Children’s experience in child care will be most beneficial when parents/guardians and caregivers/teachers develop feelings of mutual respect and trust. In such a situation, children feel a continuity of affection and concern, which facilitates their adjustment to separation and use of the facility. Especially for infants and toddlers, attention to consistency across settings will help minimize stress that can result from notable differences in routines across caregivers/teachers and settings.

Another ongoing source of stress for an infant or a young child is the separation from those they love and depend upon. Of the various programmatic elements in the facility that can help to alleviate that stress, by far the most important is the comfort in knowing that parents/guardians and caregivers/teachers know the children and their needs and wishes, are in close contact with each other, and can respond in ways that enable children to deal with separation.

The encouragement and involvement of parents/guardians in the social and cognitive leaps of the child provides parents/guardians with the confidence vital to their sense of competence. Caregivers/teachers should be able to direct parents/guardians to sources of information and activities that support child’s development and learning and be able to assist them to obtain appropriate screening and assessment when there are concerns. Communication should be sensitive to ethnic and cultural practices. The parent/guardian/caregiver/teacher partnership models positive adult behavior for school-age children and demonstrates a mutual concern for the child’s well-being (2-16).

In families where the parents/guardians are separated, it is usually in the child’s best interest for both parents/guardians to be involved in the child’s care, and informed about the child’s progress and problems in care. However, it is up to the courts to decide who has legal custody of the child.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.1.5 Helping Families Cope with Separation
2.1.1.7 Communication in Native Language Other Than English
2.1.1.8 Diversity in Enrollment and Curriculum
2.1.1.9 Verbal Interaction
REFERENCES
  1. Public Counsel Law Center in California. Guidelines for Releasing Children and Custody Issues. http://www.publiccounsel.org/publications/release.pdf.
  2. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Educ 7:229-39.
  3. Marshall, N. L. 1991. Empowering low-income parents: The role of child care. Boston, MA: EDRS.
  4. Greenman, J. 1998. Parent partnerships: What they don’t teach you can hurt. Child Care Infor Exch 124:78-82.
  5. Shores, E. J. 1998. A call to action: Family involvement as a critical component of teacher education programs. Tallahassee, FL: Southeastern Regional Vision for Education.
  6. Massachusetts State Office for Children. Establishing a successful family daycare home: A resource guide for providers. 1990. Boston: MA State Office for Children.
  7. Tijus, C. A., et al. 1997. The impact of parental involvement on the quality of day care centers. Int J Early Years Educ 5:7-20.
  8. Jones, R. 1996. Producing a school newsletter parents will read. Child Care Infor Exch 107:91-3.
  9. O’Connor, S., et al. 1996. ASQ: Assessing school age child care quality. Wellesly, MA: Center for Research on Women.
  10. Powell, D. R. 1998. Reweaving parents back into the fabric of early childhood programs: Research in review. Young Child 53:60-67.
  11. Miller, S. H., et al. 1995. Family support in early education and child care settings: Making a case for both principles and practices. Child Today 23:26-29.
  12. Dombro, A. L. 1995. Sharing the care: What every provider and parent needs to know. Child Today 23:22-5.
  13. Larner, M. 1995. Linking family support and early childhood programs: Issues, experiences, opportunities: Best practices project, 1-40. Chicago, IL: Family Resource Coalition.
  14. Endsley, R. C., et al. 1993. Parent involvement and quality day care in proprietary centers. J Res Child Educ 7:53-61.
  15. Fagan, J. 1994. Mother and father involvement in day care centers serving infants and young toddlers. Early Child Dev Care 103:95-101.
  16. Seibel, N. L., L. G. Gillespie, and T. Temple. 2008. The role of child care providers in child abuse prevention. Zero to Three 28:33-40.

2.3.1.2: Parent/Guardian Visits


Parents/guardians are welcome any time their child is in attendance.

Caregivers/teachers should inform all parents/guardians that they may visit the site at any time when their child is there, and that, under normal circumstances, they will be admitted without delay. This open-door policy should be part of the “admission agreement” or other contract between the parent/guardian and the facility/caregiver/teacher. Parents/guardians should be welcomed and encouraged to speak freely to staff about concerns and suggestions. Parents/guardians must be informed what appropriate and inappropriate parental/guardian behavior is and the consequences for inappropriate behavior.

Authorized family members and parents/guardians should check in with the facility staff every visit to ensure safety of the children in the facility.

RATIONALE
Requiring unrestricted access of parents/guardians to their children is essential to preventing the abuse and neglect of children in child care (1,2). When access is restricted, areas observable by the parents/guardians may not reflect the care the children actually receive.
COMMENTS
Caregivers/teachers should not release a child to a parent/guardian who appears impaired (see Standard 9.2.4.1). Caregivers/teachers should not attempt on their own to handle an unstable (e.g., intoxicated) parent/guardian who wants to be admitted but whose behavior poses a risk to the children. Caregivers/teachers should consult local police or the local child protection agency about their recommendations for how staff can obtain support from law enforcement authorities.

Parents/guardians can be interviewed to see if the open-door policy is consistently implemented.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.1.7 Communication in Native Language Other Than English
2.3.2.1 Parent/Guardian Conferences
2.3.2.2 Seeking Parent/Guardian Input
2.3.2.3 Support Services for Parents/Guardians
2.3.2.4 Parent/Guardian Complaint Procedures
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior
9.2.1.1 Content of Policies
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
REFERENCES
  1. Koralek, D., U.S. Department of Health and Human Services. 1992. Caregivers of young children: Preventing and responding to child maltreatment. Rev ed. The user manual series. McLean, VA: Circle, Inc.
  2. Baglin, C. A., M. Bender, eds. 1994. Handbook on quality child care for young children: Settings standards and resources. San Diego, CA: Singular Publishing Group.

2.3.2 Regular Communication

2.3.2.1: Parent/Guardian Conferences


Along with short informal daily conversations between parents/guardians and caregivers/teachers, and as a supplement to the collaborative relationships caregivers/teachers and parents/guardians form specifically to support infants and toddlers, periodic and regular planned communication (e.g., parent/guardian conferences) should be scheduled with at least one parent/guardian of every child in care:

  1. To review the child’s adjustment to care and development over time;
  2. To reach agreement on appropriate disciplinary measures;
  3. To discuss the child’s strengths, specific health issues, special needs, and concerns;
  4. To stay informed of family issues that may affect the child’s behavior in care;
  5. To identify goals for the child;
  6. To discuss resources that parents/guardians can access;
  7. To discuss the results of developmental screening.

At these planned conferences a caregiver/teacher should review with the parent/guardian the child’s health report, and the health record and assessments of development and learning that the program may do to identify medical and developmental issues that require follow-up or adjustment by the facility.

Each review should be documented in the child’s health record with the signature of the parent/guardian and the staff reviewer. These planned conferences should occur:

  1. As part of the intake process;
  2. At each health update interval;
  3. On a calendar basis, scheduled according to the child’s age:
    1. Every six months for children under six years of age and for children with special health care needs;
    2. Every year for children six years of age and older;
  4. Whenever new information is added to the child’s facility health record.

Additional conferences should be scheduled if the parent/guardian or caregiver/teacher has a concern at any time about a particular child. Any concern about a child’s health or development should not be delayed until a scheduled conference date.

Notes about these planned communications should be maintained in each child’s record at the facility and should be available for review.

RATIONALE
Parents/guardians and caregivers/teachers alike should be aware of, and should have arrived at, an agreement concerning each other’s beliefs and knowledge about how to care for children. Reviewing the health record with parents/guardians ensures correct information and can be a valuable teaching and motivational tool (1). It can also be a staff learning experience, through insight gained from parents/guardians on a child’s special circumstances.

Studies have shown that parent–child interactions characterized as structured and responsive to the child’s needs and emotions were positively related to school readiness, social skills, and receptive communication skills development (2).

A health history is the basis for meeting the child’s health, mental, safety, and social needs in the child care setting (1). Review of the health record can be a valuable educational tool for parents/guardians, through better understanding of the health report and immunization requirements (1). A goal of out-of-home care of infants and children is to identify parents/guardians who are in need of instruction so they can provide preventive health/nutrition/physical activity care at a critical time during the child’s growth and development. It is in the child’s best interest that the staff communicates with parents/guardians about the child’s needs and progress. Parent/guardian support groups and parent/guardian involvement at every level of facility planning and delivery are usually beneficial to the children, parents/guardians, and staff. Communication among parents/guardians whose children attend the same facility helps the parents/guardians to share useful information and to be mutually supportive.

COMMENTS
The need for follow-up on needed intervention increases when an understanding of the need and motivation for the intervention has been achieved through personal contact. A health history ensures that all information needed to care for the child is available to the appropriate staff member. Special instructions, such as diet, can be copied for everyday use. Compliance can be assessed by reviewing the records of these planned communications.

Parents/guardians who use child care services should be regarded as active participants and partners in facilities that meet their needs as well as their children’s. Especially for infants and toddlers, authentic relationships are crucial to the optimal development of the child. Compliance can be measured by interviewing parents/guardians and staff.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.2.7 Qualifications and Responsibilities for Health Advocates
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
9.2.3.4 Written Policy for Obtaining Preventive Health Service Information
9.2.3.5 Documentation of Exemptions and Exclusion of Children Who Lack Immunizations
9.2.3.6 Identification of Child’s Medical Home and Parental Consent for Information Exchange
9.2.3.7 Information Sharing on Therapies and Treatments Needed
9.2.3.8 Information Sharing on Family Health
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records
REFERENCES
  1. Aronson, S. 2002. Model Child Care Health Policies. 4th ed. Bryn Mawr, PA: American Academy of Pediatrics, Pennsylvania Chapter.
  2. Connell, C. M., R. J. Prinz. 2002. The impact of childcare and parent–child interactions on school readiness and social skills development for low-income African American children. J of School Psychology 40:177-93.

2.3.2.2: Seeking Parent/Guardian Input


At least twice a year, each caregiver/teacher should seek the views of parents/guardians about the strengths and needs of the indoor and outdoor learning/play environment and their satisfaction with the services offered. Caregivers/teachers should honor parents’/guardians’ requests for more frequent reviews. Anonymous surveys can be offered as a way to receive parent/guardian input without parents/guardians feeling concerned if they have negative comments or concerns about the facility or practices within a facility.
RATIONALE
Parents/guardians and caregiver/teacher alike recognize that parents/guardians have essential rights in helping to shape the kind of child care service their children receive (1).
COMMENTS
Asking parents/guardians about their concerns and observations is essential so they can share issues and engage with staff in collaborative problem-solving. Small and large family child care homes should have group meetings of all parents/guardians once or twice a year. This standard avoids mention of procedures that are inappropriate to small family child care, as it does not require any explicit mechanism (such as a parent/guardian advisory council) for obtaining or offering parental/guardian input. Individual or group meetings with parents/guardians would suffice to meet this standard. Seeking consumer input is a cornerstone of facility planning and evaluation. Centers can offer parents/guardians the chance to respond in writing. Accreditation organizations such as the National Association for the Education of Young Children (NAEYC) or the National Association for Family Child Care (NAFCC) have guidance on conducting parent/guardian surveys.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. National Association of Child Care Resource and Referral Agencies. It’s a win-win situation: When parents and providers work together. Child Care Aware. http://ccaapps.childcareaware.org/en/subscriptions/dailyparent/volume.php?id=29.

2.3.2.3: Support Services for Parents/Guardians


Caregivers/teachers should establish parent/guardian groups and parent/guardian support services. Caregivers/teachers should have a regularly established means of communicating to parents/guardians the existence of these groups and support services. Caregivers/teachers should document these services and should include intra-agency activities or other community support group offerings. The caregiver/teacher should record parental/guardian participation in these on-site activities in the facility record.

One strategy for supporting parents/guardians is to facilitate communication among parents/guardians. The facility should give consenting parents/guardians a list of names and phone numbers of other consenting parents/guardians whose children attend the same facility. The list should include an annotation encouraging parents/guardians whose children attend the same facility to communicate with one another about the service. The facility should update the list at least annually.

RATIONALE
Parental/guardian involvement at every level of program planning and delivery and parent/guardian support groups are elements that are usually beneficial to the children, parents/guardians, and staff of the facility (1). The parent/guardian association group facilitates mutual understanding between the program and parents/guardians. Parental/guardian involvement also helps to broaden parents’/guardians’ knowledge of administration of the facility and develops and enhances advocacy efforts (1).

Encouraging parents’/guardians’ communication is simple, inexpensive, and beneficial. Such communication may include the exchange of positive aspects of the facility and positive knowledge about children’s peers. If parents/guardians communicate with each other, they can share concerns about the behavior of a specific caregiver/teacher and can identify patterns of action suggestive of abuse/neglect. Parents/guardians can encourage each other to report all concerns to the director or owner of the program.

COMMENTS
Parent/guardian meetings within a facility are useful means of communication that supplement mailings and indirect contacts.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. National Association of Child Care Resource and Referral Agencies. It’s a win-win situation: When parents and providers work together. Child Care Aware. http://ccaapps.childcareaware.org/en/subscriptions/dailyparent/volume.php?id=29.

2.3.2.4: Parent/Guardian Complaint Procedures


Facilities should have in place complaint resolution procedures to jointly resolve with parents/guardians any problems that may arise. Arrangements for hearing (or receiving) the complaint and the actions (or discussion) resulting in resolution should be documented along with dates and people involved. Facilities should develop mechanisms for holding formal and informal meetings between staff and groups of parents/guardians. Substantiated complaints and their resolution(s) should be posted in a prominent location. Facilities should post the complaint and resolution procedure where parents/guardians can easily see (or view) them.
RATIONALE
Coordination between the facility and the parents/guardians is essential to promote their respective child care roles and to avoid confusion or conflicts surrounding values. In addition to routine meetings, special meetings can deal with crises and unique problems. Complaint and resolution documentation records can help program directors assess problem areas of the facility, staff, and services.
COMMENTS
Special meetings could identify facility needs, assist in developing resources, and recommend facility and policy changes to the governing body. It is most helpful to document the proceedings of these meetings to facilitate future communications and to ensure continuity of service delivery. Facility-sponsored activities could take place outside facility hours and at other venues.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.8.2.5 Handling Complaints About Caregivers/Teachers
9.1.0.1 Governing Body of the Facility
9.1.0.2 Written Delegation of Administrative Authority
9.4.1.4 Access to Facility Records
10.4.3.1 Procedure for Receiving Complaints

2.3.3 Health Information Sharing

2.3.3.1: Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior


The facility should ask parents/guardians for information regarding the child’s health, nutrition, level of physical activity, and behavioral status upon registration or when there has been an extended gap in the child’s attendance at the facility. The child’s health record should be updated if s/he have had any changes in their health or immunization status. Parents/guardians should be encouraged to sign a release of information/agreement so that child care workers can communicate directly with the child’s medical home/primary care provider.
RATIONALE
Admission of children without this information will leave the center unprepared to deal with daily and emergent health needs of the child, other children, and staff if there is a question of communicability of disease.
COMMENTS
It would be helpful to also have updated information about the health status of parents/guardians and siblings, noting any special conditions, circumstances, or stress that may be affecting the child in care. Some parents/guardians may resist providing this information. If so, the caregiver/teacher should invite them to view this exchange of information as an opportunity to express their own concerns about the facility (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.4.2.1 Contents of Child’s Records
REFERENCES
  1. Crowley, A. A., G. C. Whitney. 2005. Connecticut’s new comprehensive and universal early childhood health assessment form. J School Health 75:281-85.

2.3.3.2: Communication from Specialists


Health and safety, education, and other specialists/professionals who come into the facility to furnish special services to a child should communicate at each visit with the caregiver/teacher at the facility. The specialist/professional must also be certain that all communication shared with caregivers/teachers is shared directly with the parent/guardian. These specialists may include, but are not limited to, physicians, registered nurses, child care health consultants, behavioral consultants (e.g., psychologists, counselors, clinical social workers), occupational therapists, physical therapists, speech therapists, educational therapists, registered dietitians, and play facilitator. The discussions should be documented in the child’s Care Plan.

Specialists should use the facility’s sign in/sign out system for accurate tracking of their interactions with or on behalf of the child.

RATIONALE
Therapeutic services must be coordinated with the child’s general education program and with the parents/guardians and caregivers/teachers so everyone understands the child’s needs. To be most useful, the service providers must share the therapeutic techniques with the caregivers/teachers and parents/guardians and integrate them into the child’s daily routines, not just at therapy sessions. Parent/guardian consent to share information may be necessary. A child care health consultant can be helpful in coordinating these techniques and treatments.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.4.7 Sign-In/Sign-Out System
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records

2.4 Health Education

2.4.1 Health Education for Children

2.4.1.1: Health and Safety Education Topics for Children

Content in the STANDARD was modified on 1/10/2017 and 5/30/2018

 


Health and safety education topics for children should include physical, oral, mental, nutritional, and social and emotional health, and physical activity. These topics should be integrated daily into the program of age-appropriate activities, to include:

     a.Body awareness and use of appropriate terms for body parts

     b.Families, including that families have varying compositions, beliefs, and cultures

     c. Personal social skills, such as sharing, being kind, helping others, and communicating appropriately

     d. Expression and identification of feelings

     e.Self-esteem and self-awareness

     f.Nutrition and healthy eating, drinking water, including healthy habits and preventing obesity

     g. Healthy sleep habits

     h. Outdoor learning/play

     i. Fitness and age-appropriate physical activity

     j. Personal and dental hygiene, including wiping, flushing, handwashing, cough and sneezing etiquette, and tooth brushing

     k. Safety, such as home, vehicular car seats and safety belts, playground, bicycle, fire, firearms, water, and hat to do in an emergency, getting help, and/or dialing 911 for
         emergencies

     l. Conflict management, violence prevention, and bullying prevention

     m. Age-appropriate first aid concepts

     n.Healthy and safe behaviors

     o. Poisoning prevention and poison safety

     p. Awareness of routine preventive care

     q. Care of children with special health care needs

     r. Health risks of secondhand and third-hand smoke

     s. Appropriate use of medications

     t. Handling food safely

     u. Preventing choking and falls

RATIONALE

For young children, health education and safety education are inseparable from one another. Children learn about health and safety by experiencing risk-taking and risk control, fostered and modeled by adults who are involved with them. Whenever opportunities for learning arise, caregivers/teachers should integrate education to promote healthy and safe behaviors.1 Health and safety education does not have to be seen as a structured curriculum but as a daily component of the planned program that is part of a child’s development and habit. Health and safety education supports and reinforces a healthy and safe lifestyle (1,2).

COMMENTS

Teaching children the appropriate names for their body parts is a good way to increase body awareness and personal safety. Learning about routine health maintenance practices, such as vaccination, vision screening, blood pressure screening, oral health examinations, and blood tests, helps children understand these activities and appreciate their value rather than fearing them. Similarly, learning about the importance of nutrition, drinking water, fitness, and healthy sleeping habits helps children make responsible healthful decisions. Good sleep hygiene (3) (e.g., early and routine bedtimes) and obtaining a sufficient amount of sleep in early childhood4 are associated with improved social and emotional (5,6) cognitive, and weight outcomes (7-10).

Child care health consultants and certified health education specialists are good resources for this instruction. The National Commission for Health Education Credentialing provides information on certified health education specialists.

ADDITIONAL RESOURCES

American Academy of Pediatrics. Healthy sleep habits: how many hours does your child need? HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/sleep/Pages/Healthy-Sleep-Habits-How-Many-Hours-Does-Your-Child-Need.aspx. Updated March 23, 2017. Accessed November 14, 2017

Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24

Kobayashi K, Yorifuji T, Yamakawa M, et al. Poor toddler-age sleep schedules predict school-age behavioral disorders in a longitudinal survey. Brain Dev. 2015;37(6):572–578

Owens JA, Witmans M. Sleep problems. Curr Probl Pediatr Adolesc Health Care. 2004;34(4):154–179

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
1.6.0.3 Early Childhood Mental Health Consultants
2.1.1.1 Written Daily Activity Program and Statement of Principles
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.4.1.3 Gender and Body Awareness
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.1.5.3 Oral Health Education
3.2.2.2 Handwashing Procedure
3.2.3.2 Cough and Sneeze Etiquette
4.5.0.10 Foods that Are Choking Hazards
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
REFERENCES
  1. Sharma M. Health education and health promotion. In: Theoretical Foundations of Health Education and Health Promotion. Burlington, MA: Jones & Bartlett Learning; 2017:4–7

  2. Lyn R, Evers S, Davis J, Maalouf J, Griffin M. Barriers and supports to implementing a nutrition and physical activity intervention in child care: directors’ perspectives. J Nutr Educ Behav. 2014;46(3);171–180

  3. Anderson SE, Andridge R, Whitaker RC. Bedtime in preschool-aged children and risk for adolescent obesity. J Pediatr. 2016;176:17–22

  4. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549–1561
  5. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, Hysing M. Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study. JAMA Pediatr. 2015;169(6):575–582

  6. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857–e865

  7. Institute of Medicine. Early Childhood Obesity Prevention Policies: Goals, Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention-Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017

  8. Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149

  9. Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a systematic review and meta-analysis of prospective cohort studies. J Paediatr Child Health. 2017;53(4):378–385

  10. Bonuck K, Chervin RD, Howe LD. Sleep-disordered breathing, sleep duration, and childhood overweight: a longitudinal cohort study. J Pediatr. 2015;166(3):632–639

NOTES

Content in the STANDARD was modified on 1/10/2017 and 5/30/2018

 

2.4.1.2: Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities

Content in the STANDARD was modified on 1/10/2017.

 


The program should strongly encourage all staff members to model healthy and safe behaviors and attitudes in their contact with children in the indoor and outdoor learning/play environment, including, eating nutritious foods, drinking water or nutritious beverages when with the children, sitting with children during mealtime, and eating some of the same foods as the children. Caregivers/teachers should engage in daily movement and physical activity; limit sedentary behaviors when in the outdoor learning/play environment (e.g., not sitting in structured chairs); not watch TV; and comply with handwashing protocols, and tobacco, electronic cigarettes (e-cigarettes), and drug use policies.

Caregivers/teachers should talk about and model healthy and safe behaviors while they carry out routine daily activities. Activities should be accompanied by words of encouragement and praise for achievement.

Facilities should encourage and support staff who wish to breastfeed their own infants and those who engage in gardening to enhance interest in healthy food, science, inquiries and learning. Staff are consistently a model for children and should be cognizant of the environmental information and print messages they bring into the indoor and outdoor learning/play environment. The labels and print messages that are present in the indoor and outdoor learning/play environment or family child care home should be in line with the healthy and safe behaviors and attitudes they wish to impart to the children.

Facilities should use developmentally appropriate health and safety education materials in the children’s activities and should also share these with the families whenever possible.

All health and safety education activities should be geared to the child’s developmental age and should take into account individual personalities and interests.

RATIONALE
Modeling is an effective way of confirming that a behavior is one to be imitated. Young children are particularly dependent on adults for their nutritional needs in both the home (1) and child care environment (2). Thus, modeling healthy and safe behaviors is an important way to demonstrate and reinforce healthy and safe behaviors of caregivers/teachers and children. Young children learn better through experiencing an activity and observing behavior than through didactic training (3,4). Learning and play have a reciprocal relationship; play experiences are closely related to learning (4).

Caregivers/teachers impact the nutrition habits of the children under their care, not only by making choices regarding the types of foods that are available but by influencing children’s attitudes and beliefs about that food as well as social interactions at mealtime. This provides a unique opportunity for programs to guide children’s choices by assigning parents/guardians and caregivers/teachers to the role of nutritional gatekeepers for the young children in their care. Such intervention is consistent with the U.S. Department of Agriculture's (USDA's) and U.S. Department of Health and Human Services' (DHHS') 2015-2020 Dietary Guidelines for Americans, 8th Edition. The Dietary Guidelines focus on increased healthy eating and physical activity to reduce the current rate of overweight or obesity in American children (one in three in the nation) (5).

The effectiveness of health and safety education is enhanced when shared between the caregiver/teacher and the parents/guardians (6,7).

COMMENTS
Caregivers/teachers are important in the lives of the young children in their care. They should be educated and supported to be able to interact optimally with the children in their care. Compliance should be documented by observation. Consultation can be sought from a child care health consultant or certified health education specialist. The American Association for Health Education (AAHE) and the National Commission for Health Education Credentialing (NCHEC) provide information on certified health education specialists.

An extensive education program to make such experiential learning possible indoors and outdoors should be supported by strong community resources in the form of both consultation and materials from sources such as the health department, nutrition councils, and so forth. Suggestions for topics and methods of presentation are widely available (7). Examples include, but are not limited to, routine preventive care by health professionals; nutrition education and physical activity to prevent obesity; crossing streets safely; how to develop and use outdoor learning/play environments; car seat safety; poison safety; latch key programs; health risks from secondhand smoke (exhaled smoke from smokers into the air), thirdhand smoke (residual smoke and chemicals on the smoker's clothes and hair or on surfaces where smoking occurs) (8,9), and secondhand emission from e-cigarettes (exhaled vapors into the air) (9); personal hygiene; and oral health; including limiting sweets; rinsing the mouth with water after sweets; and regular tooth brushing. It can be helpful to place visual cues in the indoor and outdoor learning/play environments to serve as reminders (e.g., posters). “Risk Watch” is a prepared curriculum from the National Fire Protection Association (NFPA) offering comprehensive injury prevention strategies for children in preschool through eighth grade (10).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.3 Screen Time/Digital Media Use
2.4.1.1 Health and Safety Education Topics for Children
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
4.2.0.1 Written Nutrition Plan
4.2.0.6 Availability of Drinking Water
4.3.1.1 General Plan for Feeding Infants
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.5.0.4 Socialization During Meals
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.6.0.2 Nutritional Quality of Food Brought From Home
4.7.0.1 Nutrition Learning Experiences for Children
REFERENCES
  1. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The role of parents in preventing childhood obesity. Future Child 16:169-86.
  2. Ward, S., et al. 2015. Systematic review of the relationship between childcare educators' practices and preschoolers' physical activity and eating behaviors. Obesity Reviews 16: 1055-1070.
  3. Hemmeter, M. L., L. Fox, S. Jack, L. Broyles. 2007. A program-wide model of positive behavior support in early childhood settings. J Early Intervention 29:337-55.
  4. White. R.E. The power of play. A research summary on play and learning. 2012. http://www.childrensmuseums.org/images/MCMResearchSummary.pdf
  5. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. http://health.gov/dietaryguidelines/2015/guidelines/.
  6. Centers for Disease Control and Prevention. Education and community support for health literacy. 2016. http://www.cdc.gov/healthliteracy/education-support/index.html
  7. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-505. http://pediatrics.aappublications.org/content/116/4/e499
  8. Dale, L. 2014. What is thirdhand smoke, and why is it a concern? http://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/third-hand-smoke/faq-20057791.
  9. American Lung Association. E-cigarettes and Lung Health. 2016. http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html?referrer=https://www.google.com/.
  10. Kendrick, D., L. Groom, J. Stewart, M. Watson, C. Mulvaney, R. Casterton. 2007. Risk Watch: Cluster randomized controlled trial evaluating an injury prevention program. Injury Prevention 13:93-99.
NOTES

Content in the STANDARD was modified on 1/10/2017.

 

2.4.1.3: Gender and Body Awareness


The facility should prepare caregivers/teachers to appropriately discuss with the children anatomical facts related to gender identity and sex differences. When talking with parents/guardians, caregivers/teachers should take a general approach, while respecting cultural differences, acknowledging that all children engage in fantasy play, dressing up and trying out different roles (1). Caregivers/teachers should give children messages that contrast with stereotypes, such as men and women in non-traditional roles (2). Facilities should strive for developing common language and understanding among all the partners.
RATIONALE
Open discussions among adults concerning childhood sexuality increase their comfort with the subject. The adults’ comfort may reduce children’s anxiety about sexuality (3,4).
COMMENTS
Discussing sexuality and gender identity topics with young children is not always easy because the views of facility administrators, caregivers/teachers, parents/guardians, and community leaders on these topics may differ.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Stein, M., K. Zuckert, S. Dixon. 2001. Sammy: Gender identity concerns in a six year old boy. Pediatrics 107:850-854.
  2. National Association for the Education of Young Children (NAEYC). 1997. Teaching young children to resist bias. Early Years are Learning Years Series. Washington, DC: NAEYC.
  3. Couchenour, D., K. Chrisman. 2002. Healthy sexuality development: A guide for early childhood educators and families. Washington, DC: National Association for the Education of Young Children.
  4. Brill, S. A., R. Pepper. 2008. The transgender child: A handbook for families and professionals. San Francisco: Cleis.

2.4.2 Health Education for Staff

2.4.2.1: Health and Safety Education Topics for Staff

Content in the STANDARD was modified on 1/10/2017.

 


Health and safety education for staff should include physical, oral, mental, emotional, nutritional, physical activity, and social health of children. In addition to the health and safety topics for children in Standard 2.4.1.1, health education topics for staff should include:

  1. Promoting healthy mind and brain development through child care;
  2. Healthy indoor and outdoor learning/play environments;
  3. Behavior/discipline;
  4. Managing emergency situations;
  5. Monitoring developmental abilities, including indicators of potential delays;
  6. Nutrition (i.e., healthy eating to prevent obesity);
  7. Food safety;
  8. Water safety;
  9. Safety/injury prevention;
  10. Safe use, storage, and clean-up of chemicals;
  11. Hearing, vision, and language problems;
  12. Physical activity and outdoor play and learning;
  13. Immunizations;
  14. Gaining access to community resources;
  15. Maternal or parental/guardian depression;
  16. Exclusion policies;
  17. Tobacco use/smoking and electronic cigarette (e-cigarette) use/vaping;
  18. Marijuana use;
  19. Safe sleep environments and SIDS prevention;
  20. Breastfeeding support;
  21. Environmental health and reducing exposures to environmental toxins;
  22. Children with special needs;
  23. Shaken baby syndrome and abusive head trauma;
  24. Safe use, storage of firearms;
  25. Safe medication administration and appropriate antibiotic use;
  26. Safe storage of medications;
  27. Safe storage of marijuana (in all forms, including oils, liquids, and edible products); and
  28. Safe storage of toxic substances.
RATIONALE
When child care staff are knowledgeable in health and safety practices, programs are more likely to be healthy and safe (1). Compliance with twenty hours per year of staff continuing education in the areas of health, safety, child development, and abuse identification was the most significant predictor for compliance with state child care health and safety regulations (2). Child care staff often receive their health and safety education from a child care health consultant. Data support the relationship between child care health consultation and the increased quality of the health of the children and safety of the child care center environment (3,4).
COMMENTS
Community resources can provide written health- and safety-related materials. Examples of materials can be found here: https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health and http://www.childhealthonline.org/. Consultation or training can be sought from a child care health consultant (CCHC) or certified health education specialist (CHES).

Child care programs should consider offering “credit” for health education classes or encourage staff members to attend accredited education programs that can give education credits.

The American Association for Health Education (AAHE) and the National Commission for Health Education Credentialing (NCHEC) provide information on certified health education specialists.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
1.6.0.1 Child Care Health Consultants
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.2.0.4 Supervision Near Bodies of Water
2.2.0.6 Discipline Measures
2.4.1.1 Health and Safety Education Topics for Children
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.3.1 Emergency Procedures
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.3.1 Medication Administration
4.3.1.1 General Plan for Feeding Infants
5.2.9.1 Use and Storage of Toxic Substances
5.5.0.8 Firearms
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
9.4.1.19 Community Resource Information
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
REFERENCES
  1.  Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366–70. http://www.academicpedsjnl.net/article/S1876-2859(09)00123-5/abstract.
  2. Crowley, A. A., M. S. Rosenthal. 2009. Ensuring the health and safety of Connecticut’s early care and education programs. Farmington, CT: The Child Health and Development Institute of Connecticut.
  3. Alkon, A., et al. 2014. NAPSACC intervention in child care improves nutrition and physical activity knowledge, policies, practices, and children’s BMI. BMC Pediatrics 14: 215.
  4. Alkon, A., et al. 2016. Integrated pest management intervention in child care centers improves knowledge, pest control, and practices. Journal of Pediatric Health Care 30(6): e27-e41.
  5. ADDITIONAL REFERENCES:

    Rosenthal, M. S., A. A. Crowley, L. Curry. 2009. Promoting child development and behavioral health: Family child care providers’ perspectives. J Pediatric Health Care 23:289-97.
     
    Centers for Disease Control and Prevention. Get smart: Know when antibiotics work. http://www.cdc.gov/getsmart/.
     
    American Lung Association. E-cigarettes and Lung Health. 2016. http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html?referrer=https://www.google.com/
     
    National Institute on Drug Abuse. DrugFacts - Marijuana. 2016. https://www.drugabuse.gov/publications/drugfacts/marijuana
     
    Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505. http://pediatrics.aappublications.org/content/116/4/e499. 
     
    Centers for Disease Control and Prevention. Education and community support for health literacy. 2016. http://www.cdc.gov/healthliteracy/education-support/index.html
NOTES

Content in the STANDARD was modified on 1/10/2017.

 

2.4.3 Health Education for Parents/Guardians

2.4.3.1: Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians


Parents/guardians should be given opportunities to observe staff members modeling healthy and safe behavior and facilitating child development, both indoors and outdoors. Parents/guardians should also have opportunities to ask questions and to describe how effective the modeling has been. For parents/guardians who may not have the opportunity to visit their child or observe during the day, there should be alternate forms of communication between the staff and the parents/guardians. This can be handouts, written journals that would go between facility and home, newsletters, electronic communication, or events.
RATIONALE
Modeling and communication about healthy and safe behaviors that promote positive development can be an effective educational tool (1,2).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Lehman, G. R., E. S. Geller. 1990. Participative education for children: An effective approach to increase safety belt use. J Appl Behav Anal 23:219-25.
  2. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The role of parents in preventing childhood obesity. Future Child 16:169-86.

2.4.3.2: Parent/Guardian Education Plan

Content in the STANDARD was modified on 1/17/17.

 


The content of a parent/guardian education plan should be individualized to meet each family’s needs and should be sensitive to cultural values and beliefs. Written material, at a minimum, should address the most important health and safety issues for all age groups served, should be in a language understood by families, and may include the topics listed in Standard 2.4.1.1, with special emphasis on the following:

  1. Safety (such as home, community, playground, firearm, age- and size-appropriate car seat use, safe medication administration procedures, poison awareness, vehicular, or bicycle, and awareness of environmental toxins and healthy choices to reduce exposure);
  2. Value of developing healthy and safe lifestyle choices early in life and parental/guardian health (such as exercise and routine physical activity, nutrition, weight control, breastfeeding, avoidance of substance abuse and tobacco use, stress management, maternal depression, HIV/AIDS prevention);
  3. Importance of outdoor play and learning;
  4. Importance of role modeling;
  5. Importance of well-child care (such as immunizations, hearing/vision screening, monitoring growth and development);
  6. Child development and behavior including bonding and attachment;
  7. Domestic and relational violence;
  8. Conflict management and violence prevention;
  9. Oral health promotion and disease prevention;
  10. Effective toothbrushing, handwashing, diapering, and sanitation;
  11. Positive discipline, effective communication, and behavior management;
  12. Handling emergencies/first aid;
  13. Child advocacy skills;
  14. Special health care needs;
  15. Information on how to access services such as the supplemental food and nutrition program (i.e., The Women, Infants and Children [WIC] Supplemental Food Program), Food Stamps (SNAP), food pantries, as well as access to medical/health care and services for developmental disabilities for children;
  16. Handling loss, deployment, and divorce;
  17. The importance of routines and traditions (including reading and early literacy) with a child.

Health and safety education for parents/guardians should utilize principles of adult learning to maximize the potential for parents/guardians to learn about key concepts. Facilities should utilize opportunities for learning, such as the case of an illness present in the facility, to inform parents/guardians about illness and prevention strategies.

The staff should introduce seasonal topics when they are relevant to the health and safety of parents/guardians and children.

RATIONALE
Adults learn best when they are motivated, comfortable, and respected; when they can immediately apply what they have learned; and when multiple learning strategies are used. Individualized content and approaches are needed for successful intervention. Parent/guardian attitudes, beliefs, fears, and educational and socioeconomic levels all should be given consideration in planning and conducting parent/guardian education (1,2). Parental/guardian behavior can be modified by education. Parents/guardians should be involved closely with the facility and be actively involved in planning parent/guardian education activities. If done well, adult learning activities can be effective for educating parents/guardians. If not done well, there is a danger of demeaning parents/guardians and making them feel less, rather than more, capable (1,2).

The concept of parent/guardian control and empowerment is key to successful parent/guardian education in the child care setting. Support and education for parents/guardians lead to better parenting skills and abilities.

Knowing the family will help the staff such as the health and safety advocate determine content of the parent/guardian education plan and method for delivery. Specific attention should be paid to the parents’/guardians’ need for support and consultation and help locating resources for their problems. If the facility suggests a referral or resource, this should be documented in the child’s record. Specifics of what the parent/guardian shared need not be recorded.

COMMENTS
Community resources can provide written health- and safety-related materials. 
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.6.0.1 Child Care Health Consultants
2.1.1.5 Helping Families Cope with Separation
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
2.4.1.1 Health and Safety Education Topics for Children
9.4.1.19 Community Resource Information
REFERENCES
  1. National Association for the Education of Young Children. 2012. Supporting cultural competence: Accreditation of programs for young children cross-cutting theme in program standards. https://www.naeyc.org/academy/files/academy/file/TrendBriefsSupportingCulturalCompetence.pdf
  2. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505. http://pediatrics.aappublications.org/content/116/4/e499.      
  3. ADDITIONAL REFERENCES:

    Centers for Disease Control and Prevention. Education and community support for health literacy. 2016. http://www.cdc.gov/healthliteracy/education-support/index.html.
     
    Centers for Disease Control and Prevention. Tips for parents – Ideas to help children maintain a healthy weight. 2016. http://www.cdc.gov/healthyweight/children/.
     
    Office of Head Start. Head start cultural and linguistic responsiveness resource catalogue. Volume three : Cultural responsiveness  (first edition). 2012. https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/cultural-linguistic/fcp/docs/resource-catalogue-cultural-linguistic-responsiveness.pdf.
NOTES

Content in the STANDARD was modified on 1/17/17.

 

Chapter 3: Health Promotion and Protection

3.1 Health Promotion in Child Care

3.1.1 Daily Health Check

3.1.1.1: Conduct of Daily Health Check


Every day, a trained staff member should conduct a health check of each child. This health check should be conducted as soon as possible after the child enters the child care facility and whenever a change in the child’s behavior or appearance is noted while that child is in care. The health check should address:

  1. Reported or observed illness or injury affecting the child or family members since the last date of attendance;
  2. Reported or observed changes in behavior of the child (such as lethargy or irritability) or in the appearance (e.g., sad) of the child from the previous day at home or the previous day’s attendance at child care;
  3. Skin rashes, impetigo, itching or scratching of the skin, itching or scratching of the scalp, or the presence of one or more live crawling lice;
  4. A temperature check if the child appears ill (a daily screening temperature check is not recommended);
  5. Other signs or symptoms of illness and injury (such as drainage from eyes, vomiting, diarrhea, cuts/lacerations, pain, or feeling ill).

The caregiver/teacher should gain information necessary to complete the daily health check by direct observation of the child, by querying the parent/guardian, and, where applicable, by conversation with the child.

RATIONALE
Daily health checks seek to identify potential concerns about a child’s health including recent illness or injury in the child and the family. Health checks may serve to reduce the transmission of infectious diseases in child care settings by identifying children who should be excluded, and enable the caregivers/teachers to plan for necessary care while the child is in care at the facility.
COMMENTS
The daily health check should be performed in a relaxed and comfortable manner that respects the family’s culture as well as the child’s body and feelings. The child care health consultant should train the caregiver/teacher(s) in conducting a health check. The items in the standard can serve as a checklist to guide learning the procedure until it becomes routine.

The obtaining of information from the parent/guardian should take place at the time of transfer of care from the parent/guardian to the staff of the child care facility. If this exchange of information happens outside the facility (e.g., when the child is put on a bus), the facility should use an alternative means to accurately convey important information. Handwritten notes, electronic communications, health checklists, and/or daily logs are examples of how parents/guardians and staff can exchange information when face-to-face is not possible.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
Appendix F: Enrollment/Attendance/Symptom Record

3.1.1.2: Documentation of the Daily Health Check


The caregiver/teacher should conduct and document a daily health check of each child upon arrival. The daily health check documentation should be kept for one month.
RATIONALE
The vast majority of infectious diseases of concern in child care have incubation periods of less than twenty-one days (1). This information may be helpful to public health authorities investigating occasional outbreaks.
COMMENTS
The documentation should note that the daily health check was done and any deviation from the usual status of the child and family.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.4.1.9 Records of Injury
9.4.1.10 Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program
9.4.1.11 Review and Accessibility of Injury and Illness Reports
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records
REFERENCES
  1. California Childcare Health Program. CCHP health and safety checklist. Rev. ed. http://www.ucsfchildcarehealth.org/html/pandr/formsmain.htm#hscr/.

3.1.2 Routine Health Supervision

3.1.2.1: Routine Health Supervision and Growth Monitoring


The facility should require that each child has routine health supervision by the child’s primary care provider, according to the standards of the American Academy of Pediatrics (AAP) (3). For all children, health supervision includes routine screening tests, immunizations, and chronic or acute illness monitoring. For children younger than twenty-four months of age, health supervision includes documentation and plotting of sex-specific charts on child growth standards from the World Health Organization (WHO), available at http://www.who.int/childgrowth/standards/en/, and assessing diet and activity. For children twenty-four months of age and older, sex-specific height and weight graphs should be plotted by the primary care provider in addition to body mass index (BMI), according to the Centers for Disease Control and Prevention (CDC). BMI is classified as underweight (BMI less than 5%), healthy weight (BMI 5%-84%), overweight (BMI 85%-94%), and obese (BMI equal to or greater than 95%). Follow-up visits with the child’s primary care provider that include a full assessment and laboratory evaluations should be scheduled for children with weight for length greater than 95% and BMI greater than 85% (5).

School health services can meet this standard for school-age children in care if they meet the AAP’s standards for school-age children and if the results of each child’s examinations are shared with the caregiver/teacher as well as with the school health system. With parental/guardian consent, pertinent health information should be exchanged among the child’s routine source of health care and all participants in the child’s care, including any school health program involved in the care of the child.

RATIONALE
Provision of routine preventive health services for children ensures healthy growth and development and helps detect disease when it is most treatable. Immunization prevents or reduces diseases for which effective vaccines are available. When children are receiving care that involves the school health system, such care should be coordinated by the exchange of information, with parental/guardian permission, among the school health system, the child’s medical home, and the caregiver/teacher. Such exchange will ensure that all participants in the child’s care are aware of the child’s health status and follow a common care plan.

The plotting of height and weight measurements and plotting and classification of BMI by the primary care provider or school health personnel, on a reference growth chart, will show how children are growing over time and how they compare with other children of the same chronological age and sex (1,3,4). Growth charts are based on data from national probability samples, representative of children in the general population. Their use by the primary care provider may facilitate early recognition of growth concerns, leading to further evaluation, diagnosis, and the development of a plan of care. Such a plan of care, if communicated to the caregiver/teacher, can direct the caregiver’s/teacher’s attention to disease, poor nutrition, or inadequate physical activity that requires modification of feeding or other health practices in the early care and education setting (2).

COMMENTS
Periodic and accurate height and weight measurements that are obtained, plotted, and interpreted by a person who is competent in performing these tasks provide an important indicator of health status. If such measurements are made in the early care and education facility, the data from the measurements should be shared by the facility, subject to parental/guardian consent, with everyone involved in the child’s care, including parents/guardians, caregivers/teachers, and the child’s primary care provider. The child care health consultant can provide staff training on growth assessment. It is important to maintain strong linkage among the early care and education facility, school, parent/guardian, and the child’s primary care provider. Screening results (physical and behavioral) and laboratory assessments are only useful if a plan for care can be developed to initiate and maintain lifestyle changes that incorporate the child’s activities during their time at the early care and education program.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) can also be a source for the BMI data with parental/guardian consent, as WIC tracks growth and development if the child is enrolled.

For BMI charts by sex and age, see http://www.cdc.gov/growthcharts/clinical_charts.htm.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
REFERENCES
  1. Paige, D. M. 1988. Clinical nutrition. 2nd ed. St. Louis: Mosby.
  2. Kleinman, R. E. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health.
  5. Centers for Disease Control and Prevention. 2011. About BMI for children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.
  6. Holt K, Wooldridge N, Story M, Sofka D. Growth/ In adolescence, in infancy. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 95-101, 21-26, 49

3.1.3 Physical Activity and Limiting Screen Time

3.1.3.1: Active Opportunities for Physical Activity

Content in the STANDARD was modified on 05/29/2018.


The facility should promote all children’s active play every day. Children should have ample opportunity to do moderate to vigorous activities, such as running, climbing, dancing, skipping, and jumping, to the extent of their abilities.

All children, birth to 6 years of age, should participate daily in:

     a. Two to 3 occasions of active play outdoors, weather permitting (see Standard 3.1.3.2: Playing Outdoors for appropriate weather conditions)

     b. Two or more structured or caregiver/teacher/adult-led activities or games that promote movement over the course of the day—indoor or outdoor

     c. Continuous opportunities to develop and practice age-appropriate gross motor and movement skills

The total time allotted for outdoor play and moderate to vigorous indoor or outdoor physical activity can be adjusted for the age group and weather conditions.

Outdoor play

     a. Infants (birth–12 months of age) should be taken outside 2 to 3 times per day, as tolerated. There is no recommended duration of infants’ outdoor play.

     b. Toddlers (12 – 35 months) and preschoolers (3–6 years) should be allowed 60 to 90 total minutes of outdoor play (1).

These outdoor times can be curtailed somewhat during adverse weather conditions in which children may still play safely outdoors for shorter periods, but the time of indoor activity should increase so the total amount of exercise remains the same.

Total time allotted for moderate to vigorous activities:

     a. Toddlers should be allowed 60 to 90 minutes per 8-hour day for moderate to vigorous physical activity, including running.

     b. Preschoolers should be allowed 90 to 120 minutes per 8-hour day for moderate to vigorous physical activity, including running (1,2).

Infants should have supervised tummy time every day when they are awake. Beginning on the first day at the early care and education program, caregivers/teachers should interact with an awake infant on his/her tummy for short periods (3–5 minutes), increasing the amount of time as the infant shows he/she enjoys the activity (3).

There are many ways to promote tummy time with infants:

     a. Place yourself or a toy just out of the infant’s reach during playtime to get him/her to reach for you or the toy.

     b. Place toys in a circle around the infant. Reaching to different points in the circle will allow him/her to develop the appropriate muscles to roll over, scoot on his/her belly, and crawl.

     c. Lie on your back and place the infant on your chest. The infant will lift his/her head and use his/her arms to try to see your face (3,4).

Structured activities have been shown to produce higher levels of physical activity in young children, therefore it is recommended that caregivers/teachers incorporate 2 or more short, structured activities or games daily that promote physical activity (5).

Opportunities to actively enjoy physical activity should be incorporated into part-time programs by prorating these recommendations accordingly (eg, 20 minutes of outdoor play for every 3 hours in the facility).

Active play should never be withheld from children who misbehave (eg, child is kept indoors to help another caregiver/teacher while the rest of the children go outside) (6). However, children with out-of-control behavior may need 5 minutes or fewer to calm themselves or settle down before resuming cooperative play or activities.

Infants should not be seated for more than 15 minutes at a time, except during meals or naps (5). Infant equipment, such as swings, stationary activity centers, infant seats (eg, bouncers), and molded seats, should only be used for short periods, if used at all. A least-restrictive environment should be encouraged at all times (7).

Children should have adequate space for indoor and outdoor play.

RATIONALE

Time spent outdoors has been found to be a strong, consistent predictor of children’s physical activity (8). Children can accumulate opportunities for activity over the course of several shorter segments of at least 10 minutes each (9).  Free play, active play, and outdoor play are essential components of young children’s development (10). Children learn through play, developing gross motor, socioemotional, and cognitive skills. During outdoor play, children learn about their environment, science, and nature (10).

Infants’ and young children’s participation in physical activity is critical to their overall health, development of motor skills, social skills, and maintenance of healthy weight (11). Daily physical activity promotes young children’s gross motor development and provides numerous health benefits, including improved fitness and cardiovascular health, healthy bone development, improved sleep, and improved mood and sense of well-being (12).

Toddlers and preschoolers generally accumulate moderate to vigorous physical activity over the course of the day in very short bursts (15–30 seconds) (5). Children may be able to learn better during or immediately after these types of short bursts of physical activity, due to improved attention and focus (13).
Tummy time prepares infants to be able to slide on their bellies and crawl. As infants grow older and stronger they will need more time on their tummies to build their own strength (3).

Childhood obesity prevalence, for children 2 to 5 years old, has steadily decreased from 13.9% in 2004 to 9.4% in 2014 (14). Incorporating government food programs, physical activities, and wellness education into child care centers has been associated with these decreases (15).

Establishing communication between caregivers/teachers and parents/guardians helps facilitate integration of classroom physical activities into the home, making it more likely that children will stay active outside of child care hours (16). Very young children and those not yet able to walk, are entirely dependent on their caregivers/teachers for opportunities to be active (17).

Especially for children in full-time care and for children who don’t have access to safe playgrounds, the early care and education facility may provide the child’s only daily opportunity for active play. Physical activity habits learned early in life may track into adolescence and adulthood, supporting the importance for children to learn lifelong healthy physical activity habits while in the early care and education program (18).

COMMENTS

Additional Resources

Choosy Kids (https://choosykids.com)

EatPlayGrow Early Childhood Health Curriculum, Children’s Museum of Manhattan (www.eatplaygrow.org)

Head Start Early Childhood Learning & Knowledge Center, US Department of Health and Human Services, Administration for Children & Families (https://eclkc.ohs.acf.hhs.gov/physical-health/article/little-voices-healthy-choices)

Healthy Kids, Healthy Future; The Nemours Foundation (https://healthykidshealthyfuture.org)

Nutrition and Physical Activity Self-Assessment for Child Care, Center for Health Promotion and Disease Prevention, University of North Carolina (http://healthyapple.arewehealthy.com/documents/PhysicalActivityStaffHandouts_NAPSACC.pdf)

Online Physical Education Network (http://openphysed.org)

Spark (www.sparkpe.org)

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
5.3.1.10 Restrictive Infant Equipment Requirements
9.2.3.1 Policies and Practices that Promote Physical Activity
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43

  2. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889

  3. American Academy of Pediatrics. Back to sleep, tummy to play. HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/Back-to-Sleep-Tummy-to-Play.aspx. Updated January 20, 2017. Accessed January 11, 2018

  4. Zachry AH. Tummy time activities. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/The-Importance-of-Tummy-Time.aspx. Updated November 21, 2015. Accessed January 11, 2018

  5. US Department of Agriculture, US Department of Health and Human Services. Provide opportunities for active play every day. Nutrition and wellness tips for young children: provider handbook for the Child and Adult Care Food Program. https://fns-prod.azureedge.net/sites/default/files/opportunities_play.pdf. Published June 2013. Accessed January 11, 2018

  6. Centers for Disease Control and Prevention and SHAPE America-Society of Health and Physical Educators. Physical activity during school: Providing recess to all students. 2017. https://www.cdc.gov/healthyschools/physicalactivity/pdf/Recess_All_Students.pdf. Accessed January 11, 2018

  7. Moir C, Meredith-Jones K, Taylor BJ, et al. Early intervention to encourage physical activity in infants and toddlers: a randomized controlled trial. Med Sci Sports Exerc. 2016;48(12):2446–2453

  8. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889

  9. Hnatiuk JA, Salmon J, Hinkley T, Okely AD, Trost S. A review of preschool children’s physical activity and sedentary time using objective measures. Am J Prev Med. 2014;47(4):487–497

  10. Bento G, Dias G. The importance of outdoor play for young children’s healthy development. Porto Biomed J. 2017;2(5):157–160

  11. Jayasuriya A, Williams M, Edwards T, Tandon P. Parents’ perceptions of preschool activities: exploring outdoor play. Early Educ Dev. 2016;27(7):1004–1017

  12. Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Appl Physiol Nutr Metab. 2012;37(4):773–792

  13. Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cognitive function, and academic achievement in children: a systematic review. Med Sci Sports Exerc. 2016;48(6):1197–1222

  14. Centers for Disease Control and Prevention. Overweight & obesity. Childhood obesity facts. Prevalence of childhood obesity in the United States, 2011-2014. https://www.cdc.gov/obesity/data/childhood.html. Updated April 10, 2017. Accessed January 11, 2018

  15. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292–2299

  16. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272

  17. Society of Health and Physical Educators. Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5. 2nd ed. Reston, VA: SHAPE America; 2009. https://www.shapeamerica.org/standards/guidelines/activestart.aspx. Accessed January 11, 2018

  18. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta‐analysis. Obes Rev. 2016;17(2)95–107

NOTES

Content in the STANDARD was modified on 05/29/2018.

3.1.3.2: Playing Outdoors

Content in the STANDARD was modified on 8/8/2013 and 05/29/2018.


Children should play outdoors when the conditions do not pose any concerns health and safety such as a significant risk of frostbite or heat-related illness. Caregivers/teachers must protect children from harm caused by adverse weather, ensuring that children wear appropriate clothing and/or appropriate shelter is provided for the weather conditions. Weather that poses a significant health risk includes wind chill factor below -15°F (-26°C) and heat index at or above 90°F (32°C), as identified by the National Weather Service (NWS) (1). Child Care Center Directors as well as caregivers/teachers directors should monitor weather-related conditions through several media outlets, including local e-mail and text messaging weather alerts.

Caregivers/teachers should also monitor the air quality for safety. Please reference Standard 3.1.3.3 for more information.

 

Sunny weather

  1. Children should be protected from the sun between the hours of 10:00 am and 4:00 pm. Protective measures include using shade; sun-protective clothing such as hats and sunglasses; and sunscreen with UV-B and UV-A ray sun protection factor 15 or higher. Parental/guardian permission is required for the use of sunscreen.

Warm weather

  1. Children should have access to clean, sanitary water at all times, including prolonged periods of physical activity, and be encouraged to drink water during periods of prolonged physical activity (2).
  2. Caregivers/teachers should encourage parents/guardians to have children dress in clothing that is light-colored, lightweight, and limited to one layer of absorbent material that will maximize the evaporation of sweat.
  3. On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first 6 months of life. Infants receiving formula and water can be given additional formula in a bottle.

Cold weather

  1. Children should wear layers of loose-fitting, lightweight clothing. Outer garments, such as coats, should be tightly woven and be at least water repellent when rain or snow is present.
  2. Children should wear a hat, coat, and gloves/mittens kept snug at the wrist. There should be no  hood and neck strings..
  3. Caregivers/teachers should check children’s extremities for normal color and warmth at least every 15 minutes.

Caregivers/teachers should be aware of environmental hazards such as unsafe drinking water, loud noises, and lead in soil when selecting an area to play outdoors. Children should be observed closely when playing in dirt/soil so that no soil is ingested. Play areas should be fully enclosed and away from heavy traffic areas. In addition, outdoor play for infants may include riding in a carriage or stroller. Infants should be offered opportunities for gross motor play outdoors.

RATIONALE

Outdoor play is not only an opportunity for learning in a different environment; it also provides many health benefits. Outdoor play allows for physical activity that supports maintenance of a healthy weight (3) and better nighttime sleep (4). Short exposure of the skin to sunlight promotes the production of vitamin D that growing children require.

Open spaces in outdoor areas, even those located on screened rooftops in urban play spaces, encourage children to develop gross motor skills and fine motor play in ways that are difficult to duplicate indoors. Nevertheless, some weather conditions make outdoor play hazardous.

Children need protection from adverse weather and its effects. Heat-induced illness and cold injury are preventable. Weather alert services are beneficial to child care centers because they send out weather warnings, watches, and hurricane information. Alerts are sent to subscribers in the warned areas via text messages and e-mail. It is best practice to use these services but do not rely solely on this system. Weather radio or local news affiliates should also be monitored for weather warnings and advisories. Heat and humidity can pose a significant risk of heat-related illnesses, as defined by the NWS (5). Children have a greater surface area to body mass ratio than adults. Therefore, children do not adapt to extremes of temperature as effectively as adults when exposed to a high climatic heat stress or to cold. Children produce more metabolic heat per mass unit than adults when walking or running. They also have a lower sweating capacity and cannot dissipate body heat by evaporation as effectively (6).

Wind chill conditions can pose a risk of frostbite. Frostbite is an injury to the body caused by freezing body tissue. The most susceptible parts of the body are the extremities such as fingers, toes, earlobes, and the tip of the nose. Symptoms include a loss of feeling in the extremity and a white or pale appearance. Medical attention is needed immediately for frostbite. The affected area should be slowly rewarmed by immersing frozen areas in warm water (around 104°F [40°C]) or applying warm compresses for 30 minutes. If warm water is not available, wrap gently in warm blankets (7). Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. An infant with hypothermia may have bright red, cold skin and very low energy. A child’s symptoms may include shivering, clumsiness, slurred speech, stumbling, confusion, poor decision-making, drowsiness or low energy, apathy, weak pulse, or shallow breathing (7,8). Call 911 or your local emergency number if a child has these symptoms. Both hypothermia and frostbite can be prevented by properly dressing a child. Dressing in several layers will trap air between layers and provide better insulation than a single thick layer of clothing.

Generally, infectious disease organisms are less concentrated in outdoor air than indoor air. The thought is often expressed that children are more likely to become sick if exposed to cold air; however, upper respiratory infections and flu are caused by viruses, and not exposure to cold air. These viruses spread easily during the winter when children are kept indoors in close proximity. The best protection against the spread of illness is regular and proper hand hygiene for children and caregivers/teachers, as well as proper sanitation procedures during mealtimes and when there is any contact with bodily fluids.

COMMENTS

Additional Resources

  • The National Weather Service (NWS) provides up-to-date weather information on all advisories and warnings. It also provides safety tips for caregivers/teachers to use as a tool in determining when weather conditions are comfortable for outdoor play (www.nws.noaa.gov/om/heat/index.shtml).
  • The National Oceanic and Atmospheric Administration (NOAA) Weather Radio All Hazards (NWR) broadcasts continuous weather information 24 hours a day, 7 days a week, directly from the nearest NWR office. As an all-hazards radio network, it is a single source for comprehensive weather and emergency information. In conjunction with federal, state, and local emergency managers and other public officials, NWR also broadcasts warning and post-event information for all types of hazards, including natural (eg, earthquakes, avalanches), environmental (eg, chemical releases, oil spills), and public safety (eg, AMBER alerts, 911 telephone outages). A special radio receiver or scanner capable of picking up the signal is required to receive NWR. Such radios/receivers can usually be found in most electronic store chains across the country; you can also purchase NOAA weather radios online at www.noaaweatherradios.com.
  • To access the latest local weather information and warnings, visit the NWS at www.weather.gov; for local air quality conditions, visit https://www.airnow.gov.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.4.5.1 Sun Safety Including Sunscreen
8.2.0.1 Inclusion in All Activities
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. National Weather Service, National Oceanic and Atmospheric Administration. Wind chill safety. https://www.weather.gov/bou/windchill. Accessed January 11, 2018

  2. Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed January 11, 2018

  3. Cleland V, Crawford D, Baur LA, Hume C, Timperio A, Salmon J. A prospective examination of children’s time spent outdoors, objectively measured physical activity and overweight. Int J Obes (Lond). 2008;32(11):1685–1693

  4. Söderström M, Boldemann C, Sahlin U, Mårtensson F, Raustorp A, Blennow M. The quality of the outdoor environment influences children’s health—a cross-sectional study of preschoolers. Acta Paediatr. 2013;102(1):83–91

  5. KidsHealth from Nemours. Heat illness. http://kidshealth.org/en/parents/heat.html. Reviewed February 2014. Accessed January 11, 2018

  6. American Academy of Pediatrics. Children & disasters. Extreme temperatures: heat and cold. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Extreme-Temperatures-Heat-and-Cold.aspx. Accessed January 11, 2018

  7. American Academy of Pediatrics. Winter safety tips from the American Academy of Pediatrics. https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/AAP-Winter-Safety-Tips.aspx. Published January 2018. Accessed January 11, 2018

  8. American Academy of Pediatrics. Extreme temperature exposure. HealthyChildren.org Web site. https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Extreme-Temperature-Exposure.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 8/8/2013 and 05/29/2018.

3.1.3.3: Protection from Air Pollution While Children Are Outside

Content in the STANDARD was modified on 8/25/2016.

 


Supervising adults should check the air quality index (AQI) each day and use the information to determine whether it is safe for children to play outdoors.
RATIONALE
Children need protection from air pollution. Air pollution can contribute to acute asthma attacks in sensitive children and, over multiple years of exposure, can contribute to permanent decreased lung size and function (1,2).
COMMENTS
The federal Clean Air Act requires that the Environmental Protection Agency (EPA) establish ambient air quality health standards. Most local health departments monitor weather and air quality in their jurisdiction and make appropriate announcements. AQI is usually reported with local weather reports on media outlets or individuals can sign up for email or text message alerts at http://www
.enviroflash.info.

The AQI (available at http://www.airnow.gov) is a cumulative indicator of potential health hazards associated with local or regional air pollution. The AQI is divided into six categories; each category corresponds to a different level of health concern. The six levels of health concern and what they mean are:

  1. “Good” AQI is 0 - 50. Air quality is considered satisfactory, and air pollution poses little or no risk.
  2. “Moderate” AQI is 51 - 100. Air quality is acceptable, however, for some pollutants there may be a moderate health concern for a very small number of people. For example, people who are unusually sensitive to ozone may experience respiratory symptoms.
  3. “Unhealthy for Sensitive Groups” AQI is 101 - 150. Although general public is not likely to be affected at this AQI range, people with heart and lung disease, older adults, and children are at a greater risk from exposure to ozone and the presence of particles in the air.
  4. “Unhealthy” AQI is 151 - 200. Everyone may begin to experience some adverse health effects, and members of the sensitive groups may experience more serious effects.
  5. “Very Unhealthy” AQI is 201 - 300. This would trigger a health alert signifying that everyone may experience more serious health effects.
  6. “Hazardous” AQI greater than 300. This would trigger a health warning of emergency conditions. The entire population is more likely to be affected.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.2 Playing Outdoors
5.2.1.1 Ensuring Access to Fresh Air Indoors
REFERENCES
  1. Gehring, U., Gruzieva, O., Agius, R., Beelen, R., Custovic, A., Cyrys, J.,Von Berg. (2013). Air pollution exposure and lung function in children: The ESCAPE project. Environmental Health Perspectives: EHP. 121(11-12), 1357-1364.
  2. Lerodiakonou, D. (2016). Ambient air pollution, lung function, and airway responsiveness in asthmatic children. The Journal of Allergy and Clinical Immunology. 137(2), 390.
NOTES

Content in the STANDARD was modified on 8/25/2016.

 

3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical Activity

Content in the STANDARD was modified on 05/29/2018.


Caregivers/teachers should promote children’s active play and participate in children’s active games at times when they can safely do so. Caregivers/teachers should

     a. Lead structured activities to promote children’s activities 2 or more times per day.

     b. Wear clothing and footwear that permits easy and safe movement (1). 

     c. Provide prompts for children to be active (2,3). (eg, “Good throw!”).

     d. Encourage children’s physical activities that are appropriate and safe in the setting (eg, do not prohibit running on the playground when it is safe to run).

     e.Have orientation and annual training opportunities to learn about age-appropriate gross motor activities and games that promote children’s physical activity (2,4).

     f. Not sit during active play.

     g. Limit screen time and other digital media as outlined in Standard 2.2.0.3.

Caregivers/teachers should consider incorporating structured activities into the curriculum indoors or after children have been on the playground for 10 to 15 minutes. Caregivers/teachers should communicate with parents/guards about their use of screen time/digital media in the home.

RATIONALE

Children learn from the adult modeling of healthy and safe behavior. Caregivers/teachers may not be comfortable promoting active play, perhaps due to inhibitions about their own physical activity skills or lack of training. Caregivers/teachers may also assume their sole role on the playground is to supervise and keep children safe, rather than to promote physical activity. Continuing education activities are useful in disseminating knowledge about effective games to promote physical activity in early care and education while keeping children safe (4).

Children exposed to less screen time/digital media in early care and education settings engage in more moderate-to-vigorous physical activity compared with children who are exposed to more screen time (5).  This gives caregivers/teachers the opportunity to model the limitation of screen time/digital media use and to educate parents/guardians about alternative activities that families can do with their children (2). 

Additional Resource:

American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.2.0.3 Screen Time/Digital Media Use
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
9.2.3.1 Policies and Practices that Promote Physical Activity
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43

  2. Tandon PS, Saelens BE, Copeland KA. A comparison of parent and childcare provider's attitudes and perceptions about preschoolers' physical activity and outdoor time. Child Care Health Dev. 2017;43(5):679–686

  3. Tandon PS, Walters KM, Igoe BM, Payne EC, Johnson DB. Physical activity practices, policies and environments in Washington state child care settings: results of a statewide survey. Matern Child Health J. 2017;21(3):571–582

  4. Copeland KA, Khoury JC, Kalkwarf HJ. Child care center characteristics associated with preschoolers’ physical activity. Am J Prev Med. 2016;50(4):470–479

  5. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272

NOTES

Content in the STANDARD was modified on 05/29/2018.

3.1.4 Safe Sleep

3.1.4.1: Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction

Content in the STANDARD was modified on 12/05/2011 and on 12/1/2016.


Safe sleep practices help reduce the risk of sudden unexpected infant deaths (SUIDs). Facilities should develop a written policy describing the practices to be used to promote safe sleep for infants. The policy should explain that these practices aim to reduce the risk of SUIDs, including sudden infant death syndrome (SIDS), suffocation and other deaths that may occur when an infant is in a crib or asleep. About 3,500 SUIDs occurred in the U.S. in 2014 (1). 

All staff, parents/guardians, volunteers and others approved to enter rooms where infants are cared for should receive a copy of the Safe Sleep Policy and additional educational information and training on the importance of consistent use of safe sleep policies and practices before they are allowed to care for infants (i.e., first day as an employee/volunteer/subsitute). Documentation that training has occurred and that these individuals have received and reviewed the written policy before they care for children should be kept on file. Additional educational materials can be found at https://www.nichd.nih.gov/sts/materials/Pages/default.aspx

All staff, parents/guardians, volunteers and others who care for infants in the child care setting should follow these required safe sleep practices as recommended by the American Academy of Pediatrics (AAP) (2):

  1. Infants up to twelve months of age should be placed for sleep in a supine position (wholly on their back) for every nap or sleep time unless an infant’s primary health care provider has completed a signed waiver indicating that the child requires an alternate sleep position;
  2. Infants should be placed for sleep in safe sleep environments; which include a firm crib mattress covered by a tight-fitting sheet in a safety-approved crib (the crib should meet the standards and guidelines reviewed/approved by the U.S. Consumer Product Safety Commission [CPSC] (3) and ASTM International [ASTM]). No monitors or positioning devices should be used unless required by the child’s primary health care provider, and no other items should be in a crib occupied by an infant except for a pacifier;
  3. Infants should not nap or sleep in a car safety seat, bean bag chair, bouncy seat, infant seat, swing, jumping chair, play pen or play yard, highchair, chair, futon, sofa/couch, or any other type of furniture/equipment that is not a safety-approved crib (that is in compliance with the CPSC and ASTM safety standards) (3);
  4. If an infant arrives at the facility asleep in a car safety seat, the parent/guardian or caregiver/teacher should immediately remove the sleeping infant from this seat and place them in the supine position in a safe sleep environment (i.e., the infant’s assigned crib);
  5. If an infant falls asleep in any place that is not a safe sleep environment, staff should immediately move the infant and place them in the supine position in their crib;
  6. Only one infant should be placed in each crib (stackable cribs are not recommended);
  7. Soft or loose bedding should be kept away from sleeping infants and out of safe sleep environments. These include, but are not limited to: bumper pads, pillows, quilts, comforters, sleep positioning devices, sheepskins, blankets, flat sheets, cloth diapers, bibs, etc. Also, blankets/items should not be hung on the sides of cribs. Loose or ill-fitting sheets have caused infants to be strangled or suffocated (2). 
  8. Swaddling infants when they are in a crib is not necessary or recommended, but rather one-piece sleepers should be used (see Standard 3.1.4.2 for more detailed information on swaddling) (2);
  9. Toys, including mobiles and other types of play equipment that are designed to be attached to any part of the crib should be kept away from sleeping infants and out of safe sleep environments;
  10. When caregivers/teachers place infants in their crib for sleep, they should check to ensure that the temperature in the room is comfortable for a lightly clothed adult, check the infants to ensure that they are comfortably clothed (not overheated or sweaty), and that bibs, necklaces, and garments with ties or hoods are removed. (Safe clothing sacks or other clothing designed for safe sleep can be used in lieu of blankets.);
  11. Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking up;
  12. Bedding should be changed between children, and if mats are used, they should be cleaned between uses.

The lighting in the room must allow the caregiver/teacher to see each infant’s face, to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier (if used).

A caregiver/teacher trained in safe sleep practices and approved to care for infants should be present in each room at all times where there is an infant. This caregiver/teacher should remain alert and should actively supervise sleeping infants in an ongoing manner. Also, the caregiver/teacher should check to ensure that the infant’s head remains uncovered and re-adjust clothing as needed.

The construction and use of sleeping rooms for infants separate from the infant group room is not recommended due to the need for direct supervision. In situations where there are existing facilities with separate sleeping rooms, facilities have a plan to modify room assignments and/or practices to eliminate placing infants to sleep in separate rooms.

Facilities should follow the current recommendation of the AAP about pacifier use (2). If pacifiers are allowed, facilities should have a written policy that describes relevant procedures and guidelines. Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.
The facilty should encourage, provide arrangements for, and support breastfeeding. Breastfeeing or feeding an infant with their mother's expressed breast milk is also associated with a reduced risk of sleep-related infant deaths (2). 

RATIONALE
Despite the decrease in deaths attributed to sleeping practices and the decreased frequency of prone (tummy) infant sleep positioning over the past two decades, some caregivers/teachers continue to place infants to sleep in positions or environments that are not safe. Most sleep-related deaths in child care facilities occur in the first day or first week that an infant starts attending a child care program (4). Many of these deaths appear to be associated with prone positioning, especially when the infant is unaccustomed to being placed in that position (2). Training that includes observations and addresses barriers to changing caregiver/teacher practices would be most effective. Use of safe sleep policies, continued education of parents/guardians, expanded training efforts for child care professionals, statewide regulations and mandates, and increased monitoring and observation of intants while they are sleeping are critical to reduce the risk of SUIDs in child care (2). 

Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk of SUID (4,5). Recent research and demonstration projects (6,7) have revealed that:

  1. Caregivers/teachers are unaware of the dangers or risks associated with prone or side infant sleep positioning, and many believe that they are using the safest practices possible, even when they are not;
  2. Although training programs are effective in improving the knowledge of caregivers/teachers, these programs alone do not always lead to changes in caregiver/teacher practices, beliefs, or attitudes; and 
  3. Caregivers/teachers report the following major barriers to implementing safe sleep practices:They have been misinformed about methods shown to reduce the risk of SUID;
1) Facilities do not have or use written “safe sleep” policies or guidelines;
2) State child care regulations do not mandate the use of supine (wholly on their back) sleep position for infants in child care and/or training for infant caregivers/teachers;
3) Other caregivers/teachers or parents/guardians have objections to use of safe sleep practices, either because of their concern for choking or aspiration, and/or their concern that some infants do not sleep well in the supine position; and
4) Parents/guardians model their practices after what happens in the hospital or what others recommend. Infants who were placed to sleep in other positions in the hospital or home environments may have difficulty transitioning to supine positioning at home and later in child care.
COMMENTS
Background: Deaths of infants who are asleep in child care may be under-reported because of the lack of consistency in training and regulating death scene investigations and determining and reporting cause of death. Not all states require documentation that clarifies that an infant died while being cared for by someone other than their parents/guardians.

Although the cause of many sudden infant deaths may not be known, researchers believe that some infants develop in a manner that makes it challenging for them to be aroused or to breathe when they experience a life-threatening challenge during sleep. Although some state regulations require that caregivers/teachers “check on” sleeping infants every ten, fifteen, or thirty minutes, an infant can suffocate or die in only a few minutes. It is for this reason that the standards above discourage toys or mobiles in cribs and recommend direct, active, and ongoing supervision when infants are falling to sleep, are sleeping, or are becoming awake. This is also why Caring for Our Children describes a safe sleep environment as one that includes a safety-approved crib, firm mattress, firmly fitted sheet, and the infant placed on their back at all times, in comfortable, safe garments, but nothing else – not even a blanket.

When infants are being dropped off, staff may be busy. Requiring parents/guardians to remove the infant from the car seat and re-position them in the supine position in their crib (if they are sleeping), will reinforce safe sleep practices and reassure parents/guardians that their child is in a safe position before they leave the facility.

Challenges: National recommendations for reducing the risk of SUIDs are provided for use in the general population. Most research reviewed to guide the development of these recommendations was not conducted in child care settings. Because infants are at increased risk for dying from sleep-related causes in child care (4,5), caregivers/teachers must provide the safest sleep environment for the infants in their care.

When hospital staff or parents/guardians of infants who may attend child care place the infant in a position other than supine for sleep, the infant becomes accustomed to this and can have a more difficult time adjusting to child care, especially when they are placed for sleep in a new unfamiliar position.

Parents/guardians and caregivers/teachers want infants to transition to child care facilities in a comfortable and easy manner. It can be challenging for infants to fall asleep in a new environment because there are different people, equipment, lighting, noises, etc. When infants sleep well in child care, adults feel better. Placing personal items in cribs with infants and covering or wrapping infants with blankets may help the adults to believe that the child is more comfortable or feels comforted. However, this may or may not be true. These practices are not the safest practices for infants in child care, and they should not be allowed. Efforts to educate the public about the risk of sleep-related deaths promoting the use of consistent safe sleep practices need to continue.

Special Care Plans: Some facilities require staff to place infants in a supine position for sleep unless there is documentation in a child’s special care plan indicating a medical need for a different position. This can provide the caregiver/teacher with more confidence in implementing the safe sleep policy and refusing parental demands that are not consistent with safe sleep practices. It is likely that an infant will be unaccustomed to sleeping supine if his or her parents/guardians object to the supine position (and are therefore placing the infant prone to sleep at home). By providing educational information on the importance of consistent use of safe sleep policies and practices to expectant parents, facilities will help raise awareness of these issues, promote infant safety, and increase support for proper implementation of safe sleep policies and practices in the future.

Use of Pacifiers: Caregivers/teachers should be aware of the current recommendation of the AAP about pacifier use to reduce the risk of SUIDs (2). While using pacifiers to reduce the risk of SIDS seems prudent (especially if the infant is already sleeping with a pacifier at home), pacifier use has also been shown to be associated with an increased risk of ear infections. Keeping pacifiers clean and limiting their use to sleep time is best. Using pacifiers in a sanitary and safe fashion in group care settings requires special diligence.

Pacifiers should be inspected for tears before use. Pacifiers should not be clipped to an infant’s clothing or tied around an infant’s neck.

For children in the general population, the AAP recommends the following:

  1. Child care faciltites require written permission from the child’s parent/guardian for pacifier use;
  2. Consider offering a pacifier when placing the infant down for nap and sleep time;
  3. If the infant refuses the pacifier, s/he should not be forced to take it;
  4. If the infant falls asleep and the pacifier falls out of the infant’s mouth, it should be removed from the crib and does not need to be reinserted. A pacifier has been shown to reduce the risk of SIDS, even if the pacifier falls out during sleep (2);
  5. Pacifiers should not be coated in any sweet solution, and they should be cleaned and replaced regularly; and
  6. For breastfed infants, delay pacifier introduction until fifteen days of age to ensure that breastfeeding is well-established (2).

Swaddling: Hospital personnel or physicians, particularly those who work in neonatal intensive care units or infant nurseries in hospitals may recommend that newborns be swaddled in the hospital setting. Although parents/guardians may choose to continue this practice at home, swaddling infants when they are being placed to sleep or are sleeping in a child care facility is not necessary or recommended. See Standard 3.1.4.2 for more detailed information.

Concern about Plagiocephaly: If parents/guardians or caregivers/teachers are concerned about positional plagiocephaly (flat head or flat spot on head), they can continue to use safe sleep practices but also do the following:

  1. Offer infants opportunities to be held upright and participate in supervised “tummy time” when they are awake;
  2. Alter the position of the infant, and thereby alter the supine position of the infant’s head and face. This can easily be accomplished by alternating the placement of the infant in the crib – place the infant to sleep with their head facing to one side for a week and then turning the infant so that their head and face are placed the other way. Infants typically turn their head to one side toward the room or door, so if they are placed with their head toward one side of the bed for one sleep time and then placed with their head toward the other side of the bed the next time, this changes the area of the head that is in contact with the mattress.

A common question among caregivers/teachers and parents/guardians is whether they should return the infant to the supine position if they roll onto their side or their tummies. Infants up to twelve months of age should be placed wholly supine for sleep every time. In fact, all children should be placed (or encouraged to lie down) on their backs to sleep. When infants are developmentally capable of rolling comfortably from their backs to their fronts and back again, there is no evidence to suggest that they should be re-positioned into the supine position.

The California Childcare Health Program has available a Safe Sleep Policy for Infants in Child Care Programs. AAP provides a free online course on safe sleep practices.

 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.1 Methods of Supervision of Children
3.1.4.2 Swaddling
3.1.4.3 Pacifier Use
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.6.1 Strangulation Hazards
3.6.4.5 Death
4.3.1.1 General Plan for Feeding Infants
4.5.0.3 Activities that Are Incompatible with Eating
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
6.4.1.3 Crib Toys
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
REFERENCES
  1. U.S. Centers for Disease Control and Prevention. 2016. About SUID and SIDS. http://www.cdc.gov/sids/aboutsuidandsids.htm
  2. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.2016;138(6):e20162938. 
    https://pediatrics.aappublications.org/content/138/5/e20162938.
  3. U.S. Consumer Product Safety Commission (CPSC). 2012. Cribs. https://www.cpsc.gov/safety-education/safety-guides/kids-and-babies/cribs.
  4. First Candle. 2016. SIDS and daycare: A fatal combination. http://www.firstcandle.org/sids-and-daycare-a-fatal-combination/
  5. Healthy Child Care America. 2012. A child care provider’s guide to safe sleep. Helping you to reduce the risk of SIDS. http://www.healthychildcare.org/PDF/SIDSchildcaresafesleep.pdf
  6. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
  7. Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-79.
  8. Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and Breastfeeding Trial Group. 2009. Does the recommendation to use a pacifier influence the prevalence of breastfeeding? Pediatrics 155:350-54.
  9. UCSF California Childcare Health Program (CCHP). 2016. Safe sleep policy for infants in child care programs. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-Policy.
  10. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep for Infants in Child Care Programs: Reducing the Risk of SIDS and SUID. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/SIDS-Note
  11. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep: Reducing the Risk of Sudden Infant Death Syndrome (SIDS). UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-FAM
  12. Centers for Disease Control and Prevention. 2013. Sudden infant death syndrome (SIDS). http://www.cdc.gov/features/sidsawarenessmonth/.
  13. Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe sleep ® campaign materials. 2014. https://www.nichd.nih.gov/sts/materials/Pages/default.aspx.
NOTES

Content in the STANDARD was modified on 12/05/2011 and on 12/1/2016.

3.1.4.2: Swaddling

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.1.4.2

Date: 4/5/2013

Topic & Location:
Chapter 3
Health Promotion
3.1.4.2: Swaddling

Question:
Does CFOC3 ban swaddling?

Answer:

CFOC3 Standard 3.1.4.2: Swaddling states: “In child care settings, swaddling is not recommended or necessary.”

This specific language was carefully chosen and reviewed by national contributors and stakeholders, and then approved by the CFOC3 Steering Committee and each author organization (AAP, APHA, NRC). A child care setting is a group care setting, and therefore presents different health and safety concerns when compared to a private home. One of these concerns is inconsistency with caregivers/teachers. As noted in CFOC3 Standard 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Reduction, “Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk for dying from SIDS” (Moon, 2005). To that end, implementing swaddling guidelines, training, and compliance across child care programs would be a significant challenge.

We recognize the many benefits of swaddling (when done correctly) by parents/guardians for newborns and young infants in hospital nurseries and in private homes. However, the primary target audience for the CFOC3 standardsis caregivers/teachers in early education and child care settings.

The majority of standards in CFOC3 use the phrase “should” or “should not.” The national contributors that developed Standard 3.1.4.2 made the conscious decision not to use this terminology in the standard language.Thus, CFOC3 does not ban or prohibit swaddling. Instead, it states that swaddling is not recommended or necessary.

CFOC3 does, however, account for programs that may choose to swaddle in this same standard (Standard 3.1.4.2). The last sentence of the Comments section states: “If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life.”

Moreover, it is important to note that CFOC3 also includes Standard 1.1.2.1: Minimum Age to Enter Child Care, which states that Healthy full-term infants can be enrolled in child care settings as early as three months of age.” The national contributors recognized that swaddling becomes less necessary for older infants, a time at which CFOC3 recommends entering a child care setting. 

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.1.4.2

Date: 4/5/2013

Topic & Location:
Chapter 3
Health Promotion
3.1.4.2: Swaddling

Question:
Does the AAP have a Policy Statement prohibiting Swaddling?

Answer:
The American Academy of Pediatrics (AAP) does not have a Policy Statement prohibiting swaddling. The AAP does have a Policy Statement on the Safe Sleep Environment, which does recommend against loose blankets in a safe sleeping environment. “Loose bedding, such as blankets and sheets, might be hazardous and should not be used in the infant’s sleeping environment” (Task Force on Sudden Infant Death Syndrome, 2011).

The AAP Technical Report specifically addresses swaddling (page e1356) in expanded recommendations for a safe infant sleep environment. The Technical Report states that “there is insufficient evidence to recommend routine swaddling as a strategy for reducing the incident of SIDS” (Task Force on Sudden Infant Death Syndrome, 2011).
CFOC3 is co-authored by AAP, APHA, and NRC, and published by the AAP. It is consistent with AAP Policy, but is not “AAP Policy”, nor “APHA Policy”.

Citations:
Moon, R. e. (2005). Stable prevalence but changing risk factors for sudden infant death syndrome in child care settings in 2001. Pediatrics, 116(4):972-7.

Task Force on Sudden Infant Death Syndrome. (2011). Policy Statement: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 1030-1039.

Task Force on Sudden Infant Death Syndrome. (2011). Technical Report: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe infant Sleeping Environment. Pediatrics, 128:5 e1341-e1367.


In child care settings, swaddling is not necessary or recommended.
RATIONALE
There is evidence that swaddling can increase the risk of serious health outcomes, especially in certain situations. The risk of sudden infant death is increased if an infant is swaddled and placed on his/her stomach to sleep (1,2) or if the infant can roll over from back to stomach. Loose blankets around the head can be a risk factor for sudden infant death syndrome (SIDS) (3). With swaddling, there is an increased risk of developmental dysplasia of the hip, a hip condition that can result in long-term disability (4,5). Hip dysplasia is felt to be more common with swaddling because infants’ legs can be forcibly extended. With excessive swaddling, infants may overheat (i.e., hyperthermia) (6).
COMMENTS
Most infants in child care centers are at least six-weeks-old. Even with newborns, research does not provide conclusive data about whether swaddling should or should not be used. Benefits of swaddling may include decreased crying, increased sleep periods, and improved temperature control. However, temperature can be maintained with appropriate infant clothing and/or an infant sleeping bag. Although swaddling may decrease crying, there are other, more serious health concerns to consider, including SIDS and hip disease. If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
REFERENCES
  1. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
  2. Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants. J Pediatrics 157:85-91.
  3. Contemporary Pediatrics. 2004. Guide for parents: Swaddling 101. http://www.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module1/swadling.pdf.
  4. Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, W. Kuis, T. W. J. Schulpen, M. P. L’Hoir. 2007. Swaddling: A systematic review. Pediatrics 120:e1097-e1106.
  5. Mahan, S. T., Kasser J. R. 2008. Does swaddling influence developmental dysplasia of the Hip? Pediatrics 121:177-78.
  6. Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, A. Kahn. 2005. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 115:1307-11.

3.1.4.3: Pacifier Use


Facilities should be informed and follow current recommendations of the American Academy of Pediatrics (AAP) about pacifier use (1-3).

If pacifiers are allowed, facilities should have a written policy that indicates:

  1. Rationale and protocols for use of pacifiers;
  2. Written permission and any instructions or preferences from the child’s parent/guardian;
  3. If desired, parent/guardian should provide at least two new pacifiers (labeled with their child’s name using a waterproof label or non-toxic permanent marker) on a regular basis for their child to use. The extra pacifier should be available in case a replacement is needed;
  4. Staff should inspect each pacifier for tears or cracks (and to see if there is unknown fluid in the nipple) before each use;
  5. Staff should clean each pacifier with soap and water before each use;
  6. Pacifiers with attachments should not be allowed; pacifiers should not be clipped, pinned, or tied to an infant’s clothing, and they should not be tied around an infant’s neck, wrist, or other body part;
  7. If an infant refuses the pacifier, s/he should not be forced to take it;
  8. If the pacifier falls out of the infant’s mouth, it does not need to be reinserted;
  9. Pacifiers should not be coated in any sweet solution;
  10. Pacifiers should be cleaned and stored open to air; separate from the diapering area, diapering items, or other children’s personal items.

Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking up. The lighting in the room must allow the caregiver/teacher to see each infant’s face, to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier.

Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.

Caregivers/teachers should work with parents/guardians to wean infants from pacifiers as the suck reflex diminishes between three and twelve months of age. Objects which provide comfort should be substituted for pacifiers (6).

RATIONALE
Mobile infants or toddlers may try to remove a pacifier from an infant’s mouth, put it in their own mouth, or try to reinsert it in another child’s mouth. These behaviors can increase risks for choking and/or transmission of infectious diseases.

Cleaning pacifiers before and after each use is recommended to ensure that each pacifier is clean before it is inserted into an infant’s mouth (5). This protects against unknown contamination or sharing. Cleaning a pacifier before each use allows the caregiver/teacher to worry less about whether the pacifier was cleaned by another adult who may have cared for the infant before they did. This may be of concern when there are staffing changes or when parents/guardians take the pacifiers home with them and bring them back to the facility.

If a caregiver/teacher observes or suspects that a pacifier has been shared, the pacifier should be cleaned and sanitized. Caregivers/teachers should make sure the nipple is free of fluid after cleaning to ensure the infant does not ingest it. For this reason, submerging a pacifier is not recommended. If the pacifier nipple contains any unknown fluid, or if a caregiver/teacher questions the safety or ownership, the pacifier should be discarded (4).

While using pacifiers to reduce the risk of sudden infant death syndrome (SIDS) seems prudent (especially if the infant is already sleeping with a pacifier at home), pacifier use has been associated with an increased risk of ear infections and oral health issues (7).

COMMENTS
To keep current with the AAP’s recommendations on the use of pacifiers, go to http://www.aap.org.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.3 Oral Health Education
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.4.6.1 Strangulation Hazards
REFERENCES
  1. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.2016;138(6):e20162938. 
    https://pediatrics.aappublications.org/content/138/5/e20162938.
  2. Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: What should we recommend? Pediatrics117:1811-12.
  3. Mitchell, E. A., P. S. Blair, M. P. L’Hoir. 2006. Should pacifiers be recommended to prevent sudden infant death syndrome? Pediatrics 117:1755-58.
  4. Reeves, D. L. 2006. Pacifier use in childcare settings. Healthy Child Care 9:12-13.
  5. Cornelius, A. N., J. P. D’Auria, L. M. Wise. 2008. Pacifier use: A systematic review of selected parenting web sites. J Pediatric Health Care 22:159-65.
  6. American Academy of Pediatrics, Back to Sleep, Healthy Child Care America, First Candle. 2008. Reducing the risk of SIDS in child care. http://www.healthychildcare.org/pdf/SIDSfinal.pdf.
  7. Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they good for your baby? http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/pacifiers/art-20048140.

3.1.4.4: Scheduled Rest Periods and Sleep Arrangements

Content in the STANDARD was modified on 05/30/2018.


The facility should provide an opportunity for, but should not require, sleep and rest. The facility should make available a regular rest period for all children and age appropriate sleep/nap environment (See Standard 5.4.5.1). For children who are unable to sleep, the facility should provide time and space for quiet play. A facility that includes preschool-aged and school-aged children should make books, board games, and other forms of quiet play available.

Facilities that offer infant care should provide a safe sleep environment and use a written safe sleep policy that describes the practices they follow to reduce the risk of sudden infant death syndrome and other infant deaths. For example, when infants fall asleep, they must be put down to sleep on their back in a crib with a firm mattress and no blankets or soft objects.

RATIONALE

Conditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, regular times for rest, and use of routines and safe practices. Most preschool-aged children in all-day care benefit from scheduled periods of rest. This rest may take the form of actual napping, a quiet time, or a change of pace between activities. The times and duration of naps will affect behavior at home (1).

Young children need to develop healthy sleep habits for optimal development. Yet, sleep problems, i.e. short sleep duration, behavioral sleep problems, and sleep-disordered breathing all peak during the preschool years. In 2016, the National Sleep Foundation issued recommended sleep durations for newborns (14–17 hours), infants (12–15 hours), toddlers (11–14 hours), and preschoolers (10–13 hours), which include both daytime and nighttime sleep (2,3).Getting sufficient sleep helps prevent pediatric obesity. In meta-analyses, short sleep duration before 5 years of age is associated with 30% to 90% increased odds of overweight/obesity at later ages (4,5). To prevent early childhood obesity, the Institute of Medicine recommends that child care providers be required to adopt practices that promote age-appropriate sleep duration and that staff be trained to counsel parents about recommended sleep durations (6). Behavioral sleep problems (i.e., difficulty getting to/falling asleep) at 18 months of age are associated with a 60% to 80% increased risk of emotional and behavioral problems at 5 years of age (7). Irregular bedtimes throughout early childhood are associated with reduced reading, math, and spatial ability scores (8). Sleep-disordered breathing (e.g., snoring, apnea) in early childhood is associated with a 60% to 80% increase in social and emotional difficulties at 7 years of age (9).

COMMENTS

In the young infant, favorable conditions for sleep and rest include being dry, well fed, and comfortable. Infants may need 1 or 2 (or sometimes more) naps during the time they are in child care. As infants age, they typically transition to 1 nap per day, and having 1 nap per day is consistent with the schedule that most facilities follow. Different practices, such as rocking, holding a child while swaying, singing, reading, or patting an arm or back, could be used to calm the child. Lighting does not need to be turned off during nap time.

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.2.2.1 Levels of Illumination
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
REFERENCES
  1. National Sleep Foundation. How much sleep do we really need? https://sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need. Accessed November 14, 2017

  2. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549–1561

  3. Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149

  4. Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a systematic review and meta-analysis of prospective cohort studies. J Paediatr Child Health. 2017;53(4):378–385

  5. Institute of Medicine. Early Childhood Obesity Prevention Policies: Goals, Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention-Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017

  6. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, Hysing M. Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study. JAMA Pediatr. 2015;169(6):575–582

  7. Kelly, Y; Kelly, J; Sacker, A; (2013) Time for bed: associations with cognitive performance in 7-year-old children: a longitudinal population-based study. Journal of Epidemiology and Community Health , 67 (11) pp. 926-931.
  8. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857–e865

NOTES

Content in the STANDARD was modified on 05/30/2018.

3.1.4.5: Unscheduled Access to Rest Areas


All children should have access to rest or nap areas whenever the child desires to rest. These rest or nap areas should be set up to reduce distraction or disturbance from other activities. All facilities should provide rest areas for children, including children who become ill (1,2), at least until the child leaves the facility for care elsewhere. Children need to be within sight and hearing of caregivers/teachers when resting.
RATIONALE
Any child, especially children who are ill (1,2), may need more opportunity for rest or quiet activities.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
5.4.5.1 Sleeping Equipment and Supplies
5.4.6.1 Space for Children Who Are Ill
Appendix A: Signs and Symptoms Chart
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
  2. American Academy of Pediatrics. Out-of-home child care, infection control and prevention In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 125-136, 122-125, 124t

3.1.5 Oral Health

3.1.5.1: Routine Oral Hygiene Activities

Content in the STANDARD was modified on 3/10/2016.

 


Caregivers/teachers should promote the habit of regular tooth brushing. All children with teeth should brush or have their teeth brushed with a soft toothbrush of age-appropriate size at least once during the hours the child is in child care. Children under three years of age should have only a small smear (grain of rice) of fluoride toothpaste on the brush when brushing. Those children ages three and older should use a pea-sized amount of fluoride toothpaste (1). An ideal time to brush is after eating. The caregiver/teacher should either brush the child’s teeth or supervise as the child brushes his/her own teeth. Disposable gloves should be worn by the caregiver/teacher if contact with a child’s oral fluids is anticipated. The younger the child, the more the caregiver/teacher needs to be involved. The caregiver/teacher should teach the child the correct method of tooth brushing. Young children want to brush their own teeth, but they need help until about age 7 or 8. The caregiver/teacher should monitor the tooth brushing activity and thoroughly brush the child’s teeth after the child has finished brushing, preferably for a total of two minutes. Children whose teeth are properly brushed with fluoride toothpaste at home twice a day and are at low risk for dental caries may be exempt since additional brushing with fluoride toothpaste may expose a child to excess fluoride toothpaste.

The cavity-causing effect of exposure to foods or drinks containing sugar (like juice) may be reduced by having children rinse with water after snacks and meals when tooth brushing is not possible. Local dental health professionals can facilitate compliance with these activities by offering education and training for the child care staff and providing oral health presentations for the children and parents/guardians.

RATIONALE
Regular tooth brushing with fluoride toothpaste is encouraged to reinforce oral health habits and prevent gingivitis and tooth decay. There is currently no (strong) evidence that shows any benefit to wiping the gums of a baby who has no teeth. However, before the first tooth erupts, wiping a baby’s gums with clean gauze or a soft wet washcloth as part of a daily routine may make the transition to tooth brushing easier. Good oral hygiene is as important for a six-month-old child with one tooth as it is for a six-year-old with many teeth (2). Tooth brushing with fluoride toothpaste at least once a day reduces build-up of decay-causing plaque (2,3). The development of tooth decay-producing plaque begins when an infant’s first tooth appears in his/her mouth (4). Tooth decay cannot develop without this plaque which contains the acid-producing bacteria in a child’s mouth. The ability to do a good job brushing the teeth is a learned skill, improved by practice and age. There is general consensus that children do not have the necessary hand eye coordination for independent brushing until around age seven or eight so either caregiver/teacher brushing or close supervision is necessary in the preschool child. Tooth brushing and activities at home may not suffice to develop this skill or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care.
COMMENTS
The caregiver/teacher should use a small smear (grain of rice) of fluoride toothpaste spread across the width of the toothbrush for children under three years of age and a pea-sized amount for children ages three years of age and older (1). Children should attempt to spit out excess toothpaste after brushing. Fluoride is the single most effective way to prevent tooth decay. Brushing teeth with fluoride toothpaste is the most efficient way to apply fluoride to the teeth. Young children may occasionally swallow a small amount of toothpaste and this is not a health risk. However, if children swallow more than recommended amounts of fluoride toothpaste on a consistent basis, they are at risk for fluorosis, a cosmetic condition (discoloration of the teeth) caused by over exposure to fluoride during the first eight years of life (5). Other products such as fluoride rinses can pose a poisoning hazard if ingested (6).

The children can rinse with water after a snack or a meal if their teeth have been brushed with fluoride toothpaste earlier. Rinsing with water helps to remove food particles from teeth and may help prevent tooth decay.

A sink is not necessary to accomplish tooth brushing in child care. Each child can use a cup of water for tooth brushing. The child should wet the brush in the cup, brush and then spit excess toothpaste into the cup.

Caregivers/teachers should encourage replacement of toothbrushes when the bristles become worn or frayed or approximately every three to four months (7,8).

Caregivers/teachers should encourage parents/guardians to establish a dental home for their child within six months after the first tooth erupts or by one year of age, whichever is earlier (4). The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way. Currently there are insufficient numbers of dentists who incorporate infants and toddlers into their practices so primary care providers may provide oral health screening during well child care in this population while promoting the establishment of a dental home (2).

Fluoride varnish applied to all children every 3-6 months at primary care visits or at their dental home reduces tooth decay rates, and can lead to significant cost savings in restorative dental care and associated hospital costs. Coupled with parent/guardian and caregiver/teacher education, fluoride varnish is an important tool to improve children’s health (9-11).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records
REFERENCES
  1. American Academy of Pediatrics, Section on Oral Health. 2014. Maintaining and improving the oral health of young children. http://pediatrics.aappublications.org/content/134/6/1224
  2. American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.
  3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry30:112-18.
  4. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845.
  5. Centers for Disease Control and Prevention, Fluoride Recommendations Work Group. 2001. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR50(RR14): 1-42.
  6. Centers for Disease Control and Prevention. 2013. Community water fluoridation. http://www.cdc.gov/fluoridation/faqs/http://www.cdc.gov/fluoridation/faqs/
  7. American Academy of Pediatric Dentistry. Early childhood caries. Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf.
  8. American Dental Association. ADA positions and statements. ADA statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx.
  9. Marinho, V.C., et al. 2002. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database System Rev 3, no.  CD002279. http://www.ncbi.nlm.nih.gov/pubmed/12137653
  10. American Academy of Pediatric Dentistry. 2006. Talking points: AAPD perspective on physicians or other non-dental providers applying fluoride varnish. Dental Home Resource Center.http://www.aapd.org/dentalhome/1225.pdf.
  11. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine.2016. Policy statement: 2016 Recommendations for preventive pediatric health care. http://pediatrics.aappublications.org/content/early/2015/12/07/peds.2015-3908  
NOTES

Content in the STANDARD was modified on 3/10/2016.

 

3.1.5.2: Toothbrushes and Toothpaste

Content in the STANDARD was modified on 2/6/2013, 04/22/2013, and 3/10/2016.


In facilities where tooth brushing is an activity, each child should have a personally labeled, soft toothbrush of age-appropriate size. No sharing or borrowing of toothbrushes should be allowed. After use, toothbrushes should be stored on a clean surface with the bristle end of the toothbrush up to air dry in such a way that the toothbrushes cannot contact or drip on each other and the bristles are not in contact with any surface (1). Racks and devices used to hold toothbrushes for storage should be labeled and disinfected as needed. The toothbrushes should be replaced at least every three to four months, or sooner if the bristles become frayed (2-5). When a toothbrush becomes contaminated through contact with another brush or use by more than one child, it should be discarded and replaced with a new one.

Each child should have his/her own labeled toothpaste tube. Or if toothpaste from a single tube is shared among the children, it should be dispensed onto a clean piece of paper or paper cup for each child rather than directly on the toothbrush (1,6). Children under three years of age should have only a small smear of fluoride toothpaste (grain of rice) on the brush when brushing. Those three years of age and older should use a pea-sized amount of fluoride toothpaste (7). Toothpaste should be stored out of children’s reach.


           
                     Small smear of fluoride toothpaste                  Pea-sized amount of fluoride toothpaste

                             Photo Credit: National Center on Early Childhood Health and Wellness


When children require assistance with brushing, caregivers/teachers should wash their hands thoroughly between brushings for each child. Caregivers/teachers should wear gloves when assisting such children with brushing their teeth.

RATIONALE
Toothbrushes and oral fluids that collect in the mouth during tooth brushing are contaminated with infectious agents and must not be allowed to serve as a conduit of infection from one individual to another (1). Individually labeling the toothbrushes will prevent different children from sharing the same toothbrush. As an alternative to racks, children can have individualized, labeled cups and their brush can be stored bristle-up in their cup. Some bleeding may occur during tooth brushing in children who have inflammation of the gums. The Occupational Safety and Health Administration (OSHA) regulations apply where there is potential exposure to blood. Saliva is considered an infectious vehicle whether or not it contains blood, so caregivers/teachers should protect themselves from saliva by implementing standard precautions.
 
COMMENTS
Children can use an individually labeled or disposable cup of water to brush their teeth (1).

Toothpaste is not necessary if removal of food and plaque is the primary objective of tooth brushing. However, no anti-caries benefit is achieved from brushing without fluoride toothpaste.

Some risk of infection can occur when numerous children brush their teeth and spit into the sink that is not sanitized between uses.

Tooth brushing ability varies by age. Young children want to brush their own teeth, but they need help until about age seven or eight. Adults helping children brush their teeth not only help them learn how to brush, but also improve the removal of plaque and food debris from all teeth (5).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
3.6.1.5 Sharing of Personal Articles Prohibited
5.5.0.1 Storage and Labeling of Personal Articles
REFERENCES
  1. Centers for Disease Control and Prevention. 2005. Infection control in dental settings: The use and handling of toothbrushes. http://www.cdc.gov/OralHealth/InfectionControl/factsheets/toothbrushes.htm
  2. American Dental Association, Council on Scientific Affairs. 2005. ADA statement on toothbrush care: Cleaning, storage, and replacement. http://www.ada.org/1887.aspx.
  3. American Academy of Pediatric Dentistry. 2004. Early childhood caries (ECC).http://www.aapd.org/assets/2/7/ECCstats.pdf.
  4. American Dental Hygienists’ Association. Proper brushing. http://www.adha.org/oralhealth/brushing.htm.
  5. 12345 First Smiles. 2006. Oral health considerations for children with special health care needs (CSHCN). http://www.first5oralhealth.org/page.asp?page_id=432.
  6. Davies, R. M., G. M. Davies, R. P. Ellwood, E. J. Kay. 2003. Prevention. Part 4: Toothbrushing: What advice should be given to patients? Brit Dent Jour 195:135-41.
  7. American Academy of Pediatrics, Section on Oral Health. 2014 Maintaining and improving the oral health of young children. http://pediatrics.aappublications.org/content/134/6/1224.
NOTES

Content in the STANDARD was modified on 2/6/2013, 04/22/2013, and 3/10/2016.

3.1.5.3: Oral Health Education


All children with teeth should have oral hygiene education as a part of their daily activity.

Children three years of age and older should have developmentally appropriate oral health education that includes:

a.     Information on what plaque is;
b.    The process of dental decay;
c.     Diet influences on teeth, including the contribution of sugar-sweetened beverages and foods to cavity development; and
d.    The importance of good oral hygiene behaviors.

School-age children should receive additional information including:

a.    The preventive use of fluoride;
b.    Dental sealants;
c.    Mouth guards for protection when playing sports;
d.    The importance of healthy eating behaviors; and
e.    Regularly scheduled dental visits.

Adolescent children should be informed about the effect of tobacco products on their oral health and additional reasons to avoid tobacco.

Caregivers/teachers and parents/guardians should be taught to not place a child’s pacifier in the adult’s mouth to clean or moisten it or share a toothbrush with a child due to the risk of promoting early colonization of the infant oral cavity with Streptococcus mutans (1).

Caregivers/teachers should limit juice consumption to no more than four to six ounces per day for children one through six years of age.

RATIONALE
Studies have reported that the oral health of participants improved as a result of educational programs (2).
COMMENTS
Caregivers/teachers are encouraged to advise parents/guardians on the following recommendations for preventive and early intervention dental services and education:

        a.    Dental or primary care provider visits to evaluate the need for supplemental fluoride therapy (prescription pills or drops if tap water does not contain fluoride) starting at six months of age, and professionally applied topical fluoride treatments for all children every 3-6 months starting when teeth are present (3,4);
        b.    First dental visit within six months after the first tooth erupts or by one year of age, whichever is earlier and whenever there is a question of an oral health problem;
        c.    Dental sealants generally at six or seven years of age for first permanent molars and for primary molars if deep pits and grooves or other high risk factors are present (4,6).

Caregivers/teachers should provide education for parents/guardians on good oral hygiene practices and avoidance of behaviors that increase the risk of early childhood caries, such as inappropriate use of a bottle, frequent consumption of carbohydrate-rich foods, and sweetened beverages such as juices with added sweeteners, soda, sports drinks, fruit nectars, and flavored teas.

For more resources on oral health education, see:

Parent’s Checklist for Good Dental Health Practices in Child Care, a parent handout in English and Spanish, developed by the National Resource Center for Health and Safety in Child Care and Early Education at http://nrckids.org/dentalchecklist.pdf;

Bright Futures for Oral Health at http://brightfutures.aap.org/practice_guides_and_other_resources.html;

California Childcare Health Program Health and Safety in the Child Care Setting: Promoting Children’s Oral Health A Curriculum for Health Professionals and Child Care Providers (in English and Spanish) at http://cchp.ucsf.edu/ and its 12345 first smiles program at http://first5oralhealth.org;

and National Training Institute for Child Care Health Consultant’s Healthy Smiles Through Child Care Health Consultation course at http://nti.unc.edu/healthy_smiles/.
TYPE OF FACILITY
Center
RELATED STANDARDS
3.1.4.3 Pacifier Use
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
4.2.0.7 100% Fruit Juice
9.2.3.14 Oral Health Policy
REFERENCES
  1. American Academy of Pediatrics, Oral Health Initiative. Protecting All Children's Teeth (PACT): A pediatric oral health training program. Factors in Development: Bacteria. http://www2.aap.org/oralhealth/pact/
  2. Dye, B. A., J. D. Shenkin, C. L. Ogden, T. A. Marshould, S. M. Levy, M. J. Kanellis. 2004. The relationship between healthful eating practices and dental caries in children aged 2-5 years in the United States. J Am Dent Assoc 135:55-66.
  3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry30:112-18.
  4. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine.2016. Policy statement: 2016 Recommendations for preventive pediatric health care. http://pediatrics.aappublications.org/content/early/2015/12/07/peds.2015-3908 
  5. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845.
  6. American Academy of Pediatrics, Section on Pediatric Dentistry.2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.

3.2 Hygiene

3.2.1 Diapering and Changing Soiled Clothing

3.2.1.1: Type of Diapers Worn

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.1

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.1: Type of Diapers Worn

Question:
Does this standard allow for use of the newer cloth diapers (with either a removable or connected absorbent inner liner and waterproof Velcro closure cover)? 

Answer:
Yes, (for children who require cloth diapers for a medical reason), but only if the cloth diaper and cover are removed simultaneously as one unit and not removed as two separate pieces (see page 105). Please review the Comments section of this Standard for more information.

Content in the STANDARD was modified on 8/9/2017.


Facilities should adhere to the procedures outlined in 3.2.1.2: Handling Cloth Diapers and 3.2.1.4: Diaper Changing Procedure to prevent and control infections caused by fecal contact:
 
Diapers worn by children should be able to contain urine and stool and minimize exposure to human waste in the child care setting. Children should use disposable diapers with absorbent material (e.g., polymers) or cloth diapers. Cloth diapers should have an absorbent inner layer that is completely covered with an outer waterproof layer that has a waist closure (i.e., not pull-on waterproof pants). The cloth diaper and waterproof later should be changed at the same time (1). Whichever diapering system is used in the facility, clothes should be worn over diapers while the child is in the facility.

No rinsing or dumping of the contents of cloth diapers should be performed at the child care facility. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child’s family, stored in a location inaccessible to children, and given directly to the parent/guardian daily upon discharge of the child. Children of all ages who are incontinent of urine or stool should wear a barrier method, such as a disposable diaper or a cloth diaper that is completely covered with an outer waterproof layer and a waist closure.

While single unit reusable diaper systems, with an inner cloth lining attached to an outer waterproof covering, and reusable cloth diapers, worn with a front closure waterproof cover, meet the physical criteria of this standard (if used as described), they have not been evaluated for their ability to reduce fecal contamination, or for their association with diaper dermatitis (rash). Moreover, it has not been demonstrated that the waterproof covering materials remain waterproof with repeated cleaning and disinfecting. Therefore, single-use disposable diapers should be encouraged for use in child care facilities.


RATIONALE

Procedures that reduce fecal contamination help control the spread of disease. Fecal contamination has been associated with increased diarrheal rates in child care facilities (1). Gastrointestinal tract disease, or diarrhea (caused by bacteria, viruses, and parasites) and hepatitis A virus infection are spread from infected persons through fecal contamination of hands and objects. Protective procedures includes minimal handling of soiled diapers and clothing, thorough hand hygiene, and containment of fecal matter.  Fecal contamination in child care settings may be reduced when single-use, disposable diapers are used compared to cloth diapers worn with pull-on waterproof pants (3). When clothes are worn over either disposable or cloth diapers with pull-on waterproof pants, there is a reduction in contamination of the environment (1, 3).

Diaper Rash
Diaper dermatitis (rash) occurs frequently in diapered children. Diapering practices that reduce the frequency and severity of diaper dermatitis will require less application of skin creams and ointments, thereby decreasing the likelihood for fecal contamination of caregivers/teachers’ hands. Most common diaper dermatitis is caused by prolonged contact of the skin with urine, feces, or both (1). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (1). Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the diaper used (1). The use of disposable diapers with absorbent material has been associated with less frequent and less severe diaper dermatitis in some children than with the use of cloth diapers and pull-on pants made of a waterproof material (2, 3).

COMMENTS
Reusable cloth diapers worn either without a covering or with pull-on waterproof pants do not meet the physical requirements of the standard.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
5.2.7.4 Containment of Soiled Diapers
5.4.1.10 Handwashing Sinks
REFERENCES
  1. American Academy of Pediatrics. Infections Spread by the Fecal-Oral Route In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 143
  2. American Academy of Pediatrics. Healthychildren.org. 2015. Diaper rash. https://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/Diaper-Rash.aspx
  3. Counts, J.L., Helmes, C.T., Kenneally, D., Otts, D.R. Modern disposable diaper constructions: Innovations in performance help maintain healthy diapered skin. 2014. Clinical Pediatrics. 53(9S):10S-13S. 
NOTES

Content in the STANDARD was modified on 8/9/2017.

3.2.1.2: Handling Cloth Diapers


If cloth diapers are used, soiled cloth diapers and/or soiled training pants should never be rinsed or carried through the child care area to place the fecal contents in a toilet. Reusable diapers should be laundered by a commercial diaper service. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child’s family. The sealed plastic bag should be sent home with the child at the end of the day. The containers or sealed diaper bags of soiled cloth diapers should not be accessible to any child (1).
RATIONALE
Containing and minimizing the handling of soiled diapers so they do not contaminate other surfaces is essential to prevent the spread of infectious disease. Putting stool into a toilet in the child care facility increases the likelihood that other surfaces will be contaminated during the disposal (2). There is no reason to use the toilet for stool if disposable diapers are being used. Commercial diaper laundries use a procedure that separates solid components from the diapers and does not require prior dumping of feces into the toilet.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.1 Type of Diapers Worn
3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

3.2.1.3: Checking For the Need to Change Diapers


Diapers should be checked for wetness and feces at least hourly, visually inspected at least every two hours, and whenever the child indicates discomfort or exhibits behavior that suggests a soiled or wet diaper. Diapers should be changed when they are found to be wet or soiled.
RATIONALE
Frequency and severity of diaper dermatitis is lower when diapers are changed more often, regardless of the type of diaper used (1). Diaper dermatitis occurs frequently in diapered children. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (2). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1,2). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (2).

Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents can be assessed by odor. Nonetheless, since these methods of checking may be inaccurate, the diaper should be opened and checked visually at least every two hours. Even though modern disposable diapers can continue to absorb moisture for an extended period of time when they are wet, they should be changed after two hours of wearing if they are found to be wet. This prevents rubbing of wet surfaces against the skin, a major cause of diaper dermatitis.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
3.2.2.1 Situations that Require Hand Hygiene
REFERENCES
  1. Healthy Children. 2010. Ages and stages: When diaper rash strikes. http://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/When-Diaper-Rash-Strikes.aspx.
  2. Shelov, S. P., T. R. Altmann, eds. 2009. Caring for your baby and young child: Birth to age 5. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3.2.1.4: Diaper Changing Procedure

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Is the recommendation for an Environmental Protection Agency (EPA)-registered disinfectant different from the previous cleaning and sanitizing definitions?  What’s the difference between a disinfectant and sanitizing agent?

Answer:

For some surfaces it is important to disinfect to be healthy and safe (this is the deepest “clean”). For some surfaces sanitizing is enough to be healthy and safe, and for some surfaces cleaning is adequate. Remember that before some surfaces are disinfected or sanitized, the visible “dirt” must first be cleaned off.

Please see Appendix J, Selecting an Appropriate Sanitizer or Disinfectant for more information.

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 11/22/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
What is the rationale for requiring hand washing before diaper changing?

Answer:
The diaper changing process may require many interactions with the child before the process, for example evaluating whether the diaper contains stool.  Because of the potential for contamination of hands during this process, hand hygiene should be performed before collection of diaper supplies and further handling of the child to avoid contaminating the remaining diaper supplies.  However, activities in child care do not occur in isolation.  If hand hygiene has been done for another reason prior to a diaper changing event, the process does not have to be repeated if no contamination of hands has occurred.

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 7/21/2014

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Step 6 of Standard 3.2.1.4: Diaper Changing Procedure states to "Use soap and warm water, between 60°F and 120°F, at a sink to wash the child’s hands, if you can." If the child is too heavy to hold at the sink, or has a special health care need that prevents him/her from standing at the sink, it is OK to use several wipes (one after the other) to clean the child's hands?

Answer:
Wipes that have chemicals should not be used as a replacement for washing an infant's/toddler's hands.

However, Managing Infectious Diseases in Child Care and Schools, 4th Edition and Model Child Care Health Policies, 5th Edition offers an alternative method to washing the hands of an infant/toddler at the sink if they are too heavy to hold or have a special need that prevents standing at the sink. This ”three paper towel” method is as follows:

1. Wipe the child’s hands with a damp paper towel moistened with a drop of liquid soap.
2. Wipe the child’s hands with a 2nd paper towel wet with clear water.
3. Dry the child’s hands with a 3rd paper towel.

Additionally, as stated in CFOC3 Standard 3.2.2.5: Hand Sanitizers, the use of hand sanitizers by children over twenty-four months of age and adults in child care programs is an appropriate alternative to the use of traditional handwashing with soap and water if the hands are not visibly soiled.

Last, please remember to check your local and/or state regulations before implementing this strategy.

Content in the STANDARD was modified on 1/2012, 7/2012, 5/13/2013 and on 8/23/2016.


The following diaper changing procedure should be posted in the changing area, should be followed for all diaper changes, and should be used as part of staff evaluation of caregivers/teachers who diaper. The signage should be simple and should be in multiple languages if caregivers/teachers who speak multiple languages are involved in diapering. All employees who will diaper should undergo training and periodic assessment of diapering practices. Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the diaper changing table. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.

Use a fragrance-free bleach that is EPA-registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA-registered (1).

All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting.

Step 1: Get organized. Before bringing the child to the diaper changing area, perform hand hygiene, gather and bring supplies to the diaper changing area:

  1. Non-absorbent paper liner large enough to cover the changing surface from the child’s shoulders to beyond the child’s feet;
  2. Unused diaper, clean clothes (if you need them);
  3. Wipes, dampened cloths or wet paper towels for cleaning the child’s genitalia and buttocks readily available;
  4. A plastic bag for any soiled clothes or cloth diapers;
  5. Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers) and remove them before handling clean diapers and clothing;
  6. A thick application of any diaper cream (e.g., zinc oxide ointment), when appropriate, removed from the container to a piece of disposable material such as facial or toilet tissue.

Step 2: Carry the child to the changing table, keeping soiled clothing away from you and any surfaces you cannot easily clean and sanitize after the change.

  1. Always keep a hand on the child;
  2. If the child’s feet cannot be kept out of the diaper or from contact with soiled skin during the changing process, remove the child’s shoes and socks so the child does not contaminate these surfaces with stool or urine during the diaper changing.

Step 3: Clean the child’s diaper area.

  1. Place the child on the diaper change surface and unfasten the diaper, but leave the soiled diaper under the child;
  2. If safety pins are used, close each pin immediately once it is removed and keep pins out of the child’s reach (never hold pins in your mouth);
  3. Lift the child’s legs as needed to use disposable wipes, or a dampened cloth or wet paper towel to clean the skin on the child’s genitalia and buttocks and prevent recontamination from a soiled diaper. Remove stool and urine from front to back and use a fresh wipe, or a dampened cloth or wet paper towel each time you swipe. Put the soiled wipes or paper towels into the soiled diaper or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm’s reach of diaper changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.

Step 4: Remove the soiled diaper and clothing without contaminating any surface not already in contact with stool or urine.

  1. Fold the soiled surface of the diaper inward;
  2. Put soiled disposable diapers in a covered, plastic-lined, hands-free covered can. If reusable cloth diapers are used, put the soiled cloth diaper and its contents (without emptying or rinsing) in a plastic bag or into a plastic-lined, hands-free covered can to give to parents/guardians or laundry service;
  3. Put soiled clothes in a plastic-lined, hands-free plastic bag;
  4. Check for spills under the child. If there are any, use the corner of the paper to fold the paper that extends under the child's feet over the soiled area so a fresh, unsoiled paper surface is now under the child's buttocks;
  5. If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can;
  6. Whether or not gloves were used, use a fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child's hands. Put the wipes into the plastic-lined, hands-free covered can.
Step 5: Put on a clean diaper and dress the child.
  1. Slide a fresh diaper under the child;
  2. Use a facial or toilet tissue or wear clean disposable glove to apply any necessary diaper creams, discarding the tissue or glove in a covered, plastic-lined, hands-free covered can;
  3. Note and plan to report any skin problems such as redness, skin cracks, or bleeding;
  4. Fasten the diaper; if pins are used, place your hand between the child and the diaper when inserting the pin.

Step 6: Wash the child’s hands and return the child to a supervised area.

  1. Use soap and warm water, between 60°F and 120°F, at a sink to wash the child’s hands, if you can.

Step 7: Clean and disinfect the diaper-changing surface.

  1. Dispose of the disposable paper liner used on the diaper changing surface in a plastic-lined, hands-free covered can;
  2. If clothing was soiled, securely tie the plastic bag used to store the clothing and send home;
  3. Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, rinse;
  4. Wet the entire changing surface with a disinfectant that is appropriate for the surface material you are treating. Follow the manufacturer’s instructions for use;
  5. Put away the disinfectant. Some types of disinfectants may require rinsing the change table surface with fresh water afterwards.

Step 8: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the diaper change in the child’s daily log.

  1. In the daily log, record what was in the diaper and any problems (such as a loose stool, an unusual odor, blood in the stool, or any skin irritation), and report as necessary (2).
RATIONALE
The procedure for diaper changing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (3). Posting the multi-step procedure may help caregivers/teachers maintain the routine.

Assembling all necessary supplies before bringing the child to the changing area will ensure the child’s safety, make the change more efficient, and reduce opportunities for contamination. Taking the supplies out of their containers and leaving the containers in their storage places reduces the likelihood that the storage containers will become contaminated during diaper changing.

Commonly, caregivers/teachers do not use disposable paper that is large enough to cover the area likely to be contaminated during diaper changing. If the paper is large enough, there will be less need to remove visible soil from surfaces later and there will be enough paper to fold up so the soiled surface is not in contact with clean surfaces while dressing the child.

If the child’s foot coverings are not removed during diaper changing, and the child kicks during the diaper changing procedure, the foot coverings can become contaminated and subsequently spread contamination throughout the child care area.

Some experts believe that commercial baby wipes may cause irritation of a baby’s sensitive tissues, such as inside the labia, but currently there is no scientific evidence available on this issue. Wet paper towels or a damp cloth may be used as an alternative to commercial baby wipes.

If the child’s clean buttocks are put down on a soiled surface, the child’s skin can be resoiled.

Children’s hands often stray into the diaper area (the area of the child’s body covered by diaper) during the diapering process and can then transfer fecal organisms to the environment. Washing the child’s hands will reduce the number of organisms carried into the environment in this way. Infectious organisms are present on the skin and diaper even though they are not seen. To reduce the contamination of clean surfaces, caregivers/teachers should use a fresh wipe to wipe their hands after removing the gloves, or, if no gloves were used, before proceeding to handle the clean diaper and the clothing.

Some states and credentialing organizations may recommend wearing gloves for diaper changing. Although gloves may not be required, they may provide a barrier against surface contamination of a caregiver/teacher’s hands. This may reduce the presence of enteric pathogens under the fingernails and on hand surfaces. Even if gloves are used, caregivers/teachers must perform hand hygiene after each child’s diaper changing to prevent the spread of disease-causing agents. To achieve maximum benefit from use of gloves, the caregiver/teacher must remove the gloves properly after cleaning the child’s genitalia and buttocks and removing the soiled diaper. Otherwise, retained contaminated gloves could transfer organisms to clean surfaces. Note that sensitivity to latex is a growing problem. If caregivers/teachers or children who are sensitive to latex are present in the facility, non-latex gloves should be used. See Appendix D, for proper technique for removing gloves.

A safety strap cannot be relied upon to restrain the child and could become contaminated during diaper changing. Cleaning and disinfecting a strap would be required after every diaper change. Therefore safety straps on diaper changing surfaces are not recommended.

Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, application and storage. If the disinfectant is applied using a spray bottle, always assume that the outside of the spray bottle could be contaminated. Therefore, the spray bottle should be put away before hand hygiene is performed, (the last and essential part of every diaper change) (5).

Diaper-changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils.

If parents/guardians use the diaper changing area, they should be required to follow the same diaper changing procedure to minimize contamination of the diaper changing area and child care.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
5.2.7.4 Containment of Soiled Diapers
5.4.4.2 Location of Laundry Equipment and Water Temperature for Laundering
Appendix D: Gloving
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Children’s Environmental Health Network. 2016. Household chemicals. http://www.cehn.org/wp-content/uploads/Household_chemicals_1_16.pdf.
  2. National Association for the Education of Young Children. 2012. Healthy Young Children, A Manual for Programs. Fifth edition. Editor. Susan Aronson Washington, DC. 
  3. Red Book: 2015 Report of the Committee on Infectious Diseases, 30th Edition American Academy of Pediatrics Committee on Infectious Diseases; Editor: David W. Kimberlin, MD, FAAP; Associate Editors: Michael T. Brady, MD, FAAP; Mary Anne Jackson, MD, FAAP; and Sarah S. Long, MD, FAAP.

  4. Early Childhood Education Linkage System. Healthy Child Care Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster.
  5. University of California, San Francisco School of Nursing’s Institute for Health & Aging, University of California, Berkeley’s Center for Environmental Research and Children's Health, and Informed Green Solutions, California Department of Pesticide Regulation. 2013. Green cleaning, sanitizing, and disinfecting: A checklist for early care and education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf
NOTES

Content in the STANDARD was modified on 1/2012, 7/2012, 5/13/2013 and on 8/23/2016.

3.2.1.5: Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.5

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.5: Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing

Question:
Should a distinction be made between “wet” and “soiled” pull-up, clothing, and underwear? Or are these terms interchangeable in the Standard and Rationale? More specifically, are the steps required for changing a pull-up with a bowel movement the same for changing a pull-up that is only wet?

Answer:
The same changing procedure should be used regardless of the contents.

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, and 8/23/2016.


The following changing procedure for soiled pull-ups or underwear and clothing should be posted in the changing area, should be followed for all changes, and should be used as part of staff evaluation of caregivers/teachers who change pull-ups or underwear and clothing. The signage should be simple and should be in multiple languages if caregivers/teachers who speak multiple languages are involved in changing pull-ups or underwear. All employees who will change pull-ups or underwear and clothing should undergo training and periodic assessment of these practices.

Changing a child from the floor level or on a chair puts the adult in an awkward position and increases the risk of contamination of the environment. Using a toddler changing table helps establish a well-organized changing area for both the child and the caregiver/teacher. Changing tables with steps that allow the child to climb with the caregiver/teacher’s help and supervision are a good idea. This would help reduce the risk of back injury for the adults that may occur from lifting the child onto the table (1).

Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the changing surface. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.

Use fragrance-free bleach that is EPA-registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA-registered (2).

All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

Step 1: Get organized and determine whether to change the child lying down or standing up. Before bringing the child to the changing area,