Caring for Our Childen, 3rd Edition (CFOC3)

Chapter 5: Facilities, Supplies, Equipment, and Environmental Health

5.2 Quality of the Outdoor and Indoor Environment

5.2.9 Prevention and Management of Toxic Substances

5.2.9.1: Use and Storage of Toxic Substances

Content in the STANDARD was modified on 1/12/2017.

 


The following items should be used as recommended by the manufacturer and should be stored in the original labeled containers:

  1. Cleaning materials;
  2. Detergents (in all forms, including pods);
  3. Automatic dishwasher detergents (in liquid or solid forms, including pods);
  4. Aerosol cans;
  5. Pesticides;
  6. Health and beauty aids;
  7. Medications;
  8. Lawn care chemicals;
  9. Marijuana (in all forms, including oils, liquids, and edible products);
  10. Liquid nicotine and tobacco products; and 
  11. Other toxic materials. (1-6)

Safety Data Sheets (SDS) must be available onsite for each hazardous chemical that is on the premises.

These substances should be used only in a manner that will not contaminate play surfaces, food, or food preparation areas, and that will not constitute a hazard to the children or staff. When not in active use, all chemicals used inside or outside should be stored in a safe and secure manner in a locked room or cabinet, fitted with a child-resistive opening device, inaccessible to children, and separate from stored medications and food.

Chemicals used in lawn care treatments should be limited to those listed for use in areas that can be occupied by children.

Medications can be toxic if taken by the wrong person or in the wrong dose. Medications should be stored safely (see Standard 3.6.3.1) and disposed of properly (see Standard 3.6.3.2).

The telephone number for the poison center should be posted in a location where it is readily available in emergency situations (e.g., next to the telephone). Poison centers are open twenty-four hours a day, seven days a week, and can be reached at 1-800-222-1222.

RATIONALE
There are over two million human poison exposures reported to poison centers every year. Children under six years of age account for over half of those potential poisonings. The substances most commonly involved in poison exposures of children are cosmetics and personal care products, cleaning substances, and medications (7).

The SDS explains the risk of exposure to products so that appropriate precautions may be taken.

COMMENTS
Many child-resistant types of closing devices can be installed on doors to prevent young children from accessing poisonous substances. Many of these devices are self-engaging when the door is closed and require an adult hand size or skill to open the door. A locked cabinet or room where children cannot gain access is best but must be used consistently. Child-resistant containers provide another level of protection.

In states that permit recreational and/or medicinal use of marijuana, special care is needed to store edible marijuana products securely and apart from other foods. State regulations typically require that these products be clearly labeled as containing an intoxicating substance and stored in the original packaging that is tamper-proof and child-proof. Any legal edible marijuana products in a family child care home should be kept in a locked or child-resistant storage device. 
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
5.2.8.1 Integrated Pest Management
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
REFERENCES
  1. McKenzie, L.B., Ahir, N., Stolz, U. Nelson, N.G. Household cleaning product-related injuries treated in US emergency departments in 1990–2006. Pediatrics. 2010:126(3). http://pediatrics.aappublications.org/content/pediatrics/126/3/509.full.pdf
  2. Davis, M.G., Casavant, M.J., Spiller, H.A., Chounthirath, T., Smith, G.A. 2016. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013–2014. Pediatrics. doi: 10.1542/peds.2015-4529. http://pediatrics.aappublications.org/content/early/2016/04/21/peds.2015-4529.
  3. American Academy of Pediatrics Council on Environmental Health. Pesticide exposure in children. Pediatrics. 2012:130(6). http://pediatrics.aappublications.org/content/130/6/e1757.
  4. Wang, G.S., Le Lait, M.C., Deakyne, S.J., Bronstein, A.C., Bajaj, L., Roosevelt, G. 2016. Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015. JAMA Pediatr. 2016;170(9):e160971. doi:10.1001/jamapediatrics.2016.0971.
  5. American Academy of Pediatrics News. 2014.  Liquid nicotine used in e-cigarettes can kill children.
    http://www.aappublications.org/content/early/2014/12/17/aapnews.20141217-1.
  6. Safe Kids Grand Forks, Altru Health System. 2016. Electronic cigarette safety tips. http://safekidsgf.com/Documents/6053-0375-E-cigaretteSafetyTips.pdf.
  7. American Association of Poison Control Centers’ National Poison Data System. 2015. Poison center data snapshot - 2014. https://aapcc.s3.amazonaws.com/pdfs/annual_reports/2014_Annual_Report_Snapshot_FINAL.pdf.
NOTES

Content in the STANDARD was modified on 1/12/2017.

 

5.2.9.2: Use of a Poison Center


The poison center should be called for advice about any exposure to toxic substances, or any potential poisoning emergency. The national help line for the poison center is 1-800-222-1222, and specialists will link the caregiver/teacher with their local poison center. The advice should be followed and documented in the facility's files. The caregiver/teacher should be prepared for the call by having the following information for the poison center specialist:
a) The child's age and sex;
b) The substance involved;
c) The estimated amount;
d) The child's condition;
e) The time elapsed since ingestion or exposure.

The caregiver/teacher should not induce vomiting unless instructed by the poison center.
RATIONALE
Toxic substances, when ingested, inhaled, or in contact with skin, may react immediately or slowly, with serious symptoms occuring much later (1). It is important for the caregiver/teacher to call the poison center after the exposure and not "wait and see." Symptoms vary with the type of substance involved. Some common poisoning symptoms include dermatitis, nausea, vomiting, diarrhea, and congestion.
COMMENTS
Any question on possible risks for exposure should be referred to poison center professionals for proper first aid and treatment. Regional poison centers have access to the latest information on emergency care of the poisoning victim.

Caregivers/teachers can go to http://www.aapcc.org to find their local poison center or for additional information on poisoning and poison safety. They can also access a variety of services that poison centers have: poison prevention, poison control, information about toxic substances including lead and chemicals that may be found in consumer products, and even assistance with disaster planning. Caregivers/teachers should feel comfortable calling the poison center about medication dosing errors. Poison centers provide free, confidential advice on how to handle the situation.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2007. Policy statement: Poison treatment in the home. Pediatrics 119:1031.

5.2.9.3: Informing Staff Regarding Presence of Toxic Substances


Employers should provide staff with hazard information, including access to and review of the Safety Data Sheets (SDS) as required by the Occupational Safety and Health Administration (OSHA), about the presence of toxic substances such as formaldehyde, cleaning and sanitizing supplies, insecticides, herbicides, and other hazardous chemicals in use in the facility. Staff should always read the label prior to use to determine safety in use. For example, toxic products regulated by the Environmental Protection Agency (EPA) will have an EPA signal word of CAUTION, WARNING, or DANGER. Where nontoxic substitutes are available, these nontoxic substitutes should be used instead of toxic chemicals. If a nontoxic product is not available, caregivers/teachers should use the least toxic product for the job. A CAUTION label is safer than a WARNING label, which is safer than a DANGER label.
RATIONALE
These precautions are essential to the health and well-being of the staff and the children alike. Many cleaning products and art materials contain ingredients that may be toxic. Regulations require employers to make the complete identity of these materials known to users. Because nontoxic substitutes are available for virtually all necessary products, exchanging them for toxic products is required.
COMMENTS
The U.S. Department of Labor, which oversees OSHA, is responsible for protection of workers and is listed in the phone books of all large cities. Because standards change frequently, the facility should seek the latest standards from the EPA. Information on toxic substances in the environment is available from the EPA. For information on consumer products contact the U.S. Consumer Product Safety Commission (CPSC). For information on art and craft materials, contact the Art and Creative Materials Institute (ACMI). The local health jurisdiction can also be a resource for information on hazardous chemicals in child care.

The SDS explains the risk of exposure to products so that appropriate precautions may be taken.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.8.1 Integrated Pest Management
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.7 Proper Use of Art and Craft Materials
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks
REFERENCES
  1. Wargo, J. 2004. The physical school environment: An essential component of a health-promoting school. WHO Information series on School Health, document 2. Geneva: WHO. http://www.who.int/school_youth_health/media/en/physical_sch_environment.pdf.
  2. 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.

5.2.9.4: Radon Concentrations

Content in the STANDARD was modified on 05/17/2016.

 


Radon concentrations inside a home or building used for child care must be less than four picocuries (pCi) per liter of air. All facilities must be tested for the presence of radon, according to U.S. Environmental Protection Agency (EPA) testing protocols for long-term testing (i.e., greater than ninety days in duration using alpha-track or electret test devices). Radon testing should be conducted after a major renovation to the building or HVAC system (1,2). 
RATIONALE
Radon is a colorless, odorless, radioactive gas that comes from the natural breakdown of uranium in soil, rock and water, and gets into the air you breath. It can be found in soil, water, building materials, and natural gas. Radon from the soil is the main cause of radon problems. Radon typically moves up through the ground to the air above and into a home or building through cracks and other holes in the foundation. Radon can get trapped inside the home or building where it can build up. In a small number of homes, the building materials can give off radon, but the materials themselves rarely cause problems. If radon is present in the water supply, most of the risk is related to radon released into the air when water is used for showering or other household purposes (1). When radon gas is inhaled, it can cause lung cancer. Radon levels can be easily measured to determine if acceptable levels have been exceeded. The risk can be reduced by lowering the levels of radon in the home or building. Fixing buildings to reduce radon exposure may entail sealing cracks in the foundation or ventilating the area under the foundation.
COMMENTS
The average indoor radon level is estimated to be about 1.3 pCi per liter of air, and about 0.4 pCi per liter is normally found in the outside air. Most homes today can be reduced to two picocuries per liter or below (1).

Common test kits include: charcoal canisters, e-perm, alpha track detectors, and charcoal liquid scintillation devices. To find radon resources near you, see  U.S. EPA Radon Hotlines and Information Resources or contact the National Radon Program Services.


TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.1.7 Use of Basements and Below Grade Areas
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
5.2.9.15 Construction and Remodeling
REFERENCES
  1. U.S. Environmental Protection Agency (EPA). 2012. A citizen’s guide to radon: The guide to protecting yourself and your family from radon. https://www.epa.gov/radon/citizens-guide-radon-guide-protecting-yourself-and-your-family-radon.
  2. U.S. Environmental Protection Agency (EPA). 1993. Radon measurement in schools: Revised edition. https://www.epa.gov/sites/production/files/2014-08/documents/radon_measurement_in_schools.pdf.      
NOTES

Content in the STANDARD was modified on 05/17/2016.

 

5.2.9.5: Carbon Monoxide Detectors


Carbon monoxide detector(s) should be installed in child care settings if one of the following guidelines is met:

  1. The child care program uses any sources of coal, wood, charcoal, oil, kerosene, propane, natural gas, or any other product that can produce carbon monoxide indoors or in an attached garage;
  2. If detectors are required by state/local law or state licensing agency.

Facilities must meet state or local laws regarding carbon monoxide detectors. Detectors should be tested monthly. Batteries should be changed at least yearly. Detectors should be replaced at least every five years.

RATIONALE
Carbon monoxide (CO) is a deadly, colorless, odorless, poisonous gas. It is produced by the incomplete burning of various fuels, including coal, wood, charcoal, oil, kerosene, propane, and natural gas. Products and equipment powered by internal combustion engine-powered equipment such as portable generators, cars, lawn mowers, and power washers also produce carbon monoxide. Carbon monoxide detectors are the only way to detect this substance.

Carbon monoxide poisoning causes symptoms that mimic the flu; mild symptoms are typically headache, dizziness, fatigue, nausea, and diarrhea. Prolonged exposure can cause confusion, shortness of breath, unconsciousness, and even death.

On average, about 170 people in the United States die every year from carbon monoxide produced by non-automotive consumer products (1). These products include malfunctioning fuel-burning appliances such as furnaces, ranges, water heaters, and room heaters; engine-powered equipment such as portable generators; fireplaces; and charcoal that is burned in homes and other enclosed areas. In 2005 alone, the U.S. Consumer Product Safety Commission (CPSC) staff was aware of at least ninety-four generator-related carbon monoxide poisoning deaths (1). Still others die from carbon monoxide produced by non-consumer products, such as cars left running in attached garages. The Centers for Disease Control and Prevention (CDC) estimate that several thousand people go to hospital emergency rooms every year to be treated for carbon monoxide poisoning (1).

COMMENTS
Carbon monoxide detectors should be installed according to the manufacturer’s instructions. One carbon monoxide detector should be installed in the hallway outside the bedrooms in each separate sleeping area. Carbon monoxide detectors may be installed into a plug-in receptacle or high on the wall. Hard-wired or plug-in carbon monoxide detectors should have battery backup. Installing carbon monoxide detectors near heating vents, locations that can be covered by furniture or draperies, above fuel-burning appliances or in kitchens should be avoided (1).

There are a number of safety steps that child care programs can do to help prevent carbon monoxide exposure (1-3):

  1. Make sure major appliances are professionally installed and inspected according to local building codes and have older appliances checked for malfunctions and leaks;
  2. Choose vented appliances when possible;
  3. Have heating systems inspected and cleaned by a qualified technician annually and make sure the chimney is clean and with a proper draft control to ensure a proper vent for flue gases;
  4. Check the color of the flame in the burner and pilot light (a yellow-colored flame indicates the fuel is not burning efficiently and could be releasing more carbon monoxide) (4);
  5. Never use a gas oven to heat your facility;
  6. Do not burn charcoal indoors;
  7. Never operate gasoline-powered engines or generators in confined areas in or near the building;
  8. Never leave a vehicle running in a garage or closed area. Even if the garage door is open, normal circulation will not supply enough fresh air to prevent a buildup of CO gas;
  9. If the CO alarm goes off or if you have symptoms of CO poisoning, exit the building and call 9-1-1.

For other questions on CO poisoning call the poison center.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 2008. Carbon monoxide questions and answers. Document #466. Bethesda, MD: CPSC. https://www.cpsc.gov/safety-education/safety-guides/home/asbestos-home.
  2. Cowling, T. 2007. Safety first: Carbon monoxide poisoning. Healthy Child Care 10(5): 6-7. http://www.safekids.org/safetytips/field_risks/carbon-monoxide
  3. Safe Kids Worldwide.  Home Safety Fact Sheet. http://www.safekids.org/fact-sheet/home-safety-fact-sheet-2015-pdf.
  4. Tremblay, K. R., Jr. 2006. Preventing carbon monoxide problems. Colorado State University Extension. http://www.ext.colostate.edu/pubs/consumer/09939.html.

5.2.9.6: Preventing Exposure to Asbestos or Other Friable Materials


Any asbestos, fiberglass, or other friable material or any material that is in a dangerous condition found within a facility or on the grounds of the facility should be repaired or removed. Repair usually involves either sealing (encapsulating) or covering asbestos material. Any repair or removal of asbestos should be done by a contractor certified to do in accordance with existing regulations of the U.S. Environmental Protection Agency (EPA). No children or staff should be present until the removal and cleanup of the hazardous condition have been completed.

Pipe and boiler insulation should be sampled and examined in an accredited laboratory for the presence of asbestos in a friable or potentially dangerous condition.

Non-friable asbestos should be identified to prevent disturbance and/or exposure during remodeling or future activities.

RATIONALE
Removal of significant hazards will protect the staff, children, and families who use the facility. Asbestos dust and fibers that are inhaled and reach the lungs can cause lung disease (1,2).
COMMENTS
The mere presence of asbestos in a child care facility, home, or a building is not hazardous. The danger is that asbestos materials may become damaged over time. Damaged asbestos may release asbestos fibers and become a health hazard (2,3). The best thing to do with asbestos material that is in good condition is to leave it alone. Disturbing it may create a health hazard where none existed before (1).

Asbestos that is in a friable condition means that it is easily crumbled (2).

The National Asbestos School Hazard Abatement Act of 1984 specifies requirements for removal of asbestos. Contact your local health department for additional information on asbestos regulations in your area. For more information regarding asbestos and applicable EPA regulations, contact regional offices of the EPA.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). Asbestos in the home. http://www.cpsc.gov/cpscpub/pubs/453.html.
  2. U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry. 2001. Toxicological profile for asbestos. http://www.atsdr.cdc.gov/ToxProfiles/tp61-p.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.

5.2.9.7: Proper Use of Art and Craft Materials


Only art and craft materials that are approved by the Art and Creative Materials Institute (ACMI) should be used in the child care facility. Art and craft materials should conform to all applicable ACMI safety standards. Materials should be labeled in accordance with the chronic hazard labeling standard, ASTM D4236.

The facility should prohibit use of unlabeled, improperly labeled old, or donated materials with potentially harmful ingredients.

Caregivers/teachers should closely supervise all children using art and craft materials and should make sure art and craft materials are properly used, cleaned up, and stored in original containers that are fully labeled. Materials should be age-appropriate. Children should not eat or drink while using art and craft materials.

Caregivers/teachers should have emergency protocols in place in the event of an injury, poisoning, or allergic reaction. If caregivers/teachers suspect a poisoning may have occurred they should call their poison center at 1-800-222-1222. Rooms should be well ventilated while using art and craft materials.

Only ACMI-approved unscented water-based markers should be used for children’s art projects and work.

RATIONALE
Contamination and injury may occur if art and craft materials are improperly used or labeled. Labels are required on art supplies to identify any hazardous ingredients, risks associated with their use, precautions, first aid, and sources of further information (1).

Art material, approved by the ACMI, has been tested for both chronic and acute health hazards. The ACMI AP (Approved Product) Seal, with or without Performance Certification, identifies art materials that are safe and that are certified in a toxicological evaluation by a medical expert to contain no materials in sufficient quantities to be toxic or injurious to humans, including children, or to cause acute or chronic health problems. This seal is currently replacing the previous non-toxic seals: CP (Certified Product), AP (Approved Product), and HL Health Label (Non-Toxic) over a ten-year phase-in period. Such products are certified by ACMI to be labeled in accordance with the chronic hazard labeling standard, ASTM D4236, and the U.S. Labeling of Hazardous Art Materials Act (LHAMA). Additionally, products bearing the AP Seal with Performance Certification or the CP Seal are certified to meet specific requirements of material, workmanship, working qualities, and color developed by ACMI and others through recognized standards organizations, such as the American National Standards Institute (ANSI) and ASTM International. Some products cannot attain this performance certification because no quality standard currently exists for certain types of products (1).

Children have been known to try and eat fruit-scented markers. Solvent-based/permanent markers can trigger headaches and/or asthma (3).

COMMENTS
Non-toxic art and craft supplies intended for children are readily available.

Some products labeled “non-toxic” are not necessarily a safer alternative; thus the need to check for the proper labeling.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.4 Ventilation When Using Art Materials
REFERENCES
  1. Art and Creative Materials Institute. 2010. Safety - what you need to know. http://www.acminet.org/Safety.htm.
  2. 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.
  3. U.S. Consumer Product Safety Commission (CPSC). Art and craft safety guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015.pdf.

5.2.9.8: Use of Play Dough and Other Manipulative Art or Sensory Materials


The child care program should have the following procedures on the use and life span of manipulative art or sensory materials such as clay, play dough, etc:

  1. If handmade, these materials should be made fresh each week, labeled, dated and stored in airtight containers;
  2. If purchased, these products should be stored in their original packaging;
  3. Products that are labeled as toxic are prohibited;
  4. The surface upon which they are used and the tools used with these materials should be cleaned and sanitized before and after use;
  5. Children should practice hand hygiene before and after each use;
  6. Material should be discarded if it is sneezed upon, put into a child’s mouth, or in any other way possibly contaminated;
  7. Children with latex or gluten allergies should be given their own portion of the material and that individual portion should be stored separately if for repeat use.
  8. Children with cuts, sores, scratches and colds with sneezing and runny noses should be given their own portion of the material and that individual portion should be stored separately if for repeat use.
RATIONALE
Hand hygiene, supervision of children, and discarding material that is contaminated are appropriate hygienic practices when using these materials. Providing children with their own portion of modeling material helps prevent cross-contamination (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
REFERENCES
  1. Life Tips. Cutting down on playdough germs. http://parent.lifetips.com/tip/43479/day-care-and-babysitters/concerns-and
    -coping/cutting-down-on-playdough-germs.html.

5.2.9.9: Plastic Containers and Toys


The facility should use infant bottles, plastic containers, and toys that do not contain Polyvinyl chloride (PVC), Bisphenol A (BPA), or phthalates. When possible, caregivers/teachers should substitute materials such as paper, ceramic, glass, and stainless steel for plastics.
RATIONALE
Plastics can contain chemicals and metals, which are used as additives and stabilizers. Some of these additives and stabilizers can be toxic, such as lead (e.g., toys, vinyl lunchboxes). Plastics can release chemicals into food and drink; some types of plastics are more likely to do so than others (polycarbonate, PVC, polystyrene). Effects are not fully studied or understood, but in animal studies, some plastics have been tied to a wide range of negative health effects including endocrine (hormone) disruption and cancer (1,11).

PVC, also known as vinyl, is one of the most commonly used types of plastics today. PVC is present in many things used daily, from water bottles and containers, to wallpaper, wall paneling, credit cards, and children’s toys. Some of the substances added to PVC are among the hormone-disrupting chemicals that may pose hazards to human health and child development. PVC products, including certain toys, may have chemicals such as lead, cadmium, and phthalates, which can flake, leach, or off-gas, causing the release of these chemicals into the surroundings (2).

Phthalates is a class of chemicals used to make plastics flexible (3,4,11). Phthalates are used in many products: vinyl flooring, plastic clothing (e.g., raincoats), detergents, adhesives, personal-care products (fragrances, nail polish, soap), and is commonly found in vinyl (PVC) plastic products (toys, plastic bags) (13). In a national study, some phthalates have been found in 97% (5) of the people tested with generally higher concentrations found in children (6). In animal studies, health effects range from developmental and reproductive toxicity to damage to the liver (7,8).

Bisphenol A (BPA) is used when making polycarbonate and other plastic products. BPA is widely used in consumer products (infant bottles, protective coating in food cans, toys, containers, and personal care products) (13). It can leach from these products and potentially cause harm to those in contact with them. It can also have estrogen (female hormone)-like effects, which may impact biological systems at very low doses. Children may be exposed via: ingestion (diet and sucking/mouthing plastics), inhalation (of dust), and dermal contact. A national study found BPA in the urine of over 90% of people tested; children were found to have higher levels than adults (9). BPA has been found in pregnant women, umbilical cord blood, and placentas at levels demonstrated in animals to alter development (10).

COMMENTS
The Consumer Product Safety Improvement Act (CPSIA) empowers the U.S. Consumer Product Safety Commission (CPSC) to set regulations protecting consumers of these products with testing and labeling. As of this writing new CPSC requirements are under development. Consumers of products for children should look for products that state “phthalate-free” or “BPA-free” or certification by Toy Safety Certification Program (TSCP) or American National Standards Institute (ANSI).

Following are guidelines by which caregivers/teachers may reduce exposure to phthalates and BPA:

  1. When possible, opt for glass, porcelain or stainless steel containers, particularly for hot food or liquids (12);
  2. If using plastic, do not use plastic or plastic wrap for heating in microwave (try substituting a paper towel or waxpaper for covering foods) (12);
  3. Check the symbol on the bottom of the plastic items including toys before buying. The plastics industry has developed identification codes to label different types of plastic. The identification system divides plastic into seven distinct types and uses a number code generally found on the bottom of containers. For a table that explains the seven code system, go to http://www.natureworksllc.com/the-ingeo-journey/end-of-life-options/recycling/plastic-codes.aspx. Contact the manufacturer if there is a question about the chemical content of a plastic item;
  4. Best plastic choices are 1 (PETE), 2 (HDPE), 4 (LDPE), 5 (PP) and plastics labeled “phthalate-free” or “BPA-free”;
  5. Avoid plastics labeled 3 (V), 6 (PS), and 7 (PC). Polycarbonate containers that contain BPA usually have a number 7 on the bottom;
  6. Use alternatives to polycarbonate “7” infant bottles. Alternatives include glass infant bottles, BPA free, and products made of safer plastics such as polyethylene and polypropylene that are less likely to release harmful plasticizers (12) (safer non-polycarbonate bottles are usually cloudy and squeezable);
  7. Do not use latex rubber nipples or plastic bottle liners;
  8. Avoid canned foods when possible;
  9. If infant formula is used, it is best to use powdered formula in a can;
  10. Do not place plastics in the dishwasher;
  11. If using hard polycarbonate plastics (PC) such as water bottles/infant bottles, do not use for warm/hot liquids;
  12. Dispose of plastic bottles when they are old and scratched;
  13. Toys should be certified by the Toy Safety Certification Program (TSCP) or American National Standards Institute (ANSI).

For more tips on safer food use of plastics, see the Institute for Agriculture and Trade Policy (IATP) Website: Smart Plastics Guide: Healthier Food Uses of Plastics, available at http://www.iatp.org/foodandhealth/.

For more tips on safer alternatives to PVC plastics, see the Center for Health, Environment, and Justice (CHEJ) Website: The Campaign for Safe Healthy Consumer Products, available at http://www.besafenet.com/pvc/.

For general information on plastics and on how to recycle them, see the U.S. Environmental Protection Agency (EPA) Website: Common Wastes and Materials: Plastics, at http://www.epa.gov/osw/conserve/materials/plastics.htm.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.3.1.2 Product Recall Monitoring
REFERENCES
  1. Eco-Healthy Child Care. 2010. Plastics and plastic toys. Children’s Environmental Health Network. http://www.cehn.org/files/Plastics_Plastic_Toys_Dec2010.pdf.
  2. BE SAFE. The dangers of polyvinyl chrloride (PVC). http://www.ussafety.com/media_vault/documents/1264894110.pdfhttp://www.ussafety.com/media_vault/documents/1264894110.pdf
  3. Huff, J. 1982. Di(2-ethylhexyl) adipate: Condensation of the carcinogenesis bioassay, technical report.Environ Health Perspectives 45:205-7.
  4. Kluwe, W. M. 1986. Carcinogenic potential of phthalic acid esters and related compounds: Structure-activity relationships. Environ Health Perspectives 65:271-78.
  5. Silva, M. J., D. B. Barr, J. A. Reidy, et al. 2004. Urinary levels of seven phthalate metabolites in the U.S. population from the National Health and Nutrition Examination Survey (NHANES), 1999-2000. Environ Health Perspectives 112:331-38.
  6. Kolarik, B., K. Naydenov, M. Larsson, et al. 2008. The association between phthalates in dust and allergic diseases among Bulgarian children. Environ Health Perspectives 116:98-103.
  7. Centers for Disease Control and Prevention (CDC). 2009. Fourth national report on human exposure to environmental chemicals. Atlanta, GA: CDC. http://www.cdc.gov/exposurereport/pdf/FourthReport.pdf.
  8. Blount, B. C., M. Silva, S. Caudill, et al. 2000. Levels of seven urinary phthalate metabolites in a human reference population. Environ Health Perspectives 108:979-82.
  9. Calafat, A. M., X. Ye, L. Wong, et al. 2008. Exposure of the U.S. population to bisphenol A and 4-tertiary-octylphenol: 2003-2004. Environ Health Perspectives 116:39-44.
  10. Ikezuki, Y., O. Tsutsumi, Y. Takai, Y. Kamei, Y. Taketani. 2002. Determination of bisphenol A concentrations in human biological fluids reveals significant early prenatal exposure. Human Reproduction 17:2839-41.
  11. American Academy of Pediatrics. 2007. Technical report: Pediatric exposure and potential toxicity of phthalate plasticizers. Pediatrics 119:1031.
  12. California Childcare Health Program (CCHP). 2008. Banning chemicals called phthalates in childhood products. Berkeley, CA: CCHP.http://www.ucsfchildcarehealth.org/pdfs/factsheets/BannedChem_0308.pdf.
  13. U.S. Consumer Product Safety Commission. 2009. Prohibition on the sale of certain products containing specified phthalates. http://www.cpsc.gov/about/cpsia/108rfc.pdf.

5.2.9.10: Prohibition of Poisonous Plants


Poisonous or potentially harmful plants are prohibited in any part of a child care facility that is accessible to children. All plants not known to be nontoxic should be identified and checked by name with the local poison center (1-800-222-1222) to determine safe use.
RATIONALE
Plants are important to our health and well-being and are a great lesson in learning to understand and respect our environment. However, some plants can be harmful when eaten or touched (1,2). Plants are among the most common household substances that children ingest. Determining the toxicity of every commercially available household plant is difficult. A more reasonable approach is to keep any unknown plant out of the environment that children use. All outdoor plants and their leaves, fruit, and stems should be considered potentially toxic (1).
COMMENTS
Cuttings, trimmings, and leaves from potentially harmful plants must be disposed of safely so children do not have access to them.

For toxic, frequently ingested products and plants, see the American Academy of Pediatrics’ (AAP) Handbook of Common Poisonings in Children, available at http://www.aap.org.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
Appendix Y: Non-Poisonous and Poisonous Plants
REFERENCES
  1. American Academy of Pediatrics. 2011. Handbook of common poisonings in children. 4th ed. Elk Grove Village, IL: AAP.
  2. 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.

5.2.9.11: Chemicals Used to Control Odors

Content in the STANDARD was modified on 8/25/2016.

 


The use of the following should be prohibited:

  1. Incense;
  2. Moth crystals or moth balls;
  3. Air fresheners or sanitizers (both manmade and natural, e.g. essential oils); and
  4. Toilet/urinal deodorizer blocks (1,2).
RATIONALE
Many chemicals are sold to cover up noxious odors or ward off pests. Many of these chemicals are hazardous (3). As an alternative, caregivers/teachers should remove the source of noxious odors to the extent possible by dissipating noxious odors through cleaning and ventilation (e.g., opening windows) and controlling pests using nontoxic methods.

Toilet/urinal deodorizer blocks commonly contain para-dichlorobenzene (PDCB), a toxic chemical, designated as a possible human carcinogen (4), that has no cleaning function. These deodorizers only serves to mask odors that should be eliminated by proper cleaning.

COMMENTS
Contact the poison center at 1-800-222-1222 or the U.S. Environmental Protection Agency (EPA) Regional offices listed in the federal agency section of the telephone directory for assistance in identifying hazardous products.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.8.1 Integrated Pest Management
REFERENCES
  1. Potera, C. (2011). Scented Products Emit a Bouquet of VOCs. Environmental Health Perspectives 119(1), a16. http://dx.doi.org/10.1289/ehp.119-a16.  
  2. 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
  3. U.S. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health (NIOSH). 2015.Indoor environmental quality. http://www.cdc.gov/niosh/topics/indoorenv/chemicalsodors.html
  4. Suhua, W., L. Rongzhu, Y. Changqing, X. Guangwei, H. Fangan, J. Junjie, X. Wenrong, M. Aschner. 2010. Lipid peroxidation and changes of trace elements in mice treated with paradichlorobenzene. Biol Trace Elem Res 136:320-36.
  5. Focus (1998). Scents and Sensitivity. Environmental Health Perspectives 106(12), A594-A599. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1533259/pdf/envhper00535-0024-color.pdf.
  6. Children’s Environmental Health Network. (March 2016). Fragrances. Retrieved from http://www.cehn.org/our-work/eco-healthy-child-care/ehcc-faqs/fragrances/.
NOTES

Content in the STANDARD was modified on 8/25/2016.

 

5.2.9.12: Treatment of CCA Pressure-Treated Wood

Content in the STANDARD was modified on 8/25/2016.

 


Two coats of waterproof stain or sealant (e.g., semi-transparent stain, but not paint) should be applied at least once a year if it is oil-based, and twice a year if it is water-based - to all chromated copper arsenate (CCA)-treated surfaces (playground equipment, benches, decks, picnic tables) to which a child may have access. High-traffic areas may require more frequent treatments. Children should not be allowed to eat while playing on the equipment, and should be instructed to wash their hands after playing on CCA-treated surfaces. Cover picnic tables with a plastic coated (non-PVC) tablecloth; avoid contact of food and drink with CCA-treated wood. These precautions should be followed even if a protective coating has been applied to CCA treated wood (1,2).

Care must be used in the handling and maintenance of any CCA-treated wooden structures. For instance, burning CCA-treated wood will release arsenic into the air, and sanding or cutting CCA-treated wood will create toxic dust. Do not power wash or apply harsh cleaning products, such as bleach or acidic cleansers to CCA treated wood. Use a mild soap and water solution and disposable cleaning supplies. When disposing of items made of CCA-treated wood, they should be taken to a hazardous waste facility (1,2).
RATIONALE
The Consumer Product Safety Commission advises that arsenic exposure in children from contact with CCA-treated wood playground structures is estimated to be about 3.5 micrograms each day that includes a playground visit (3).The health effects related to arsenic include irritation of the stomach and intestines, birth or developmental effects, cancer, and infertility and miscarriages in women (1,3). Children can be exposed to the arsenic in CCA-treated wood by touching surfaces made from this material (3). Based on limited data, applying certain penetrating coatings may reduce the amount of arsenic that comes out of the wood (3).

The Safety Data Sheet (SDS) for every chemical product that the facility uses should be checked and available to anyone who uses or who might be exposed to the chemical in the child care facility to be sure that the chemical does not pose a risk to children and adults.
COMMENTS
CCA-treated wood is found extensively in outdoor structures, furniture, and play equipment built prior to December 31, 2003 when manufacturers of CCA reached a voluntary agreement with the Environmental Protection Agency (EPA) to end the manufacture of CCA-treated wood for most consumer applications. EPA has indicated that some stocks of wood treated with CCA before this date might have been found on shelves until mid-2004. If a wooden structure was built prior to December 31, 2003 and is not of a rot-resistant type of wood (e.g., redwood, cedar) it is safe to assume it does contain arsenic. If the date the equipment was built is unknown or was built shortly after December 31, 2003, test kits are available from many common retailers.

While available data are very limited, some studies suggest that applying certain penetrating coatings (e.g., oil-based, semi-transparent stains) on a regular basis may reduce the migration of wood preservative chemicals from CCA-treated wood (4). In selecting a finish, caregivers/teachers should be aware that, in some cases, “film-forming” or non-penetrating stains on outdoor surfaces such as decks and fences are not recommended, as subsequent peeling and flaking may ultimately have an impact on durability as well as exposure to the preservatives in the wood.

To eliminate the risk of children’s exposure to arsenic from CCA-treated wood it is recommended it be replaced. If this is not feasible, replacing the components children come in contact with the most (e.g., handrails, retaining walls) will limit their exposure.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.1.0.8 Enclosures for Outdoor Play Areas
6.2.1.1 Play Equipment Requirements
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
REFERENCES
  1. Children’s Environmental Health Network. (March 2016). Chromated Copper Arsenate (CCA). Retrieved from http://www.cehn.org/our-work/eco-healthy-child-care/ehcc-faqs/cca/.
  2. Gray, S., J. Houlihan. 2002. All hands on deck: Nationwide consumer testing of backyard decks and playsets shows high levels of arsenic on old wood. Washington, DC: Environmental Working Group. http://static.ewg.org/reports/2002/AllHandsOnDeck.pdf?_ga=1.104104071.62695211.145805821.
  3. U.S. Consumer Product Safety Commission (CPSC). Fact sheet: Chromated copper arsenate (CCA)-treated wood used in playground equipment. http://www.cpsc.gov/PageFiles/122137/270.pdf.
  4. U.S. Environmental Protection Agency. 2008. Chromated copper arsenate (CCA): Consumer advice related to CCA-treated wood. https://www.epa.gov/ingredients-used-pesticide-products/chromated-copper-arsenate-cca.
NOTES

Content in the STANDARD was modified on 8/25/2016.

 

5.2.9.13: Testing for Lead

Content in the STANDARD was modified on 08/15/2014.


In all centers, both exterior and interior surfaces covered by paint with lead levels of 0.009% or 90 ppm and above, and accessible to children, should be removed by a safe chemical or physical means or made inaccessible to children, regardless of the condition of the surface.

In large and small family child care homes, flaking or deteriorating lead-based paint on any surface accessible to children should be removed or abated according to health department regulations. Where lead paint is removed, the surface should be refinished with lead-free paint or nontoxic material. Sanding, scraping, or burning of lead-based paint surfaces should be prohibited. Children and pregnant women should not be present during lead renovation or lead abatement activities.

Any surface and the grounds around and under surfaces that children use at a child care facility, including dirt and grassy areas should be tested for excessive lead in a location designated by the health department. Caregivers/teachers should check the U.S. Consumer Product Safety Commission’s Website, http://www.cpsc.gov, for warnings of potential lead exposure to children and recalls of play equipment, toys, jewelry used for play, imported vinyl mini-blinds and food contact products. If they are found to have toxic levels, corrective action should be taken to prevent exposure to lead at the facility. Only nontoxic paints should be used.

RATIONALE
Ingestion of lead paint can result in high levels of lead in the blood, which affects the central nervous system and can cause mental retardation (2,3). Paint and other surface coating materials should comply with lead content provisions of the Code of Federal Regulations, Title 16, Part 1303.

Some imported vinyl mini-blinds contain lead and can deteriorate from exposure to sunlight and heat and form lead dust on the surface of the blinds (1). The U.S. Consumer Product Safety Commission (CPSC) recommends that consumers with children six years of age and younger remove old vinyl mini-blinds and replace them with new mini-blinds made without added lead or with alternative window coverings. See Comments for resources.

Lead is a neurotoxin. Even at low levels of exposure, lead can cause reduction in a child’s IQ and attention span, and result in reading and learning disabilities, hyperactivity, and behavioral difficulties. Lead poisoning has no “cure.” These effects cannot be reversed once the damage is done, affecting a child’s ability to learn, succeed in school, and function later in life. Other symptoms of low levels of lead in a child’s body are subtle behavioral changes, irritability, low appetite, weight loss, sleep disturbances, and shortened attention span (2,3).

COMMENTS
House paints made before 1978 may contain lead. If there is any doubt about the presence of lead in existing paint, contact the health department for information regarding testing. Lead is used to make paint last longer. The amount of lead in paint was reduced in 1950 and further reduced again in 1978. Houses built before 1950 likely contain lead paint, and houses built after 1950 have less lead in the paint. House paint sold today has little or no lead. Lead is prohibited in contemporary paints. Lead-based paint is the most common source of lead poisoning in children (3).

In buildings where lead has been removed from the surfaces, lead paint may have contaminated surrounding soil. Therefore, the soil in play areas around these buildings should be tested. Outdoor play equipment was commonly painted with lead-based paints, too. These structures and the soil around them should be checked if they are not known to be lead-free.

The danger from lead paint depends on:

  1. Amount of lead in the painted surface;
  2. Condition of the paint;
  3. Amount of lead (from paint, chips, soil, or dust) that gets into the child.

Children nine months through five years of age are at the greatest risk for lead poisoning. Most children with lead poisoning do not look or act sick. A blood lead test is the only way to know if children are being lead poisoned. Children should have a test result below 5 ug/dL (2,4).

A booklet called Protect Your Family from Lead in Your Home is available from the U.S. Environmental Protection Agency (EPA), the CPSC, and U.S. Department of Housing and Urban Development (HUD). The EPA also has a pamphlet called Finding a Qualified Lead Professional for Your Home, which provides information on how to identify qualified lead inspectors and risk assessors. Before starting a renovation project on a facility built before 1978, the contractor or property owner is required to have parents/guardians sign a pre-renovation disclosure form, which indicates that the parents/guardians received Renovate Right: Important Lead Hazard Information for Families, Child Care Providers, and Schools, available at http://www.epa.gov/lead/pubs/renovaterightbrochure.pdf. The contractor must also make renovation information available to the parents/guardians of children under age six that attend child care centers or homes, and provide to owners and administrators of pre-1978 child care facilities to be renovated a copy of Renovate Right: Important Lead Hazard Information for Families, Child Care Providers, and Schools (5).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.9.15 Construction and Remodeling
5.3.1.2 Product Recall Monitoring
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 1996. CPSC finds lead poisoning hazard for young children in imported vinyl miniblinds. http://www.cpsc.gov/CPSCPUB/PREREL/PRHTML96/96150.html.
  2. Advisory Committee on Childhood Lead Poisoning Prevention. 2012. Low level lead exposure harms children: A renewed call for primary prevention. Atlanta, GA: CDC. http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf.
  3. U.S. Environmental Protection Agency (EPA). 2010. The lead-safe certified guide to renovate right. Washington, DC: EPA. http://www.epa.gov/lead/pubs/renovaterightbrochure.pdf.
  4. Centers for Disease Control and Prevention (CDC). 2012. Announcement: Response to the advisory committee on childhood lead poisoning prevention report, low level lead exposure harms children: A renewed call for primary prevention. MMWR. Atlanta, GA: CDC. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6120a6.htm?s_cid=mm6120a6_e.
  5. U.S. Environmental Protection Agency. 2010. Lead in paint, dust, and soil: Renovation, repair and painting (RRP). http://www.epa.gov/lead/pubs/renovation.htm.
NOTES

Content in the STANDARD was modified on 08/15/2014.

5.2.9.14: Shoes in Infant Play Areas


Adults and children should remove or cover shoes before entering a play area used by a specific group of infants. These individuals, as well as the infants playing in that area, may wear shoes, shoe covers, or socks that are used only in the play area for that group of infants.
RATIONALE
When infants play, they touch the surfaces on which they play with their hands, and then put their hands in their mouths. Lead and other toxins in soil around a facility can be a hazard when tracked into a facility on shoes (1).
COMMENTS
Facilities can meet this standard in several ways. The facility can designate contained play surfaces for infant play on which no one walks with shoes. Individuals can wear shoes or slippers that are worn only to walk in the infant play area or they can wear clean cloth or disposable shoe covers over shoes that have been used to walk outside the infant play area.

This standard applies to shoes that have been worn outdoors, in the play areas of other groups of children, and in toilet and diaper changing areas. All of these locations are potential sources of contamination.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Environmental Protection Agency. 2009. Lead in paint, dust and soil: Basic information. http://www.epa.gov/lead/pubs/
    leadinfo.htm.

5.2.9.15: Construction and Remodeling

Content in the STANDARD was modified on 05/17/2016.


Construction, remodeling, painting, or alterations of structures during child care operations should be isolated from areas where children are present and done in a manner that will prevent hazards or unsafe conditions (such as fumes, dust, safety, and fire hazards).

Low volatile organic compounds (VOC) paints and materials should be used in child care areas. Painted areas should be ventilated until they are fully dry and odor-free before children are permitted to occupy them.

RATIONALE
Children should be protected from activities and equipment associated with construction and renovation of the facility that may cause injury or illness.

Volatile organic compounds (VOCs) are emitted as gases from certain solids or liquids. VOCs include a variety of chemicals, some of which may have short- and long-term adverse health effects. Some organic compounds can cause cancer in animals; some are suspected or known to cause cancer in humans. Key signs or symptoms associated with exposure to VOCs include eye irritation, nose and throat discomfort, headache, allergic skin reaction, difficulty breathing, nausea, vomiting, nose bleeds, fatigue, and dizziness (1).

COMMENTS
Ideally, construction and renovation work should be done when the facility is not in operation and when there are no children present. Many facilities arrange to schedule such work on weekends. If this is not possible, temporary barriers can be constructed to restrict access of children to those areas under construction. A plastic vapor barrier sheet could be temporarily hung to prevent dust and fumes from drifting into those areas where children are present. However, the minimum number of egress/escape paths should be maintained without compromise during the rehabilitation work.

Common renovation activities like sanding, cutting, and demolition can create hazardous lead dust and chips by disturbing lead-based paint, which can be harmful to adults and children. U.S. Environmental Protection Agency (EPA) regulations require persons performing renovation, repair, and painting activities in homes, child care facilities, and schools built before 1978 to give a renovation-specific lead hazard information pamphlet to the owners and occupants of the building. Persons performing these activities in child care facilities and schools must also provide general information about the renovation to the parents/guardians of children using the facility. The renovation-specific pamphlet, called The Lead-Safe Certified Guide to Renovate Right, is available at https://www.epa.gov/lead/lead-safe-certified-guide-renovate-right (2).

EPA regulations require training and certification of renovation contractors and building maintenance personnel performing renovation, repair and painting projects that disturb lead-based paint in homes, child care facilities, and schools built before 1978. They are required to follow specific work practices to prevent lead contamination. The EPA recommends that anyone performing renovation, repair, and painting projects in pre-1978 homes, child care facilities and schools follow lead-safe work practices, which include containing the work area to keep dust and debris inside the area, minimizing the creation of dust, and cleaning the work area thoroughly after the project has been completed.

The two most effective counter-measures against VOCs are to avoid VOC-emitting products and to ventilate areas when using VOC-emitting products. Caregivers/teachers can choose from many high quality latex-based paints that emit low levels of VOCs. Some major paint manufacturers offer special odorless VOC-free products (3).

When planning or beginning new construction, consideration should be given to using the least toxic or non-toxic materials.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.4 Radon Concentrations
5.2.9.13 Testing for Lead
5.3.1.4 Surfaces of Equipment, Furniture, Toys, and Play Materials
REFERENCES
  1. U.S. Environmental Protection Agency. 2010. An introduction to indoor air quality: Volatile organic compounds (VOCs). http://www.epa.gov/iaq/voc.html.
  2. U.S. Environmental Protection Agency (EPA). 2010. The lead-safe certified guide to renovate right. Washington, DC: EPA. http://www.epa.gov/lead/pubs/renovaterightbrochure.pdf.
  3. U.S. Environmental Protection Agenda (EPA). 2016. Information for child care providers about indoor air quality. Washington, D.C.: EPA. https://www.epa.gov/childcare/information-child-care-providers-about-indoor-air-quality
NOTES

Content in the STANDARD was modified on 05/17/2016.