Special Collection

Environmental Health in Early Care and Education

A Joint Collaborative Project of

American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1019

American Public Health Association
800 I Street, NW
Washinton, DC 20001-3710

National ResourceCenter for Health and Safety in
Child Care and Early Education
University of Colorado, College of Nursing
13120 E 19th Avenue
Aurora, CO 80045

Support for this project was provided by the
Maternal and Child Health Bureau,
Health Resources and Services Administration,
U.S. Department of Health and Human Services
(Cooperative Agreement #U46MC09810)

Special acknowledgement is given for the technical assistance provided by Eco-Healthy Child Care, a
program of the Children's Environmental Health Network.


Introduction

Caring for Our Children: Environmental Health in Early Care and Education (EH) is a collection of 123 nationally recognized health and safety standards that have the greatest impact on environmental health in early care and education settings. These standards and the associated 9 Appendices are a subset of materials available in Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs, 3rd Edition(CFOC3). CFOC3 is a nationally recognized best practice health and safety standards for the early care and education environment.

Another important subset of CFOC3 is Stepping Stones, 3rd Edition (SS3), which presents the 138 essential CFOC3 standards that, when put into practice, are most likely to prevent various adverse outcomes in early care and education settings. The S3s standards included in this collection are designated with an asterisk (*). These noted standards represent the most critical environmental health standards.

The purpose of this collection is to serve as a compilation of best practices for environmentally-healthy early care and education programs. In some cases, additional resources may be needed in order to meet the standard.

The Importance of Children's Environmental Health

Environmental health is the field that studies how substances or other environtmental factors have an impact on human health. The presence of naturally occurring and man-made chemicals in the air, water, food, pesticides, cleaning products, furniture, and buildings/homes is relevant to early care and education settings. Other important factors include pests, weather, allergens such as mold and fungi, and noise and lighting. All of these factors can impace human health.

Children live in an environment vastly different from previous generations. One of these changes is that every day, they are exposed to dozens, perhaps hundreds, of chemicals that did not exist 50 or 100 years ago. The extent of such exposures is relatively new. Currently, more than 80,000 chemicals are in use in the United States (1). For the majority of the thousands of new chamicals produced, little is known about their health effects on humans, especially their effects on children's developing systems (2).

These chemical exposures mean that traces of synthetic compounds are found in all humans and animals around the world (3). For example, a recent report from the Centers for Disease Control and Prevention (CDC) found Bishenol A (or BPA, a compound found in some plastics, the lining of food cans, children's bottles and cups, and many other items) in more than 90 percent of the U.S. population (4). Other research has found that BPA interferes with hormones and has been linked to a variety of harmful health effects (5).

We now know that what is safe for an adult may not be safe for a child (6). Children are vulnerable to harm from environmental toxins because of their developing systems and unique behaviors, for example their proximity to the floor, mouthing behaviors, and respiratory rate. The primary task of a developing fetus, infancy, and childhood is growth and development. If growth and development are hampered at any of these stages, the chances of a healthy adulhood dramatically decreases (7,8). For some chemicals, such as lead and mercury, we now know that exposure levels can interfere with growth and development, which can result in life-long harm to the child (9).

Because of this, children's vulnerability and emerging knowledge, science- and health-based organizations are increasingly recommending best practices to protect children from unnecessary chemical exposures. For example, in 2012 the American Academy of Pediatrics (AAP) issued a policy statement and technical report that urged minimizing children's exposures to pesticides (10). In the spring of 2014, AAP, the American Lung Association, and other health groups went on record recommending avoiding exposure to fragrances and other unnecessary chemicals as a best practice (11,12).

Every day, approximately 11 million children under the age of 5 in the U.S. attend early care and education programs (13). An average of 36 hours per week is spent in these programs (14). It is important for children for children to be in health and safe environments with caregivers/teachers who understand and follow basic environmental health and safety best practices.

Also, pregnant women and women who may become pregnant, a population represented in the ECE provider community, require specific consideration of their exposures to have confidene that their health is adequately protected.

This resource can be used by a variety of stakeholders to learn about and recognize the potential environmental hazards in the early care and education setting, and take action to remove or minimize these hazards. Taking these steps will help reduce health risks from environmental hazards in an early care and education settings.

Overview and Organization of Content


The intended audiences for this document are:


Standard Determination

'Environmental health' is a term with multiple definitions. One could identify the vast majority of CFOC3 standards as having the potential to influence the environment and environmental health of an early care and education setting. For the purposes of this compilation, it was determined to focus on those standards that addressed naturally occurring and man-made chemicals in the air, water, food, pesticides, cleaning products, furniture, buildings/homes, and other factors, including pests, weather, allergens such as mold and fungi, and noise and lighting.

Thus, one factor used in reviewing the standards for inclusion was to ask: 'If this standard was not followed, would the resulting harm be considered the result of an environmental health incident (e.g. a chemical or allergen exposure, noise level); a physical injury (e.g. a fall); or an infectious agent (bacteria, virus)?' Only those standards for which the answer would be 'an environmental health incident' were included.


There were numerous steps that determined the standards and material to be included in EH:

  1. The NRC staff searched the CFOC3 database (http://cfoc.nrckids.org/) for standards that included key terms such as 'chemical' and 'environmental' in all chapters of CFOC3 except Chapter 5.
  2. The Children's Environmental Health Network (CEHN)(http://www.cehn.org) staff searched the CFOC3 database and selected Chapter 5 standards for the collection and also added to the list provided by the NRC of applicable standrds from other chapters.
  3. The NRC staff then reviewed Stepping Stones, 3rd Edition (SS3) to determine if any of those standards not already included should be a part of EH.
  4. The list of standards was shared with the CFOC3 Chair of the Environmental Quality Technical Panel and the CFOC3 Steering Committee and they provided feedback.
  5. This feedback was incorporated into a draft document that included all introductory material and then shared with a group of reviewers, which included parents/guardians, early care and education providers, health care professionals, early childhood researchers, licensors and regulators, and representatives from national organizations for their feedback and recommendations.
  6. This feedback was then compiled by the NRC staff into a draft document sent to the CFOC3 Steering Committee for their final approval.

*** The full edition is available on the National Resource Center for Health and Safety in Child Care and Early Education (NRC) website at http://cfoc.nrckids.org/. Since publication (2011), several standards have been updated. Please consult the NRC website for the most current standard language. Print copies can be purchased from the American Academy of Pediatrics (http://www.aap.org) and the American Public Health Association (http://www.apha.org/publications/bookstore/.)


References

  1. American Academy of Pediatrics Council on Environmental Health. 2011. Policy Statement - Chemical-management policy: Prioritizing children's health. Pediatrics 127(5):983-90.
  2. Schaefer, M. 1994. Children and toxic substances: Confronting a major public health challenge. Environmental Health Perspectives 102(Supp 2):155-156.
  3. Colborn, T., Dumanosk, D., and Myers, J.P. 1996. Our Stolen Future. New York, NY: Dutton.
  4. Centers for Disease Control and Prevention. 2009. Fourth national report on human exposure to environmental chemicals. www.cdc.gov/exposurereport/.
  5. National Toxicology Program. 2008. NTP-CERHR Monograph on the potential human reproductive and developmental effects of Bisphenol A. NIH Publication No. 08-5994.
  6. Pronczuk-Garbino, J., Ed. World Health Organization. 2004. Children's health and the environment: A global perspective. http://whqlibdoc.who.int/publications/2005/9241562927_eng.pdf.
  7. Landigan, P.J., Carlson, J.E. 1995. Environmental policy and children's health. Critical Issues for Children and Youths 5(2):34-52.
  8. National Institute of Environmental Health Services. 2011. Child development and environmental toxins. https://www.niehs.nih.gov/health/assets/docs_a_e/child_development_and_environmental_toxins_508.pdf.
  9. National Scientific Council on the Developing Child. 2006. Early exposure to toxic substances damages brain architecture. http://developingchild.harvard.edu/index.php/activities/council/.
  10. American Academy of Pediatrics Council on Environmental Health. 2012. Policy statement: Pesticide exposure in children. Pediatrics 130(6):1757-63.
  11. Roberts, J.R., Karr, C.J., American Academy of Pediatrics Council on Environmental Health. 2012. Technical report: Pesticide exposure in children. Pediatrics 130(6):1765-88.
  12. American Academy of Pediatrics, American Lung Association, American Thoracic Society, Children's Environmental Health Network, and National Medical Association, letter to Gina McCarthy, U.S. EPA Administrator, March 13, 2014. http://www.cehn.org/files/Design%20for%20Environment%20letter%20201403.pdf.
  13. Child Care Aware © of America. 2014. About child care. http://www.naccrra.org/about-child-care.
  14. Child Care Aware © of America. 2013. Parents and the high cost of child care 2013. http://usa.childcareaware.org/sites/default/files/Cost%20of%20Care%202013%20110613.pdf.

Resources

As with all areas in health, new research comes forth and we recommend that users continue to visit the following web sites for the most up-to-date information on environmental health:

Air Quality Index
American Academy of Pediatrics (AAP) Council on Environmental Health
American Public Health Association (APHA) Environmental and Occupational Health
Art & Creative Materials Institute
Center for Environmental Research & Children's Health (CERCH)
Children's Environmental Health Network (CEHN) Eco-Healthy Child Care ®
Centers for Disease Control and Prevention
Agency for Toxic Substances and Disease Registry
Styrene
Children's Health and the Built Environment
Environmental Working Group (EWG)
Green Cleaning, Sanitizing, and Disinfecting: A Toolkit for Early Care and Education
Leadership in Energy and Environmental Design (LEED)
Making Child Care Centers SAFER; A Non-Regulatory Approach to Improving Child Care Center Sitting
Midwest Pesticide Action Center Resource Guide for Integrated Pest Management in Schools/ Childcares
Pediatric Environmental Health Specialty Initys (PEHSU)
U.S. Consumer Product Safety Commission (CPSC)
U.S. Department of Agriculture
Farm to Child Care
U.S. Environmental Protection Agency (EPA)
Air Cleaners
America's Children and the Environment, 3rd Edition (ACE3)
Art Supplies: Teacher's Classroom Checklist
Asbestos
Fish Consumption Advisories
What You Need to Know about Mercury in Fish and Shellfish
Healthy Child Care
Lead
Mercury
Plastics
Radon
Reduce, Reuse, and Recycle
Water: Consumer Information

For questions or assistence on these standards or CFOC3, please contact:
National Resource for Health and Safety in Child Care and Early Education (NRC)
Toll-free Hotline: 1-844-401-4040
Email: info@nrckids.org
Website: http://nrckids.org

Acknowledgements

The American Academy of Pediatrics (AAP), the American Public Health Association (APHA), and the National Resource Center for Health and Safety in Child Care and Early Education (NRC) would like to acknowledge the outstanding contributions of all persons and organizations involved in the creation of: Caring for Our Children: Environmental Health in Early Care and Education (EH).

This collection was inspired by CFOC3's comprehensive approach to environmental health, which includes new and expanded standards addressing this vital topic. The development of EH was supported in part by technical assistance from the Children's Environmental Health Network (CEHN).

Twenty individuals, representing seventeen organizations, reviewed and validated the chosen standards. This broad collaboration and review from the best minds in the field has led to a comprehensive and useful tool. We would like to acknowledge those individuals and those whose names may have been omitted. Our sincere appreciation goes to all of our collegues who willingly gave their time and expertise to the development of this resource.


CFOC3 Steering Committee

Danette Swanson Glassy, MD, FAAP
Co-Chair, American Academy of Pediatrics
Mercer Island, WA

Brian Johnston, MD, MPH
Co-Chair, American Public Health Association
Seattle, WA

Marilyn J. Krajicek, EdD, RN, RAAN
Director, National Resource Center for Health and Safety in Child Care and Early Education
Aurora, CO

Barbara U. Hamilton, MA
Project Officer, U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau
Rockville, MD


National Resource Center for Health and Safety in Child Care and Early Education Project Team

Marilyn Krajicek, EdD, RN, FAAN - Director

Jean M. Cimino, MPH - CFOC3 Content Manager

Betty Geer, MSN, RN, CPNP - Healthcare Professional

Doug Chapman, BS - Information Technologist

Sue Purcell, MA - Project Specialist

Linda Satkowiak, ND, RN, CNS, NCSN - Child Care Health and Safety Nurse Consultant

Gerri Steinke, PhD - Evaluator

Lorina Washington, BA - Administrative Assistant


Children's Environmental Health Network Project Team

Carol Stroebel - Director of Training and Policy

Hester Paul, MS - Director of Eco-Healthy Child Care



Organizational and Stakeholder Reviewers

Nancy Alleman, BSN, RN, CPNP, SCN
American Academy of Pediatrics ECELS - Healthy Child Care PA
Media, PA

Ally Beasley, MPH
United States Environmental Protection Agency Office of Children's Health Protection
Washington, D.C.

Asa Bradman, PhD, MS

Center for Environmental Research and Children's Health (CERCH), School of Public Health, UC Berkeley
Berkeley, CA

Steven B. Eng, MPH, CIPHI(C), Frasier Health
Port Moody, British Colombia, Canada

Jennifer Grauer, parent
Denver, CO

Gwendolyn N. Hudson, PhD, MPH, CPH
U.S. Public Health Service FDA, Center for Food Safety and Applied Nutrition Office of Compliance
College Park, MD

Sara Sroka Kihn, MS, RN, NCSN
Children's Hospital Colorado
Aurora, CO

Mira Killmeyer, MBA
Great Heights Preschool
Denver, CO

Vickie Leonard, RN, NP, PhD
Pediatric Environmental Health Specialty Unit, University of Colorado
San Francisco, CA

Ada Otter, DNP, ARNP, FNP-BC
Northwest Pediatric Environmental Health Specialty Unity
Seattle WA

Jeannie Reardon, MPH Leadership, BS
NC Child Care Health and Safety Resource Center, UNC Gillings School of Global Public Health
Raleigh, NC

Karen Riley, RN BSN
Caring 4 Kids Nurse Consulting, LLC
Thornton, CO

Carley Schneider, BS
Family Star Monessori School
Denver, CO

Tarah S. Somers, RN, MSN/MPH
Agency for Toxic Substances and Disease Registry, Region 1 (New England) Office
Boston, MA

Libby Ungvary, Med
American Academy of Pediatrics ECELS - Healthy Child Care PA
Media, PA

Table of Contents

I. Staffing and Training

1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.4.1.1 Pre-service Training
1.4.2.3 Orientation Topics
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
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.5.0.2 Orientation of Substitutes
1.6.0.1 Child Care Health Consultants
1.7.0.4 Occupational Hazards

II. Program Activities for Healthy Development

2.1.1.3 Coordinated Child Care Health Program Model
2.4.2.1 Health and Safety Education Topics for Staff
2.4.3.2 Parent/Guardian Education Plan

III. Health Promotion and Protection

3.1.3.2 Playing Outdoors
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
3.2.2.2 Handwashing Procedure
3.2.2.5 Hand Sanitizers
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.3.2 Labeling, Storage, and Disposal of Medications

IV. Nutrition and Food Service

4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.9 Warming Bottles and Infant Foods
4.5.0.2 Tableware and Feeding Utensils
4.8.0.7 Ventilation Over Cooking Surfaces
4.8.0.8 Microwave Ovens
4.9.0.13 Method for Washing Dishes by Hand

V. Facilities, Supplies, and Equipment

A. Location, Layout, and Construction

5.1.1.2 Inspection of Buildings
5.1.1.5 Environmental Audit of Site Location
5.1.1.6 Structurally Sound Facility
5.1.1.7 Use of Basements and Below Grade Areas
5.1.1.9 Unrelated Business in a Child Care Area
5.1.1.11 Separation of Operations from Child Care Areas
5.1.3.1 Weather-Tightness and Water-Tightness of Openings

B. Quality of Outdoor and Indoor Equipment

5.1.3.3 Screens for Ventilation Openings
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.1.2 Indoor Temperature and Humidity
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
5.2.1.4 Ventilation When Using Art Materials
5.2.1.5 Ventilation of Recently Carpeted or Paneled Areas
5.2.1.6 Ventilation to Control Odors
5.2.1.8 Maintenance of Air Filters
5.2.1.9 Type and Placement of Room Thermometers
5.2.1.10 Gas, Oil, or Kerosene Heaters, Generators, Portable Gas Stoves, and Charcoal and Gas Grills
5.2.1.12 Fireplaces, Fireplace Inserts, and Wood/Corn Pellet Stoves
5.2.1.15 Maintenance of Humidifiers and Dehumidifiers
5.2.2.1 Levels of Illumination
5.2.2.3 High Intensity Discharge Lamps, Multi-Vapor, and Mercury Lamps
5.2.3.1 Noise Levels
5.2.5.1 Smoke Detection Systems and Smoke Alarms
5.2.6.1 Water Supply
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.6.4 Water Test Results
5.2.6.5 Emergency Safe Drinking Water and Bottled Water
5.2.6.6 Water Handling and Treatment Equipment
5.2.6.7 Cross-Connections
5.2.7.1 On-Site Sewage Systems
5.2.7.2 Removal of Garbage
5.2.7.3 Containment of Garbage
5.2.7.6 Storage and Disposal of Infectious and Toxic Wastes
5.2.8.1 Integrated Pest Management
5.2.8.2 Insect Breeding Hazard
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.2 Use of a Poison Center
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.2.9.7 Proper Use of Art and Craft Materials
5.2.9.8 Use of Play Dough and Other Manipulative Art or Sensory Materials
5.2.9.9 Plastic Containers and Toys
5.2.9.10 Prohibition of Poisonous Plants
5.2.9.11 Chemicals Used to Control Odors
5.2.9.12 Treatment of CCA Pressure-Treated Wood
5.2.9.13 Testing for Lead
5.2.9.14 Shoes in Infant Play Areas
5.2.9.15 Construction and Remodeling

C. General Furnishings/Equipment and Maintenance

5.3.1.1 Safety of Equipment, Materials, and Furnishings
5.3.1.4 Surfaces of Equipment, Furniture, Toys, and Play Materials
5.3.1.6 Floors, Walls, and Ceilings
5.4.1.5 Chemical Toilets
5.4.2.6 Maintenance of Changing Tables
5.5.0.5 Storage of Flammable Materials
5.6.0.4 Microfiber Cloths, Rags, and Disposable Towels and Mops Used for Cleaning
5.7.0.1 Maintenance of Exterior Surfaces
5.7.0.2 Removal of Hazards From Outdoor Areas
5.7.0.3 Removal of Allergen Triggering Materials From Outdoor Areas
5.7.0.5 Cleaning Schedule for Exterior Areas
5.7.0.6 Storage Area Maintenance and Ventilation
5.7.0.7 Structure Maintenance
5.7.0.10 Cleaning of Humidifiers and Related Equipment

VI. Play Areas/Playgrounds

6.1.0.1 Size and Location of Outdoor Play Area
6.1.0.2 Size and Requirements of Indoor Play Area
6.1.0.7 Shading of Play Area
6.1.0.8 Enclosures for Outdoor Play Areas
6.2.1.1 Play Equipment Requirements
6.2.1.8 Material Defects and Edges on Play Equipment
6.2.4.1 Sandboxes
6.2.4.2 Water Play Tables
6.2.4.3 Sensory Table Materials
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.1 Pool Water Quality
6.3.4.2 Chlorine Pucks
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

VII. Administration

9.2.1.1 Content of Policies
9.2.3.10 Sanitation Policies and Procedures
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy
9.4.1.2 Maintenance of Records
9.4.1.6 Availability of Documents to Parents/Guardians

VIII. Licensing and Community Action

10.3.5.1 Education, Experience and Training of Licensing Inspectors
10.5.0.1 State and Local Health Department Role
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

Appendices

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix D: Gloving
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix L: Cleaning Up Body Fluids
Appendix S: Physical Activity: How Much Is Needed?
Appendix Y: Non-Poisonous and Poisonous Plants
Appendix P: Situations that Require Medical Attention Right Away

I. Staffing and Training

Standard 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
8.7.0.3 Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
REFERENCES
  1. 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.
  2. Centers for Disease Control and Prevention (CDC). 2011. Immunization schedules. http://www.cdc.gov/vaccines/recs/schedules/.
  3. 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.
  4. 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.
  5. 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.
  6. Ulione, M. S. 1997. Health promotion and injury prevention in a child development center. J Pediatr Nurs 12:148-54.

Standard 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
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
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy
9.4.3.3 Training Record
REFERENCES
  1. 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.
  2. 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).
  3. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
  4. Hayney M. S., J. C. Bartell. 2005. An immunization education program for childcare providers. J of School Health 75:147-49.
  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.

Standard 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. Centers for Disease Control and Prevention (CDC). 2016. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
  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. 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.

Standard 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
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
3.5.0.2 Caring for Children Who Require Medical Procedures
3.6.3.1 Medication Administration
9.4.3.3 Training Record
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
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. Crowley, A. A. 1990. Health services in child care day care centers: A survey. J Pediatr Health Care 4:252-59.
  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.
  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. 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.

Standard 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. 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.
  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. 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.

Standard 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.

Standard 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
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
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
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

Standard 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. Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81.
  2. 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.
  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 Nurs 32:530-37.
  4. Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health consultation: A conceptual model. J for Specialists in Pediatric Nurs 13:74-88.
  5. Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
  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. Farrer, J., A. Alkon, K. To. 2007. Child care health consultation programs: Barriers and opportunities. Maternal Child Health J 11:111-18.
  8. 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.
  9. Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
  10. Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21.
  11. 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.

Standard 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.

II. Program Activities for Healthy Development

Standard 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. 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. 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.
  3. Coordinated Health/Care. Maximize your benefits: FAQs about care coordination. https://www.cchcare.com/router
    .php?action=about.
  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. 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.
  6. Centers for Disease Control and Prevention. 2008. Healthy youth! Coordinates school health programs. http://www.cdc.gov/healthyyouth/CSHP/.

Standard 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
1.4.2.3 Orientation Topics
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
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.6.0.1 Child Care Health Consultants
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
1.4.3.1 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
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
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
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
9.4.1.19 Community Resource Information
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
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
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
REFERENCES
  1. 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
  2. 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.
  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. 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.
  5.  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.
NOTES

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

 

Standard 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
9.4.1.19 Community Resource Information
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
REFERENCES
  1. 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.      
  2. 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
  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.

 

III. Health Promotion and Protection

Standard 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

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. 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

  4. KidsHealth from Nemours. Heat illness. http://kidshealth.org/en/parents/heat.html. Reviewed February 2014. Accessed January 11, 2018

  5. 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

  6. 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

  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.

Standard 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. Lerodiakonou, D. (2016). Ambient air pollution, lung function, and airway responsiveness in asthmatic children. The Journal of Allergy and Clinical Immunology. 137(2), 390.
  2. 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.
NOTES

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

 

Standard 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. Early Childhood Education Linkage System. Healthy Child Care Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster.
  2. 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.

  3. 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
  4. National Association for the Education of Young Children. 2012. Healthy Young Children, A Manual for Programs. Fifth edition. Editor. Susan Aronson Washington, DC. 
  5. Children’s Environmental Health Network. 2016. Household chemicals. http://www.cehn.org/wp-content/uploads/Household_chemicals_1_16.pdf.
NOTES

Content in the STANDARD was modified on 1/2012, 7/2012, 5/13/2013 and on 8/23/2016.

Standard 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, perform hand hygiene, and gather and bring supplies to the changing area.

  1. Non-absorbent paper liner large enough to cover the changing surface;
  2. Unused pull-up or underwear, 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, including underwear, or pull-ups;
  5. Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or pull-ups) and remove them before handling clean pull-ups or underwear and clothing.

Step 2: Avoid contact with soiled items.

  1. If the child is standing, it may cause the clothing, shoes and socks to become soiled. The caregiver/teacher must remove these items before the change begins;
  2. To avoid contaminating the child’s clothes, have the child hold their shirt, sweater, etc. up above their waist during the change. This keeps the child’s hands busy and the caregiver/teacher knows where the child’s hands are during the changing process. Caregivers/teachers can also use plastic clothes pins that can be washed and sanitized to keep the clothing out of the way;
  3. If disposable pull-ups were used, pull the sides apart, rather than sliding the garment down the child’s legs. If underwear is being changed, remove the soiled underwear and any soiled clothing, doing your best to avoid contamination of surfaces;
  4. To avoid contamination of the environment and/or the increased risk of spreading germs to the other children in the room, do not rinse the soiled clothing in the toilet or elsewhere. Place all soiled garments in a plastic-lined, hands-free plastic bag to be cleaned at the child’s home;
  5. If the child’s shoes are soiled, the caregiver/teacher must wash and sanitize them before putting them back on the child. It is a good idea for the child care facility to request a few extra pair of socks and shoes from the parent/caregiver to be kept at the facility in case these items become soiled (1).

Step 3: Clean the child’s skin and check for spills.

  1. 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. Remove stool and urine from front to back and use a fresh wipe, dampened cloth or wet paper towel each time you swipe. Put the soiled wipes or paper towels into the soiled pull-up 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;
  2. Check for spills under the child. If there are any, use the paper that extends beyond or under the child's feet to fold over the soiled area so a fresh, unsoiled paper surface is now under the child;
  3. If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can;
  4. 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 4: Put on a clean pull-up or underwear and clothing, if necessary.

  1. Assist the child, as needed, in putting on a clean disposable pull-up or underwear, then in re-dressing (1);
  2. Note and plan to report any skin problems such as redness, skin cracks, or bleeding;
  3. Put the child’s socks and shoes back on if they were removed during the changing procedure (1).

Step 5: 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 6: Clean and disinfect the changing surface.

  1. Dispose of the disposable paper liner used on the 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 7: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the change in the child’s daily log.

  1. In the daily log, record what was in the pull-up or underwear and any problems (such as a loose stool, an unusual odor, blood in the stool, or any skin irritation), and report as necessary (3).

RATIONALE
Children who are learning to use the toilet may still wet/soil their pull-ups or underwear and clothing. Changing these undergarments can lead to risk for spreading infection due to the contamination of surfaces from urine or feces (1). The procedure for changing a child’s soiled undergarment and clothing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (4,5). 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 changing.

Commonly, caregivers/teachers do not use disposable paper that is large enough to cover the area likely to be contaminated during 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 changing, and the child kicks during the changing procedure, the foot coverings can become contaminated and subsequently spread contamination throughout the child care area.

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 changing area (the area of the child’s body covered by the soiled pull-ups or underwear) during the changing process and can then transfer fecal organisms to the environment. Washing the child’s hands will reduce the number or organisms carried into the environment in this way. Infectious organisms are present on the skin and pull-ups or underwear 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 pull-up or underwear and the clothing.

Some states and credentialing organizations may recommend wearing gloves for 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 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 pull-up or underwear. 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 changing. Cleaning and disinfecting a strap would be required after every change. Therefore safety straps on 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 change) (6).

Changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils.

COMMENTS
Children with disabilities may require diapering and the method of diapering will vary according to their abilities. However, principles of hygiene should be consistent regardless of method. Toddlers and preschool age children without physical disabilities frequently have toileting issues as well. These soiling/wetting episodes can be due to rapid onset gastroenteritis, distraction due to the intensity of their play, and emotional disruption secondary to new transition. These include new siblings, stress in the family, or anxiety about changing classrooms or programs, all of which are based on their inability to recognize and articulate their stress and to manage a variety of impulses.

Development is not a straight trajectory, but rather a cycle of forward and backward steps as children gain mastery over their bodies in a wide variety of situations. It is normal and developmentally appropriate for children to revert to immature behaviors as they gain developmental milestones while simultaneously dealing with immediate struggles which they are internalizing. Even for preschool and kindergarten aged children, these accidents happen and these incidents are called ‘accidents’ because of the frequency of these episodes among normally developing children. It is important for caregivers/teachers to recognize that the need to assist young children with toileting is a critical part of their work and that their attitude regarding the incident and their support of children as they work toward self-regulation of their bodies is a component of teaching young children.
 

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
2.1.2.5 Toilet Learning/Training
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. 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.
  4. 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.

  5. Early Childhood Education Linkage Systems. Healthy Child Care Pennsylvania. 2016. Changing soiled underwear. http://www.ecels-healthychildcarepa.org/publications/fact-sheets/item/116-changing-soiled-underwear?highlight=WyJzb2lsZWQiXQ.
  6. Early Childhood Education Linkage System. Healthy Child Care Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster.
NOTES

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, and 8/23/2016.

Standard 3.2.2.2: Handwashing Procedure

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.2.2

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.2.2: Handwashing Procedure

Question:
This standard recommends that children and staff members rub their hands with a soapy lather for at least 20 seconds. Why was this changed from 10 seconds?

Answer:
This recommendation follows the recommendation of the Centers for Disease Control (CDC). This reference can be found at: http://www.cdc.gov/handwashing/.

Content in the STANDARD was modified on 8/9/2017.

 

Children and staff members should wash their hands using the following method:
 

  1. Check to be sure a clean, disposable paper (or single-use cloth) towel is available;
  2. Turn on clean, running water to a comfortable temperature (1);
  3. Moisten hands with water and apply soap (not antibacterial) to hands;
  4. Rub hands together vigorously until a soapy lather appears, hands are out of the water stream, and continue for at least twenty seconds (sing Happy Birthday silently twice) (2). Rub areas between fingers, around nail beds, under fingernails, jewelry, and back of hands. Nails should be kept short; acrylic nails should not be worn (3);
  5. Rinse hands under clean, running water that is at a comfortable temperature until they are free of soap and dirt. Leave the water running while drying hands;
  6. Dry hands with the clean, disposable paper or single use cloth towel;
  7. If taps do not shut off automatically, turn taps off with a disposable paper or single use cloth towel;
  8. Throw the disposable paper towel into a lined trash container; or place single-use cloth towels in the laundry hamper; or hang individually labeled cloth towels to dry. Use hand lotion to prevent chapping of hands, if desired.

The use of alcohol based hand sanitizers is an alternative to traditional handwashing (with soap and water) if soap and water is not available and if hands are not visibly dirty (4,5). A single pump of an alcohol-based sanitizer should be dispensed. Hands should be rubbed together, distributing sanitizer to all hand and finger surfaces and hands should be permitted to air dry. Alcohol based hand sanitizer dispensers should be kept out of reach of children, and active supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes (6).

Situations/times that children and staff should wash their hands should be posted in all handwashing areas.

Use of antimicrobial soap is not recommended in child care settings. There are no data to support use of antibacterial soaps over other liquid soaps.

Children and staff who need to open a door to leave a bathroom or diaper changing area should open the door with a disposable towel to avoid possibly re-contaminating clean hands. If a child can not open the door or turn off the faucet, they should be assisted by an adult.

RATIONALE
Running clean water over the hands removes visible soil. Wetting the hands before applying soap helps to create a lather that can loosen soil. The soap lather loosens soil and brings it into solution on the surface of the skin. Rinsing the lather off into a sink removes the soil from the hands that the soap brought into solution. Acceptable forms of soap include liquid and powder.
 
Alcohol-based hand sanitizers do not kill norovirus and spore-forming organisms which are common causes of diarrhea in child care settings (4). This is sufficient reason to limit or even avoid the use of hand sanitizers with infants and toddlers (children less than 2 years of age) because they are the age group at greatest risk of spreading diarrheal disease due to frequent diaper changing. Hand washing is the preferred method. However, while hand sanitizers are not recommended for children under the age of 2, they are not prohibited.
 
COMMENTS

Pre-moistened cleansing towelettes do not effectively clean hands and should not be used as a substitute for washing hands with soap and running water. When running water is unavailable or impractical, the use of alcohol-based hand sanitizer (Standard 3.2.2.5) is a suitable alternative.

Outbreaks of disease have been linked to shared wash water and wash basins (7). Water basins should not be used as an alternative to running water. Camp sinks and portable commercial sinks with foot or hand pumps dispense water as for a plumbed sink and are satisfactory if filled with fresh water daily. The staff should clean and disinfect the water reservoir container and water catch basin daily.

Single-use towels should be used unless an automatic electric hand-dryer is available.

The use of cloth roller towels is not recommended because children often use cloth roll dispensers improperly, resulting in more than one child using the same section of towel.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
5.4.1.10 Handwashing Sinks
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Ogunsola FT, Adesiji YO. Comparison of four methods of hand washing in situations of inadequate water supply. West Afr J Med. 2008(27):24-28.
  2. Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5.
  3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Show me the science-When and how to use hand sanitizer. CDC.gov Web site. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Updated July 13, 2017. Accessed October 23, 2017.
  4. American Academy of Pediatrics. Managing infectious diseases in child care and schools: A quick reference guide. Aronson SS, Shope TR, eds. 2017.  4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
  5. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. MMWR. 2002;51(RR16).
  6. American Academy of Pediatrics. Children in out-of-home child care. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 30th ed. Red Book: 2015 Report of the Committee on Infectious Diseases.  30th Ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.
  7. Centers for Disease Control and Prevention. Handwashing: Clean hands save lives. CDC.gov Web site. http://www.cdc.gov/handwashing/. Updated September 27, 2017. Accessed October 23, 2017.
NOTES

Content in the STANDARD was modified on 8/9/2017.

 

Standard 3.2.2.5: Hand Sanitizers

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.2.5

Date: 10/13/2011

Topic & Location:
Chapter 3
Standard 3.2.2.5: Hand Sanitizers

Question:
Is there evidence to address the flammability risk of hand sanitizers and the recommended countermeasures with this product?

Answer:
Hand sanitizers are flammable as noted on product labels. Standard 5.5.0.5: Storage of Flammable Materials was updated in the 2nd printing of CFOC3 to address that hand sanitizers in volume should be stored in a separate building, in a locked area, away from high temperatures and ignition sources, and inaccessible to children.

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.

 

The use of hand sanitizers by children and adults in child care programs is an appropriate alternative to the use of traditional handwashing if soap and water is not available and if hands are not visibly dirty (1,2).
 
Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of hand sanitizers with eyes and mucous membranes (3).
The technique for using hand sanitizers is:

Hand sanitizers using an alcohol-based active ingredient must contain 60% to 95% alcohol to be effective in killing most germs including multi-drug resistant pathogens. Child care programs should follow the manufacturer’s instructions for use, check instructions to determine how much product and how long the hand sanitizer needs to remain on the skin surface to be effective.
 
Where alcohol-based hand sanitizer dispensers are used:
  1. The maximum individual dispenser fluid capacity should be as follows:
  2. 0.32 gal (1.2 L) for dispensers in individual rooms, corridors, and areas open to corridors;
  3. 0.53 gal (2.0 L) for dispensers in suites of rooms;
  4. Where aerosol containers are used, the maximum capacity of the aerosol dispenser should be 18 oz. (0.51 kg) and should be limited to Level 1 aerosols as defined in NFPA 30B: Code for the Manufacture and Storage of Aerosol Products;
  5. Wall mounted dispensers should be separated from each other by horizontal spacing of not less than 48 in. (1,220 mm);
  6. Wall mounted dispensers should not be installed above or adjacent to ignition sources such as electrical outlets;
  7. Wall mounted dispensers installed directly over carpeted floors should be permitted only in child care facilities protected by automatic sprinklers (5).
When alcohol based hand sanitizers are offered in a child care facility, the facility should encourage parents/guardians to teach their children about their use at home.

RATIONALE
Studies have demonstrated that using an alcohol-based hand sanitizer after washing hands with soap and water is effective in reducing illness transmission in the home, in child care centers and in health care settings (6-8).
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately (5).

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount (1,3,4). 
COMMENTS
Even in health care settings, the Centers for Disease Control and Prevention (CDC) guidelines recommend washing hands that are visibly soiled or contaminated with organic material with soap and water as an adjunct to the use of alcohol-based sanitizers (6).
 
While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms) (1). These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene.

Some hand sanitizing products contain non-alcohol and “natural” ingredients. The efficacy of non-alcohol containing hand sanitizers is variable and therefore a non-alcohol-based product is not recommended for use.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.2.2 Handwashing Procedure
3.2.2.1 Situations that Require Hand Hygiene
5.5.0.5 Storage of Flammable Materials
REFERENCES
  1. ADDITIONAL REFERENCE:
     
    American Association of Poison Control Centers. 2016. Hand sanitizer. http://www.aapcc.org/alerts/hand-sanitizer/
  2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Handwashing: Clean hands save lives!  http://www.cdc.gov/handwashing/.
  3. Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. Comparing hand washing to hand sanitizers in reducing elementary school students’ absenteeism. Pediatric Nurs 33:368-72.
  4. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Summaries of Infectious Diseases. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
  6. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5.
  7. Centers for Disease Control and Prevention. When & how to wash your hands. 2015. https://www.cdc.gov/handwashing/when-how-handwashing.html
  8. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html.
  9. 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.
NOTES

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.

 

Standard 3.2.3.4: Prevention of Exposure to Blood and Body Fluids

Child care facilities should adopt the use of Standard Precautions developed for use in hospitals by The Centers for Disease Control and Prevention (CDC). Standard Precautions should be used to handle potential exposure to blood, including blood-containing body fluids and tissue discharges, and to handle other potentially infectious fluids.

In child care settings:

  1. Use of disposable gloves is optional unless blood or blood containing body fluids may contact hands. Gloves are not required for feeding human milk, cleaning up of spills of human milk, or for diapering;
  2. Gowns and masks are not required;
  3. Barriers to prevent contact with body fluids include moisture-resistant disposable diaper table paper, disposable gloves, and eye protection.

Caregivers/teachers are required to be educated regarding Standard Precautions to prevent transmission of bloodborne pathogens before beginning to work in the facility and at least annually thereafter. Training must comply with requirements of the Occupational Safety and Health Administration (OSHA).

Procedures for Standard Precautions should include:

  1. Surfaces that may come in contact with potentially infectious body fluids must be disposable or of a material that can be disinfected. Use of materials that can be sterilized is not required.
  2. The staff should use barriers and techniques that:
    1. Minimize potential contact of mucous membranes or openings in skin to blood or other potentially infectious body fluids and tissue discharges; and
    2. Reduce the spread of infectious material within the child care facility. Such techniques include avoiding touching surfaces with potentially contaminated materials unless those surfaces are disinfected before further contact occurs with them by other objects or individuals.
  3. When spills of body fluids, urine, feces, blood, saliva, nasal discharge, eye discharge, injury or tissue discharges occur, these spills should be cleaned up immediately, and further managed as follows:
    1. For spills of vomit, urine, and feces, all floors, walls, bathrooms, tabletops, toys, furnishings and play equipment, kitchen counter tops, and diaper-changing tables in contact should be cleaned and disinfected as for the procedure for diaper changing tables in Standard 3.2.1.4, Step 7;
    2. For spills of blood or other potentially infectious body fluids, including injury and tissue discharges, the area should be cleaned and disinfected. Care should be taken and eye protection used to avoid splashing any contaminated materials onto any mucus membrane (eyes, nose, mouth);
    3. Blood-contaminated material and diapers should be disposed of in a plastic bag with a secure tie;
    4. Floors, rugs, and carpeting that have been contaminated by body fluids should be cleaned by blotting to remove the fluid as quickly as possible, then disinfected by spot-cleaning with a detergent-disinfectant. Additional cleaning by shampooing or steam cleaning the contaminated surface may be necessary. Caregivers/teachers should consult with local health departments for additional guidance on cleaning contaminated floors, rugs, and carpeting.

Prior to using a disinfectant, clean the surface with a detergent and rinse well with water. Facilities should follow the manufacturer’s instruction for preparation and use of disinfectant (3,4). For guidance on disinfectants, refer to Appendix J, Selecting an Appropriate Sanitizer or Disinfectant.

If blood or bodily fluids enter a mucous membrane (eyes, nose, mouth) the following procedure should occur. Flush the exposed area thoroughly with water. The goal of washing or flushing is to reduce the amount of the pathogen to which an exposed individual has contact. The optimal length of time for washing or flushing an exposed area is not known. Standard practice for managing mucous membrane(s) exposures to toxic substances is to flush the affected area for at least fifteen to twenty minutes. In the absence of data to support the effectiveness of shorter periods of flushing it seems prudent to use the same fifteen to twenty minute standard following exposure to bloodborne pathogens (5).

RATIONALE
Some children and adults may unknowingly be infected with HIV or other infectious agents, such as hepatitis B virus, as these agents may be present in blood or body fluids. Thus, the staff in all facilities should adopt Standard Precautions for all blood spills. Bacteria and viruses carried in the blood, such as hepatitis B, pose a small but specific risk in the child care setting (3). Blood and body fluids containing blood (such as watery discharges from injuries) pose a potential risk, because bloody body fluids contain the highest concentration of viruses. In addition, hepatitis B virus can survive in a dried state in the environment for at least a week and perhaps even longer. Some other body fluids such as saliva contaminated with blood or blood-associated fluids may contain live virus (such as hepatitis B virus) but at lower concentrations than are found in blood itself. Other body fluids, including urine and feces, do not pose a risk for bloodborne infections unless they are visibly contaminated with blood, although these fluids may pose a risk for transmission of other infectious diseases.

Touching a contaminated object or surface may spread illnesses. Many types of infectious germs may be contained in human waste (urine, feces) and body fluids (saliva, nasal discharge, tissue and injury discharges, eye discharges, blood, and vomit). Because many infected people carry infectious diseases without having symptoms, and many are contagious before they experience a symptom, staff members need to protect themselves and the children they serve by adhering to Standard Precautions for all activities.

Gloves have proven to be effective in preventing transmission of many infectious diseases to health care workers. Gloves are used mainly when people knowingly contact or suspect they may contact blood or blood-containing body fluids, including blood-containing tissue or injury discharges. These fluids may contain the viruses that transmit HIV, hepatitis B, and hepatitis C. While human milk can be contaminated with blood from a cracked nipple, the risk of transmission of infection to caregivers/teachers who are feeding expressed human milk is almost negligible and this represents a theoretical risk. Wearing of gloves to feed or clean up spills of expressed human milk is unnecessary, but caregivers/teachers should avoid getting expressed human milk on their hands, if they have any open skin or sores on their hands. If caregivers/teachers have open wounds they should be protected by waterproof bandages or disposable gloves.

Cleaning and disinfecting rugs and carpeting that have been contaminated by body fluids is challenging. Extracting as much of the contaminating material as possible before it penetrates the surface to lower layers helps to minimize this challenge. Cleaning and disinfecting the surface without damaging it requires use of special cleaning agents designed for use on rugs, or steam cleaning (3). Therefore, alternatives to the use of carpeting and rugs are favored in the child care environment.

COMMENTS
The sanctions for failing to comply with OSHA requirements can be costly, both in fines and in health consequences. Regional offices of OSHA are listed at http://www.epa.gov/aboutepa/index.html#regional/ and in the telephone directory with other federal offices.

Either single-use disposable gloves or utility gloves should be used when disinfecting. Single-use disposable gloves should be used only once and then discarded immediately without being handled. If utility gloves are used, they should be cleaned after every use with soap and water and then dipped in disinfectant solution up to the wrist. The gloves should then be allowed to air dry. The wearing of gloves does not prevent contamination of hands or of surfaces touched with contaminated gloved hands. Hand hygiene and sanitizing of contaminated surfaces is required when gloves are used.

Ongoing exposures to latex may result in allergic reactions in both the individual wearing the latex glove and the individual who contacts the latex glove. Reports of such reactions have increased (1).

Caregivers/teachers should take the following steps to protect themselves, children, volunteers, and visitors from latex exposure and allergy in the workplace (6):

  1. Use non-latex gloves for activities that are not likely to involve contact with infectious materials (food preparation, diapering, routine housekeeping, general maintenance, etc.);
  2. Use appropriate barrier protection when handling infectious materials. Avoid using latex gloves BUT if latex gloves are chosen, use powder-free gloves with reduced protein content;
    1. Such gloves reduce exposures to latex protein and thus reduce the risk of latex allergy;
    2. Hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex (allergic contact dermatitis);
  3. Use appropriate work practices to reduce the chance of reactions to latex;
  4. When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration);
  5. After removing latex gloves, wash hands with a mild soap and dry thoroughly;
  6. Practice good housekeeping, frequently clean areas and equipment contaminated with latex-containing dust;
  7. Attend all latex allergy training provided by the facility and become familiar with procedures for preventing latex allergy;
  8. Learn to recognize the symptoms of latex allergy: skin rash; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock.

Natural fingernails that are long or wearing artificial fingernails or extenders is not recommended. Child care facilities should develop an organizational policy on the wearing of non-natural nails by staff (2).

For more information on safety with blood and body fluids, consult Healthy Child Care Pennsylvania’s “Keeping Safe When Touching Blood or Other Body Fluids” at http://www.ecels-healthychildcarepa.org/content/Keeping Safe 07-27-10.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.4 Diaper Changing Procedure
7.6.1.3 Staff Education on Prevention of Bloodborne Diseases
Appendix D: Gloving
Appendix L: Cleaning Up Body Fluids
REFERENCES
  1. Email communication from Amy V. Kindrick, MD, MPH, Senior Consultant, National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline), UCSF School of Medicine at San Francisco General Hospital to Elisabeth L.M. Miller, BSN, RN, BC, PA Chapter American Academy of Pediatrics, Early Childhood Education Linkage System – Healthy Child Care Pennsylvania. November 11, 2009.
  2. Rutala, W. A., D. J. Weber, HICPAC. 2008. Guideline for disinfection and sterilization in healthcare facilities. Center for Disease Control and Prevention. https://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.
  3. Kotch, J. B., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics 120: e29-e36.
  4. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/Isolation/Isolation2007.pdf
  5. De Queiroz, M., S. Combet, J. Berard, A. Pouyau, H. Genest, P. Mouriquand, D. Chassard. 2009. Latex allergy in children: Modalities and prevention. Pediatric Anesthesia 19:313-19.
  6. American Latex Allergy Association. Creating a safe school for latex-sensitive children. 1996-2016. http://latexallergyresources.org/articles/web-article-creating-safe-school-latex-sensitive-children

Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting

Keeping objects and surfaces in a child care setting as clean and free of pathogens as possible requires a combination of:

  1. Frequent cleaning; and
  2. When necessary, an application of a sanitizer or disinfectant.

Facilities should follow a routine schedule of cleaning, sanitizing, and disinfecting as outlined in Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting.

Cleaning, sanitizing and disinfecting products should not be used in close proximity to children, and adequate ventilation should be maintained during any cleaning, sanitizing or disinfecting procedure to prevent children and caregivers/teachers from inhaling potentially toxic fumes.

RATIONALE
Young children sneeze, cough, drool, use diapers and are just learning to use the toilet. They hug, kiss, and touch everything and put objects in their mouths. Illnesses may be spread in a variety of ways, such as by coughing, sneezing, direct skin-to-skin contact, or touching a contaminated object or surface. Respiratory tract secretions that can contain viruses (including respiratory syncytial virus and rhinovirus) contaminate environmental surfaces and may present an opportunity for infection by contact (1-3).
COMMENTS
The terms cleaning, sanitizing and disinfecting are sometimes used interchangeably which can lead to confusion and result in cleaning procedures that are not effective (4).

For example, if there is visible soil on a diaper changing or table surface, clean it with detergent and water before spraying the surface with a sanitizer or disinfectant. Using a sanitizer or disinfectant as this “first step” is not effective because the purpose of the solution is to either sanitize or disinfect. Each term has a specific purpose and there are many methods that may be used to achieve such purpose.

Task

Purpose

Clean

To remove dirt and debris by scrubbing and washing with a detergent solution and rinsing with water. The friction of cleaning removes most germs and exposes any remaining germs to the effects of a sanitizer or disinfectant used later.

Sanitize

To reduce germs on inanimate surfaces to levels considered safe by public health codes or regulations.

Disinfect

To destroy or inactivate most germs on any inanimate object, but not bacterial spores.

Note: The term “germs” refers to bacteria, viruses, fungi and molds that may cause infectious disease. Bacterial spores are dormant bacteria that have formed a protective shell, enabling them to survive extreme conditions for years. The spores reactivate after entry into a host (such as a person), where conditions are favorable for them to live and reproduce (5).

Only U.S. Environmental Protection Agency (EPA)-registered products that have an EPA registration number on the label can make public health claims that can be relied on for reducing or destroying germs. The EPA registration label will also describe the product as a cleaner, sanitizer, or disinfectant. In addition, some manufacturers of cleaning products have developed "green cleaning products". As new environmentally-friendly cleaning products appear in the market, check to see if they are 3rd party certified by Green Seal: http://www.greenseal.org, UL/EcoLogic: http://www.ecologo.org, and/or EPA's Safer Choice: http://www.epa.gov/saferchoice. Use fragrance-free bleach that is EPA-registered as a sanitizing or disinfecting solution (6). If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA-registered (7). All products must be used accordining to manufacturer's instructions. The following resource may be useful: Green Cleaning, Sanitizing, and Disinfecting: A Toolkit for Early Care and Education

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, cleaning, sanitizing and disinfecting supplies in use in the facility. The SDS explain the risk of exposure to products so that appropriate precautions may be taken.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
5.2.1.6 Ventilation to Control Odors
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Butz, A. M., P. Fosarelli, D. Dick, et al. 1993. Prevalence of rotavirus on high-risk fomites in day-care facilities. Pediatrics 92:202-5.
  2. Thompson, S. C. 1994. Infectious diarrhoea in children: Controlling transmission in the child care setting. J Paediatric Child Health 30:210-19.
  3. Children’s Environmental Health Network 2016. Household chemicals.   http://cehn.org/wp-content/uploads/2015/12/Household_chemicals_1_16.pdf.
  4. Children’s Environmental Health Network Fragrances. Retrieved from: http://www.cehn.org/our-work/eco-healthy-child-care/ehcc-faqs/fragrances/.
  5. U.S. Centers for Disease Control and Prevention. 2014. How to clean and disinfect schools to help slow the spread of flu. http://www.cdc.gov/flu/school/cleaning.htm Microbiology Procedure. Sporulation in bacteria. http://www.microbiologyprocedure.com/microorganisms/sporulation-in-bacteria.htm.
  6. D. Leduc, eds. 2015. Well beings: A guide to health in child care. 3rd ed. (revised) Ottawa, Ontario: Canadian Paediatric Society.

Standard 3.4.1.1: Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.4.1.1

Date: 11/7/2012

Topic & Location:
Chapter 3
Health Promotion
Standard 3.4.1.1: Use of Tobacco, Alcohol, and Illegal Drugs

Question:
Should child care providers and other adults who have contact with children be allowed to smoke electronic cigarettes in the presence of children?

Answer:

Electronic cigarettes, also known as e-cigarettes, are a fairly new alternative to traditional smoking cigarettes. E-cigarettes are battery-operated products designed to deliver nicotine, flavor and other chemicals. They turn nicotine, which is highly addictive, and other chemicals into a vapor that is inhaled by the user (U.S. FDA, 2012).

Currently, the research on the safety of this product is limited. However, the use of e-cigarettes would fall into the same category tobacco, alcohol, and illegal drugs products that are prohibited from being used on the premises of the program (both indoor and outdoor environments) and in any vehicles used by the program at all times. Additionally, children model adult behavior. Cigarette smoking in any form is not a healthy behavior.

U.S. FDA, 2013 article

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

 

The use of tobacco, electronic cigarettes (e-cigarettes), alcohol, and drugs should be prohibited on the premises of the program (both indoor and outdoor environments), during work hours including breaks, and in any vehicles used by the program at all times. Caregivers/teachers should be prohibited from wearing clothing that smells of smoke when working or volunteering. The use of legal drugs (e.g. marijuana, prescribed narcotics, etc.) that have side effects that diminish the ability to property supervise and care for children or safely drive program vehicles should also be prohibited. 

RATIONALE
Scientific evidence has linked respiratory health risks to secondhand smoke. No children, especially those with respiratory problems, should be exposed to additional risk from the air they breathe. Infants and young children exposed to secondhand smoke are at risk of severe asthma; developing bronchitis, pneumonia, and middle ear infections when they experience common respiratory infections; and Sudden Infant Death Syndrome (SIDS) (1-6). Separation of smokers and nonsmokers within the same air space does not eliminate or minimize exposure of nonsmokers to secondhand smoke. Tobacco smoke contamination lingers after a cigarette is extinguished and children come in contact with the toxins (7). Thirdhand smoke exposure also presents hazards. Thirdhand smoke refers to gases and particles clinging to smokers’ hair and clothing, cushions and carpeting, and outdoor equipment, after tobacco smoke has dissipated (8). The residue includes heavy metals, carcinogens and radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or playing on the floor. Residual toxins from smoking at times when the children are not using the space can trigger asthma and allergies when the children do use the space (2,3).

Cigarettes and materials used to light them also present a risk of burn or fire. In fact, cigarettes used by adults are the leading cause of ignition of fatal house fires (9).

Alcohol use, illegal and legal drug use, and misuse of prescription or over-the-counter (OTC) drugs prevent caregivers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and response time. Safe child care necessitates alert, unimpaired caregivers/teachers.

The use of alcoholic beverages and legal drugs in family child care homes after children are not in care is not prohibited, but these items should be safely stored at all times.

COMMENTS
The age, defenselessness, and dependence upon the judgment of caregivers/teachers of the children under care make this prohibition an absolute requirement.

As more states move toward legalizing marijuana use for recreational and/or medicinal purposes, it is important for caregivers/teachers to be aware of the impact marijuana used medicinally and/or recreationally has on their ability to provide safe care. Staff modeling of healthy and safe behavior at all times is essential to the care and education of young children. 
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.1 Use and Storage of Toxic Substances
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
REFERENCES
  1. ADDITIONAL REFERENCES:

    Centers for Disease Control and Prevention. 2009. Facts: Preventing residential fire injuries. http://www.cdc.gov/injury/pdfs/Fires2009CDCFactSheet-FINAL-a.pdf
     
    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/.
     
    Children’s Hospital Colorado. 2016. Acute marijuana intoxication. https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/acute-marijuana-intoxication/.
  2. 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
  3. Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, M. F. Hovell, R. C. McMillen. 2009. Beliefs about the health effects of “thirdhand” smoke and home smoking bans. Pediatrics 123: e74-e79.
  4. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf.
  5. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf
  6. Schwartz, J., K. L. Timonen, J. Pekkanen. 2000. Respiratory effects of environmental tobacco smoke in a panel study of asthmatic and symptomatic children. Am J Resp Crit Care Med 161:802-6.
  7. U.S. Department of Health and Human Services. 2007. Children and secondhand smoke exposure. Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
  8. American Academy of Pediatrics. Healthychildren.org. 2015. The dangers of secondhand smoke. https://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/Dangers-of-Secondhand-Smoke.aspx
  9. Centers for Disease Control and Prevention. 2016. Health effects of secondhand smoke. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/
  10. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommenations for a safe infant sleeping environment. Pediatrics. 2016;138(6):e20162938.
    http://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938
NOTES

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

 

Standard 3.4.5.1: Sun Safety Including Sunscreen

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.4.5.1

Date: 2/17/2012

Topic & Location:
Chapter 3
Health Promotion
3.4.5.1: Sun Safety Including Sunscreen

Question:
Why does this standard state that sunscreen should be applied thirty minutes before going outdoors, but the AAP reference listed on page 127 states that sunscreen should be applied 15-30 minutes before going outside?

Answer:
The recommendation of how many minutes prior to going outside sunscreen should be applied was revised from 30 minutes to 15-30 minutes on January 30, 2012, which was after the publication of CFOC, 3rd Edition.

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

Caregivers/teachers should implement the following procedures to ensure sun safety for themselves and the children under their supervision:

  1. Keep infants younger than six months out of direct sunlight. Find shade under a tree, umbrella, or the stroller canopy;
  2. Wear a hat or cap with a brim that faces forward to shield the face;
  3. Limit sun exposure between 10 AM and 4 PM, when UV rays are strongest;
  4. Wear child safe shatter resistant sunglasses with at least 99% UV protection;
  5. Apply sunscreen (1).

Over-the-counter ointments and creams, such as sunscreen that are used for preventive purposes do not require a written authorization from a primary care provider with prescriptive authority. However, parent/guardian written permission is required, and all label instructions must be followed. If the skin is broken or an allergic reaction is observed, caregivers/teachers should discontinue use and notify the parent/guardian.

If parents/guardians give permission, sunscreen should be applied on all exposed areas, especially the face (avoiding the eye area), nose, ears, feet, and hands and rubbed in well especially from May through September. Sunscreen is needed on cloudy days and in the winter at high altitudes. Sun reflects off water, snow, sand, and concrete. “Broad spectrum” sunscreen will screen out both UVB and UVA rays. Use sunscreen with an SPF of 15 or higher, the higher the SPF the more UVB protection offered. UVA protection is designated by a star rating system, with four stars the highest allowed in an over-the-counter product.

Sunscreen should be applied thirty minutes before going outdoors as it needs time to absorb into the skin. If the children will be out for more than one hour, sunscreen will need to be reapplied every two hours as it can wear off. If children are playing in water, reapplication will be needed more frequently. Children should also be protected from the sun by using shade and sun protective clothing. Sun exposure should be limited between the hours of 10 AM and 4 PM when the sun’s rays are the strongest.

Sunscreen should be applied to the child at least once by the parents/guardians and the child observed for a reaction to the sunscreen prior to its use in child care.

RATIONALE
Sun exposure from ultraviolet rays (UVA and UVB) causes visible and invisible damage to skin cells. Visible damage consists of freckles early in life. Invisible damage to skin cells adds up over time creating age spots, wrinkles, and even skin cancer (2,4).

Exposure to UV light is highest near the equator, at high altitudes, during midday (10 AM to 4 PM), and where light is reflected off water or snow (5).

COMMENTS
Protective clothing must be worn for infants younger than six months. For infants older than six months, apply sunscreen to all exposed areas of the body, but be careful to keep away from the eyes (3). If an infant rubs sunscreen into her/his eyes, wipe the eyes and hands clean with a damp cloth. Unscented sunblocks or sunscreen with titanium dioxide or zinc oxide are generally safer for children and less likely to cause irritation problems (6). If a rash develops, have parents/guardians talk with the child’s primary care provider (1).

Sunscreen needs to be applied every two hours because it wears off after swimming, sweating, or just from absorbing into the skin (1).

There is a theoretical concern that daily sunscreen use will lower vitamin D levels. UV radiation from sun exposure causes the important first step in converting vitamin D in the skin into a usable form for the body. Current medical research on this topic is not definitive, but there does not appear to be a link between daily normal sunscreen use and lower vitamin D levels (7). This is probably because the vitamin D conversion can still occur with sunscreen use at lower levels of UV exposure, before the skin becomes pink or tan. However, vitamin D levels can be influenced significantly by amount of sun exposure, time of the day, amount of protective clothing, skin color and geographic location (8). These factors make it difficult to apply a safe sunscreen policy for all settings. A health consultant may assist the program develop a local sunscreen policy that may differ from above if there is a significant public health concern regarding low vitamin D levels.

EPA provides specific UV Index information by City Name, Zip Code or by State, to view go to http://www.epa.gov/sunwise/uvindex.html.

A good resource for reading materials for young children and parents/guardians can be found at Healthy Child Care Pennsylvania’s Self Learning Module “Sun Safety” at http://www.ecels-healthychildcarepa.org/content/Sun Safey SLM 6-23-10 v5%20.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.3.1 Medication Administration
6.1.0.7 Shading of Play Area
REFERENCES
  1. Misra, M., D. Pacaud, A. Petryk, P. F. Collett-Solberg, M. Kappy. 2008. Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics 122:398-417.
  2. Norval, M., H. C. Wulf. 2009. Does chronic sunscreen use reduce vitamin D production to insufficient levels? British J Dermatology 161:732-36.
  3. Yan, X. S., G. Riccardi, M. Meola, A. Tashjian, J. SaNogueira, T. Schultz. 2008. A tear-free, SPF50 sunscreen product. Cutan Ocul Toxicol 27:231-39.
  4. Weinberg, N., M. Weinberg, S. Maloney. Traveling safely with infants and children. Medic8. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-7-international-travel-infants-children/traveling-safely-with-infants-and-children.
  5. Maguire-Eisen, M., K, Rothman, M. F. Demierre. 2005. The ABCs of sun protection for children. Dermatology Nurs 17:419-22,431-33.
  6. Kenfield, S., A. Geller, E. Richter, S. Shuman, D. O’Riordan, H. Koh, G. Colditz. 2005. Sun protection policies and practices at child care centers in Massachusetts. J Comm Health 30:491-503.
  7. American Academy of Dermatology. 2010. Skin, hair and nail care: Protecting skin from the sun. Kids Skin Health.http://www.kidsskinhealth.org/grownups/skin_habits_sun.html.
  8. American Academy of Pediatrics. 2008. Sun safety. http://www.healthychildren.org/english/safety-prevention/at-play/pages/Sun-Safety.aspx.
NOTES

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

Standard 3.4.5.2: Insect Repellent and Protection from Vector-Borne Diseases

Content in the STANDARD was modified on 4/5/2017.

 

Most insects do not carry human disease and most insect bites only cause mild irritation. Insect repellents may be used with children older than 2 months in child care where there are specific disease outbreaks and alerts. As with all pesticides, care should be taken to limit children’s exposure to insect repellents (1). Caregivers/teachers should consult with a child care health consultant, the primary care provider, or the local health department about the appropriate use of repellents based on the likelihood that local insects are carrying potentially dangerous diseases (e.g., local cases of meningitis from mosquito bites). This information should be shared with parents/guardians, and collective decisions made about use.
Insect repellent requires the written permission of parents/guardians and label instructions must be followed. It does not require written permission from a primary care provider.

Repellents containing DEET
Repellents with 10%-30% DEET offer the broadest protection against mosquitoes, ticks, flies, chiggers, and fleas. Caregivers/teachers should read product labels and confirm that the product is 1) safe for children and 2) contains no more than 30% DEET. Most product labels for registrations containing DEET recommend consultation with a physician if applying to a child less than six months of age.
The use of DEET should reflect how much time the child will be exposed to biting insects (2):

Other Types of Insect Repellents
Picaridin and IR3535 are other products registered at the Environmental Protection Agency (EPA) identified as providing repellent activity sufficient to help people avoid the bites of disease carrying mosquitoes (4). Para-menthane-diol (PMD) or pil of lemon eucalyptus products, according to their product labels, should NOT be used on children under three years of age (4,5).

General Guidelines for Use of Insect Repellents with Children
As noted above, insect repellents may be applied to children older than two months. In addition to consulting label instructions, teachers/caregivers may follow these guidelines:
a.    Apply insect repellent to the caregiver/teacher’s hands first.
b.    When applying insect repellent on a child, use just enough to cover exposed skin.
c.    Do not apply under clothing.
d.    Do not use on children’s hands.
e.    Avoid applying to areas around the eyes and mouth.
f.     Do not use over cuts or irritated skin.
g.    Do not use near food.
h.    After returning indoors, wash treated skin immediately with soap and water.
i.     Caregivers/teachers should wash their hands after applying insect repellent to the children in the group.
j.     If the child gets a rash or other skin reaction from an insect repellent, stop using the repellent, wash the repellent off with mild soap and water, and call a local poison center (1-800-222-1222) for further guidance (4). If repellent is used on broken skin or an allergic reaction is observed, discontinue use and notify the parent/guardian.
 
Protection from ticks
In places where ticks are likely to be found (6), caregivers/teachers should take the following steps to protect children in their care from ticks:
 
a.    Remove leaf litter and clear tall grasses and brush around homes and buildings and at the edges of lawns;
b.    Place wood chips or gravel between lawns and wooded areas to restrict tick migration to recreational areas;
c.    Mow the lawn and clear brush and leaf litter frequently;
d.    Keep playground equipment, decks, and patios away from yard edges and trees;
e.    Ensure that children wear light colored clothing, long sleeves and pants, tuck pants into socks; and
f.     Conduct tick checks of children when returning indoors (7).

How to Remove a Tick (8):
It is important to remove the tick as soon as possible. Use the following steps:
a.   If possible, clean the area with an antiseptic solution or soap and water. Take care not to scrub the tick too hard. Just clean the skin around it;
b.   Use blunt, fine tipped tweezers or gloved fingers to grasp the tick as close to the skin as possible;
c.   Pull slowly and steadily upwards to allow the tick to release;
d.   If the tick’s head breaks off in the skin, use tweezers to remove it like you would a splinter;
e.   Wash the area around the bite with soap;
f.    Following the removal of the tick, wash your hands, the tweezers, and the area thoroughly with soap and warm water.

Take care not to do the following:
a.    Do not use sharp tweezers.
b.    Do not crush, puncture, or squeeze the tick’s body.
c.    Do not use a twisting or jerking motion to remove the tick.
d.    Do not handle the tick with bare hands.
e.    Do not try to make the tick let go by holding a hot match or cigarette close to it.
f.     Do not try to smother the tick by covering it with petroleum jelly or nail polish.

RATIONALE
Mosquitoes and ticks can carry pathogens that may cause serious diseases (i.e., vector-borne diseases such as West Nile virus and Lyme disease) (7).
Zika is a mosquito-borne virus that usually causes mild illness that lasts from several days to a week. The mosquito that spreads Zika virus is found everywhere in the world including the United States. Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects (9). Information and recommendations regarding Zika are rapidly evolving. Please visit the Centers for Disease Control and Prevention (CDC) Zika updates page for the most recent information: http://www.cdc.gov/zika/index.html (9). 
COMMENTS
Insect repellents should be EPA-registered and labeled as approved for use in the child’s age range.
Aerosol sprays are not recommended. Pump sprays are a better choice. Regardless of the type of spray used, caregivers/teachers should spray the insect repellent into her/his hand and then apply to the child. It is not recommended to directly spray the child with the insect repellent to prevent unintentional injury to eyes and mouth. Preschool children, toddlers, and infants should not apply insect repellent to themselves. School age children can apply insect repellent to themselves if they are supervised to make sure that they are applying it correctly.
Parents/guardians should be notified when insect repellent is applied to their child since it is recommended that treated skin is washed with soap and water.
If a product gets in the eyes, flush with water and consult the poison center at 1-800-222-1222.
Several resources are available on reducing exposure to ticks and mosquitoes based on habits, protective attire, and insect repellent use. The following resources offer detailed information on preventing exposure to ticks and mosquitoes in early care and education settings:
1. Integrated Pest Management: Mosquitoes: http://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/ipm_mosquitoes.pdf
2. CCHP IPM Handout for Family Child Care Homes: Mosquitoes: http://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/Mosquitoes_FCCH_IPM.pdf
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.5.1 Sun Safety Including Sunscreen
3.2.2.1 Situations that Require Hand Hygiene
5.2.8.1 Integrated Pest Management
REFERENCES
  1. ADDITIONAL REFERENCE:

    U.S. Environmental Protection Agency. 2016. Find the insect repellent that is right for you. https://www.epa.gov/insect-repellents/find-insect-repellent-right-you.
     
  2. Centers for Disease Control and Prevention. 2016. About zika. https://www.cdc.gov/zika/about/index.html
  3. Centers for Disease Control and Prevention. 2015. Tick removal. https://www.cdc.gov/ticks/removing_a_tick.html
  4. Centers for Disease Control and Prevention. 2015. Geographic distribution of ticks that bite humans. https://www.cdc.gov/ticks/geographic_distribution.html
  5. Centers for Disease Control and Prevention. 2016. Avoid bug bites. https://wwwnc.cdc.gov/travel/page/avoid-bug-bites
  6. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2015. West nile virus: Insect repellent use and safety. http://www.cdc.gov/westnile/faq/repellent.html.
  7. Center for Disease Control and Prevention. 2015. Chapter 2 - Protection against mosquitos, ticks, & other anthropods. https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/sun-exposure
  8. National Pesticide Information Center. 2015. Pesticides and children. http://npic.orst.edu/health/child.html
  9. 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.
  10. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2010. Lyme disease: Protect yourself from tick bites.http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld_Prevention_Avoid.htm.
NOTES

Content in the STANDARD was modified on 4/5/2017.

 

Standard 3.5.0.1: Care Plan for Children with Special Health Care Needs

Reader’s Note: Children with special health care needs are defined as “...those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” (1).

Any child who meets these criteria should have a Routine and Emergent Care Plan completed by their primary care provider in their medical home. In addition to the information specified in Standard 9.4.2.4 for the Health Report, there should be:

  1. A list of the child’s diagnosis/diagnoses;
  2. Contact information for the primary care provider and any relevant sub-specialists (i.e., endocrinologists, oncologists, etc.);
  3. Medications to be administered on a scheduled basis;
  4. Medications to be administered on an emergent basis with clearly stated parameters, signs, and symptoms that warrant giving the medication written in lay language;
  5. Procedures to be performed;
  6. Allergies;
  7. Dietary modifications required for the health of the child;
  8. Activity modifications;
  9. Environmental modifications;
  10. Stimulus that initiates or precipitates a reaction or series of reactions (triggers) to avoid;
  11. Symptoms for caregiver/teachers to observe;
  12. Behavioral modifications;
  13. Emergency response plans – both if the child has a medical emergency and special factors to consider in programmatic emergency, like a fire;
  14. Suggested special skills training and education for staff.

A template for a Care Plan for children with special health care needs is provided in Appendix O.

The Care Plan should be updated after every hospitalization or significant change in health status of the child. The Care Plan is completed by the primary care provider in the medical home with input from parents/guardians, and it is implemented in the child care setting. The child care health consultant should be involved to assure adequate information, training, and monitoring is available for child care staff.

RATIONALE
Children with special health care needs could have a variety of different problems ranging from asthma, diabetes, cerebral palsy, bleeding disorders, metabolic problems, cystic fibrosis, sickle cell disease, seizure disorder, sensory disorders, autism, severe allergy, immune deficiencies, or many other conditions (2). Some of these conditions require daily treatments and some only require observation for signs of impending illness and ability to respond in a timely manner (3).
COMMENTS
A collaborative approach in which the primary care provider and the parent/guardian complete the Care Plan and the parent/guardian works with the child care staff to implement the plan is helpful. Although it is usually the primary care provider in the medical home completing the Care Plan, sometimes management is shared by specialists, nurse practitioners, and case managers, especially with conditions such as diabetes or sickle cell disease.

Child care health consultants are very helpful in assisting in implementing Care Plans and in providing or finding training resources. The child care health consultant may help in creating the care plan, through developing a draft and/or facilitate the primary care provider to provide specific directives to follow within the child care environment. The child care health consultant should write out directives into a “user friendly” language document for caregivers/teachers and/or staff to implement with ease.

Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (4). Confidentiality should be maintained at each step in compliance with any laws or regulations that are pertinent to all parties such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Insurance Portability and Accountability Act (commonly known as HIPAA) (4).

For additional information on care plans and approaches for the most prevalent chronic diseases in child care see the following resources:

Asthma: How Asthma-Friendly Is Your Child-Care Setting? at http://www.nhlbi.nih.gov/health/public/lung/asthma/chc_chk.htm;

Autism: Learn the Signs/ACT Early at http://www.cdc.gov/ncbddd/autism/actearly/;

Food Allergies: Guides for School, Childcare, and Camp at http://www.foodallergy.org/section/guidelines1/;

Diabetes: “Diabetes Care in the School and Day Care Setting” at http://care.diabetesjournals.org/content/29/suppl_1/s49.full;

Seizures: Seizure Disorders in the ECE Setting at http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/
SeizuresEN032707_adr.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.3.1 Medication Administration
4.2.0.10 Care for Children with Food Allergies
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.
  2. American Association of Nurse Anesthetists. 2003. Creating a latex-safe school for latex-sensitive children. http://www
    .anesthesiapatientsafety.com/patients/latex/school.asp.
  3. U.S. Department of Health and Human Services, Health Resources and Services Administration. The national survey of children with special health care needs: Chartbook 2005-2006. http://mchb.hrsa.gov/cshcn05/.
  4. McPherson, M., P. Arango, H. Fox, C. Lauver, M. McManus, P. Newacheck, J. Perrin, J. Shonkoff, B. Strickland. 1998. A new definition of children with special health care needs. Pediatrics 102:137-40.

Standard 3.6.1.3: Thermometers for Taking Human Temperatures

Digital thermometers should be used with infants and young children when there is a concern for fever. Tympanic (ear) thermometers may be used with children four months and older. However, while a tympanic thermometer gives quick results, it needs to be placed correctly in the child’s ear to be accurate.

Glass or mercury thermometers should not be used. Mercury containing thermometers and any waste created from the cleanup of a broken thermometer should be disposed of at a household hazardous waste collection facility.

Rectal temperatures should be taken only by persons with specific health training in performing this procedure. Oral (under the tongue) temperatures can be used for children over age four. Individual plastic covers should be used on oral or rectal thermometers with each use or thermometers should be cleaned and sanitized after each use according to the manufacturer’s instructions. Axillary (under the arm) temperatures are less accurate, but are a good option for infants and young children when the caregiver/teacher has not been trained to take a rectal temperature.

RATIONALE
When using tympanic thermometers, too much earwax can cause the reading to be incorrect. Tympanic thermometers may fail to detect a fever that is actually present (1). Therefore, tympanic thermometers should not be used in children under four months of age, where fever detection is most important.

Mercury thermometers can break and result in mercury toxicity that can lead to neurologic injury. To prevent mercury toxicity, the American Academy of Pediatrics (AAP) encourages the removal of mercury thermometers from homes. This includes all child care settings as well (1).

Although not a hazard, temporal thermometers are not as accurate as digital thermometers (2).

COMMENTS
The site where a child’s temperature is taken (rectal, oral, axillary, or tympanic) should be documented along with the temperature reading and the time the temperature was taken, because different sites give different results and affect interpretation of temperature.

More information about taking temperatures can be found on the AAP Website http://www.healthychildren.org/English/health-issues/conditions/fever/pages/How-to-Take-a
-Childs-Temperature.aspx.

Safety and child abuse concerns may arise when using rectal thermometers. Caregivers/teachers should be aware of these concerns. If rectal temperatures are taken, steps must be taken to ensure that all caregivers/teachers are trained properly in this procedure and the opportunity for abuse is negligible (for example, ensure that more than one adult present during procedure). Rectal temperatures should be taken only by persons with specific health training in performing this procedure and permission given by parents/guardians.

Many state or local agencies operate facilities that collect used mercury thermometers. Typically, the service is free. For more information on household hazardous waste collections in your area, call your State environmental protection agency or your local health department.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Dodd, S. R., G. A. Lancaster, J. V. Craig, R. L. Smyth, P. R. Williamson. 2006. In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity. J Clin Epidemiol 59:354-57.
  2. Healthy Children. 2010. Health issues: How to take a child’s temperature. American Academy of Pediatrics. http://www.healthychildren.org/English/health-issues/conditions/fever/pages/How-to-Take-a-Childs-Temperature.aspx.

Standard 3.6.3.2: Labeling, Storage, and Disposal of Medications

Any prescription medication should be dated and kept in the original container. The container should be labeled by a pharmacist with:

Over-the-counter medications should be kept in the original container as sold by the manufacturer, labeled by the parent/guardian, with the child’s name and specific instructions given by the child’s prescribing health professional for administration.

All medications, refrigerated or unrefrigerated, should:

Medication should not be used beyond the date of expiration. Unused medications should be returned to the parent/guardian for disposal. In the event medication cannot be returned to the parent or guardian, it should be disposed of according to the recommendations of the US Food and Drug Administration (FDA) (1). Documentation should be kept with the child care facility of all disposed medications. The current guidelines are as follows:

  1. If a medication lists any specific instructions on how to dispose of it, follow those directions.
  2. If there are community drug take back programs, participate in those.
  3. Remove medications from their original containers and put them in a sealable bag. Mix medications with an undesirable substance such as used coffee grounds or kitty litter. Throw the mixture into the regular trash. Make sure children do not have access to the trash (1).

RATIONALE
Child-resistant safety packaging has been shown to significantly decrease poison exposure incidents in young children (1).

Proper disposal of medications is important to help ensure a healthy environment for children in our communities. There is growing evidence that throwing out or flushing medications into our sewer systems may have harmful effects on the environment (1-3).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.3.1 Medication Administration
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
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. U.S. Environmental Protection Agency. 2009. Pharmaceuticals and personal care products as pollutants (PPCPs). http://www.epa
    .gov/ppcp/.
  3. U.S. Food and Drug Administration. 2010. Disposal by flushing of certain unused medicines: What you should know. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
    EnsuringSafeUseofMedicine/SafeDisposalofMedicines/
    ucm186187.htm.

IV. Nutrition and Food Service

Standard 4.2.0.11: Ingestion of Substances that Do Not Provide Nutrition

Content in this standard was modified on August 23, 2016 and November 10, 2017.

All children should be monitored to prevent them from eating substances that do not provide nutrition (often referred to as pica) (1,2). The parents/guardians of children who repeatedly place nonnutritive substances in their mouths should be notified and informed of the importance of having their children visit their primary health care provider or a local health department. In collaboration with the child’s parent/guardian, an assessment of the child’s eating behavior and dietary intake, along with any other health issues, should occur to begin an intervention strategy.

RATIONALE
The occasional ingestion of nonnutritive substances can be a part of everyday living and is not necessarily a concern. For example, ingestion of nonnutritive substances can occur from mouthing, placing dirty hands in the mouth, or eating dropped food. However, because of this normal behavior it is that much more important to minimize harmful residues in the facility to reduce children’s exposure. Pica involves the recurrent ingestion of substances that do not provide nutrition. Pica is most prevalent among children between the ages of 1 and 3 years (3). Among children with intellectual developmental disability and concurrent mental illness, the incidence exceeds 25% (3).
Children who have iron deficiency anemia regularly ingest nonnutritive substances. Dietary intake plays an important role because certain nutrients, such as those ingested with a diet high in fat or lecithin, increase the absorption of lead, which can result in toxicity (3). Lead, when present in the gastrointestinal tract, is absorbed in place of calcium. Children will absorb more lead than an adult. Whereas an adult absorbs approximately 10% of ingested lead, a toddler absorbs approximately 30% to 50% of ingested lead. Children who ingest paint chips or contaminated soil can develop lead toxicity, which can lead to developmental delays and neurodevelopmental disability. Currently, there is consensus that repeated ingestion of some nonfood items results in an increased lead burden of the body (3,4). Early detection and intervention in nonfood ingestion can prevent nutritional deficiencies and growth/developmental disabilities. Eating soil or drinking contaminated water could result in an infection with a parasite.
COMMENTS
Common sources of lead include lead-based paint (in buildings constructed before 1978 or constructed on properties that were formerly the site of buildings constructed before 1978); contaminated drinking water (from public water systems, supply pipes, or plumbing fixtures); contaminated soil (from old exterior paint); the storage of acidic foods in open cans or ceramic containers/pottery with a lead glaze; certain types of art supplies; some imported toys and inexpensive play jewelry; and polyvinyl chloride (PVC) vinyl products (eg, beach balls, soft PVC-containing dolls, rubber ducks, chew toys, nap mats). These sources and others should be addressed concurrently with a nutritionally adequate diet as a prevention strategy. It is important to reduce exposure to possible lead sources, promote a healthy and balanced diet, and encourage blood lead level (BLL) testing of children. If a child’s BLL is 5 mcg/dL or greater, it is important to identify and remove the child’s source of lead exposure. 
RELATED STANDARDS
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.9.13 Testing for Lead
REFERENCES
  1. Moya J, Bearer CF, Etzel RA. Children’s behavior and physiology and how it affects exposure to environmental contaminants. Pediatrics. 2004;113(4 Suppl 3):996–1006
  2. McNaughten B, Bourke T, Thompson A. Fifteen-minute consultation: the child with pica. Arch Dis Child Educ Pract Ed. May 2017;edpract-2016-312121
  3. Miao D, Young SL, Golden CD. A meta?analysis of pica and micronutrient status. Am J Hum Biol. 2015;27(1):84–93
  4. Centers for Disease Control and Prevention. Gateway to health communication & social marketing practice. Pica behavior and contaminated soil. https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/pica.html. Updated September 15, 2017. Accessed September 20, 2017
NOTES

Content in this standard was modified on August 23, 2016 and November 10, 2017.

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.3.1.3

Date: 10/17/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.3: Preparing, Feed-ing, and Storing Human Milk

Question:
I cannot find any information in the new CFOC as to how long a bottle of breast milk can be kept after it is fed to an infant.  It states that a bottle of formula should be discarded after one hour.  I would think that it should be the same, since saliva is introduced into the bottle regardless of its contents, but I want to make sure.
Can you offer some guidance?

Answer:
This Standard provides two references at the end of the “Guide-lines for Storage of Human Milk” chart on page 166. Both re-sources state that breast milk should be discarded after it is fed to an infant.

  1. The Academy of Breastfeeding Medicine Protocol Committee states: “Milk left in the feeding container after a feeding should be discarded and not used again.”
  2. The Centers for Disease Control (CDC) states: “Do not save milk from a used bottle for use at another feeding.”
A specific amount of time is not given (similar to the formula standard). The milk could be used again if it’s the same feeding (for example, if the infant takes a short break from eating), but if it is clearly a different feeding, it should be thrown away.

Content in the STANDARD was modified on 8/23/2016.

 

Expressed human milk should be placed in a clean and sanitary bottle with a nipple that fits tightly or into an equivalent clean and sanitary sealed container to prevent spilling during transport to home or to the facility. Only cleaned and sanitized bottles, or their equivalent, and nipples should be used in feeding. The bottle or container should be properly labeled with the infant’s full name and the date and time the milk was expressed. The bottle or container should immediately be stored in the refrigerator on arrival.

The mother’s own expressed milk should only be used for her own infant. Likewise, infant formula should not be used for a breastfed infant without the mother’s written permission.

Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates, sometimes labeled with #3, #6, or #7 (1). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

Non-frozen human milk should be transported and stored in the containers to be used to feed the infant, identified with a label which will not come off in water or handling, bearing the date of collection and child’s full name. The filled, labeled containers of human milk should be kept refrigerated. Human milk containers with significant amount of contents remaining (greater than one ounce) may be returned to the mother at the end of the day as long as the child has not fed directly from the bottle.

Frozen human milk may be transported and stored in single use plastic bags and placed in a freezer (not a compartment within a refrigerator but either a freezer with a separate door or a standalone freezer). Human milk should be defrosted in the refrigerator if frozen, and then heated briefly in bottle warmers or under warm running water so that the temperature does not exceed 98.6°F. If there is insufficient time to defrost the milk in the refrigerator before warming it, then it may be defrosted in a container of running cool tap water, very gently swirling the bottle periodically to evenly distribute the temperature in the milk. Some infants will not take their mother’s milk unless it is warmed to body temperature, around 98.6°F. The caregiver/teacher should check for the infant’s full name and the date on the bottle so that the oldest milk is used first. After warming, bottles should be mixed gently (not shaken) and the temperature of the milk tested before feeding.

Expressed human milk that presents a threat to an infant, such as human milk that is in an unsanitary bottle, is curdled, smells rotten, and/or has not been stored following the storage guidelines of the Academy of Breastfeeding Medicine as shown later in this standard, should be returned to the mother.

Some children around six months to a year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child’s fine motor skills allow use of a cup. The caregiver/teacher should use a clean small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and mother should work together on cup feeding of human milk to ensure the child is receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of feeding. Two to three ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (about an ounce) can be discarded.

Human milk can be stored using the following guidelines from the Academy of Breastfeeding Medicine:

 

Guidelines for Storage of Human Milk

Location

Temperature

Duration

Comments

Countertop, table

Room temperature (up to 77°F or 25°C)

6-8 hours

Containers should be covered and kept as cool as possible; covering the container with a cool towel may keep milk cooler.

Insulated cooler bag

5°F – 39°F or -15°C – 4°C

24 hours

Keep ice packs in contact with milk containers at all times, limit opening cooler bag.

Refrigerator

39°F or 4°C

5 days

Store milk in the back of the main body of the refrigerator.

Freezer compartment of a refrigerator

5°F or -15°C

2 weeks

Store milk toward the back of the freezer, where temperature is most constant. Milk stored for longer durations in the ranges listed is safe, but some of the lipids in the milk undergo degradation resulting in lower quality.

Freezer compartment of refrigerator with separate doors

0°F or -18°C

3-6 months

Chest or upright deep freezer

-4°F or -20°C

6-12 months

Source: Academy of Breastfeeding Medicine Protocol Committee. 2010. Clinical protocol #8: Human milk storage information for home use for healthy full term infants, revised. Breastfeeding Med 5:127-30. http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf.

From the Centers for Disease Control and Prevention Website: Proper handling and storage of human milk – Storage duration of fresh human milk for use with healthy full term infants. http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm.


RATIONALE
Labels for containers of human milk should be resistant to loss of the name and date/time when washing and handling. This is especially important when the frozen bottle is thawed in running tap water. There may be several bottles from different mothers being thawed and warmed at the same time in the same place.

By following this standard, the staff is able, when necessary, to prepare human milk and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect human milk (2,3). Written guidance for both staff and parents/guardians should be available to determine when milk provided by parents/guardians will not be served. Human milk cannot be served if it does not meet the requirements for sanitary and safe milk.

Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk. Unless there is visible blood in the milk, the risk of exposure to infectious organisms either during feeding or from milk that the infant regurgitates is not significant.

Returning unused human milk to the mother informs her of the quantity taken while in the early care and education program.

Excessive shaking of human milk may damage some of the cellular components that are valuable to the infant.
It is difficult to maintain 0°F consistently in a freezer compartment of a refrigerator or freezer, so caregivers/teachers should carefully monitor, with daily log sheets, temperature of freezers used to store human milk using an appropriate working thermometer. Human milk contains components that are damaged by excessive heating during or after thawing from the frozen state (4). Currently, there is nothing in the research literature that states that feedings must be warmed at all prior to feeding. Frozen milk should never be thawed in a microwave oven as 1) uneven hot spots in the milk may cause burns in the infant and 2) excessive heat may destroy beneficial components of the milk.

By following safe preparation and storage techniques, nursing mothers and caregivers/teachers of breastfed infants and children can maintain the high quality of expressed human milk and the health of the infant (5,6).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.4 Feeding Human Milk to Another Mother’s Child
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
5.2.9.9 Plastic Containers and Toys
REFERENCES
  1. Binns, C. 2016. The long-term public health benefits of breastfeeding. Asia-Pacific Journal of Public Health. 28(1):7.
  2. Boué, G., Cummins, E., Guillou, S., Antignac, J., Bizec, B., & Membré, J. 2016. Public health risks and benefits associated with breast milk and infant formula consumption. Critical Reviews in Food Science and Nutrition. Feb 6:1-20.
  3. La Leche League International. (2014). Storage guidelines: LLLI guidelines for storing breastmilk. http://www.llli.org/faq/milkstorage.html.
  4. Centers for Disease Control and Prevention. 2016. Proper handling and storage of human milk. Atlanta, GA. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm.
  5. United States Cooperative Expansion System. 2015. Guidelines for child care providers to prepare and feed bottles to infants. 2015. http://articles.extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare-and-feed-bottles-to-infants.
  6. Harley, K.G., Gunier, R.B., Kogut, K., Johnson, C., et al. 2013. Prenatal and early childhood bisphenol a concentrations and behavior in school-aged children. Environ Res. 126: 43-50.
NOTES

Content in the STANDARD was modified on 8/23/2016.

 

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Formula provided by parents/guardians or by the facility should come in a factory-sealed container. The formula should be of the same brand that is served at home and should be of ready-to-feed strength or liquid concentrate to be diluted using cold water from a source approved by the health department. Powdered infant formula, though it is the least expensive formula, requires special handling in mixing because it cannot be sterilized. The primary source for proper and safe handling and mixing is the manufacturer’s instructions that appear on the can of powdered formula. Before opening the can, hands should be washed. The can and plastic lid should be thoroughly rinsed and dried. Caregivers/teachers should read and follow the manufacturer’s directions. Caregivers/teachers should only use the scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop may vary from manufacturer to manufacturer and product to product. Also, a scoop can be contaminated with a potential allergen from another type of formula. If instructions are not readily available, caregivers/teachers should obtain information from their local WIC program or the World Health Organization’s Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines at: http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf (1).

Formula mixed with cereal, fruit juice, or any other foods should not be served unless the child’s primary care provider provides written documentation that the child has a medical reason for this type of feeding.

Iron-fortified formula should be refrigerated until immediately before feeding. For bottles containing formula, any contents remaining after a feeding should be discarded.

Bottles of formula prepared from powder or concentrate or ready-to-feed formula should be labeled with the child’s full name and time and date of preparation. Any prepared formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been given to an infant should be covered, labeled with date and time of preparation and child’s full name, and may be stored in the refrigerator for up to twenty-four hours. An open container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening and child’s full name, and discarded at forty-eight hours if not used (2). The caregiver/teacher should always follow manufacturer’s instructions for mixing and storing of any formula preparation. Some infants will require specialized formula because of allergy, inability to digest certain formulas, or need for extra calories. The appropriate formula should always be available and should be fed as directed. For those infants getting supplemental calories, the formula may be prepared in a different way from the directions on the container. In those circumstances, either the family should provide the prepared formula or the caregiver/teacher should receive special training, as noted in the infant’s care plan, on how to prepare the formula. Formula should not be used beyond the stated shelf life period (3).

Parents/guardians should supply enough clean and sterilized bottles to be used throughout the day. The bottles must be sanitary, properly prepared and stored, and must be the same brand in the early care and education program and at home. Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

RATIONALE
Caregivers/teachers help in promoting the feeding of infant formula that is familiar to the infant and supports family feeding practice. By following this standard, the staff is able, when necessary, to prepare formula and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect formula. Written guidance for both staff and parents/guardians must be available to determine when formula provided by parents/guardians will not be served. Formula cannot be served if it does not meet the requirements for sanitary and safe formula.

Staff preparing formula should thoroughly wash their hands prior to beginning preparation of infant feedings of any type. Water used for mixing infant formula must be from a safe water source as defined by the local or state health department. If the caregiver/teacher is concerned or uncertain about the safety of the tap water, s/he should "flush" the water system by running the tap on cold for 1-2 minutes or use bottled water (4). Warmed water should be tested in advance to make sure it is not too hot for the infant. To test the temperature, the caregiver/teacher should shake a few drops on the inside of her/his wrist. A bottle can be prepared by adding powdered formula and room temperature water from the tap just before feeding. Bottles made in this way from powdered formula can be ready for feeding as no additional refrigeration or warming would be required.

Adding too little water to formula puts a burden on an infant’s kidneys and digestive system and may lead to dehydration (5). Adding too much water dilutes the formula. Diluted formula may interfere with an infant’s growth and health because it provides inadequate calories and nutrients and can cause water intoxication. Water intoxication can occur in breastfed or formula-fed infants or children over one year of age who are fed an excessive amount of water. Water intoxication can be life-threatening to an infant or young child (6).If a child has a special health problem, such as reflux, or inability to take in nutrients because of delayed development of feeding skills, the child’s primary care provider should provide a written plan for the staff to follow so that the child is fed appropriately. Some infants are allergic to milk and soy and need to be fed an elemental formula which does not contain allergens. Other infants need supplemental calories because of poor weight gain.

Infants should not be fed a formula different from the one the parents/guardians feed at home, as even minor differences in formula can cause gastrointestinal upsets and other problems (7).

Excessive shaking of formula may cause foaming that increases the likelihood of feeding air to the infant.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys
REFERENCES
  1. United States Department of Agriculture, Food and Nutrition Service. 2017. Feeding infants: A guide for use in the child nutrition programs. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs.
  2. Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: A deadly form of child abuse. The Journal of Law Enforcement. 4(4).
  3. Seattle Children's Hospital. 2014. Topics covered for formula feeding: Is this your child's symptoms? Seattle, WA. http://www.seattlechildrens.org/medical-conditions/symptom-index/bottle-feeding-formula-questions/.
  4. Centers for Disease Control and Prevention. 2016. Water. https://www.cdc.gov/nceh/lead/tips/water.htm.
  5. Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html.
  6. U.S. Department of Health & Human Services, U.S. Food & Drug Administration. 2016. Food safety for moms to be: Once baby arrives. College Park, MD. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm.
  7. World Health Organization. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/powdered-infant-formula/en/.
NOTES

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Standard 4.3.1.9: Warming Bottles and Infant Foods

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.3.1.9

Date: 10/13/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.9: Warming Bottles and Infant Foods

Question:
I have concerns about the standards recommending glass and ceramic containers due to concerns about using plastic.  Once again, it is good in theory, but I don’t feel it is safe. I had a center that had a glass bottle drop and shatter in their infant room. 

Answer:
BPA-free plastic bottles, those labeled #1, #2, #4, or #5, can be used to avoid the use of glass.

For those child care and early education facilities that choose to use glass bottles, a relatively new option is to use a bottle sleeve with the glass bottle to reduce the risk of shattered glass. Efficacy on this product is still being proven. Overall, glass is safer than plastic with BPA.

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

Bottles and infant foods do not have to be warmed; they can be served cold from the refrigerator. If a caregiver/teacher chooses to warm them, bottles or containers of infant foods should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 120°F (49°C). Bottles should not be left in a pot of water to warm for more than 5 minutes. Bottles and infant foods should never be warmed in a microwave oven because uneven hot spots in milk and/or food may burn the infant (1,2).

Infant foods should be stirred carefully to distribute the heat evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way. Bottles used for infant feeding should be made of the following substances (3):

     a. Bisphenol A (BPA)-free plastic; plastic labeled #1, #2, #4, or #5, or 

     b. Glass (a silicone sleeve/jacket covering a glass bottle to prevent breakage is permissible).

When a slow-cooking device, such as a crock-pot, is used for warming human milk, infant formula, or infant food, the device (and cord) should be out of children’s reach. The device should contain water at a temperature that does not exceed 120°F (49°C), and be emptied, cleaned, sanitized, and refilled with fresh water daily. When a bottle warmer is used for warming human milk, infant formula, or infant food, it should be out of children’s reach and used according to manufacturer’s instructions.

RATIONALE

Bottles of human milk or infant formula that are warmed at room temperature or in warm water for an inappropriate period provide an ideal medium for bacteria to grow. Infants have received burns from hot water dripping from an infant bottle that was removed from a crock-pot or by pulling the crock-pot down on themselves by means of a dangling cord. Caution should be exercised to avoid raising the water temperature above a safe level for warming infant formula or infant food.

Additional Resource

Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs)


TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
REFERENCES
  1. US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm. Updated November 8, 2017. Accessed January 11, 2018

  2. Cowan D, Ho B, Sykes KJ, Wei JL. Pediatric oral burns: a ten-year review of patient characteristics, etiologies and treatment outcomes. Int J Pediatr Otorhinolaryngol. 2013;77(8):1325–1328

  3. Environmental Working Group. Guide to baby-safe bottles and formula. https://www.ewg.org/research/ewg%E2%80%99s-guide-baby-safe-bottles-and-formula#.WlfPqWeWzct. Updated October, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

Standard 4.5.0.2: Tableware and Feeding Utensils

Tableware and feeding utensils should meet the following requirements:

  1. Dishes should have smooth, hard, glazed surfaces and should be free from cracks or chips. Sharp-edged plastic utensils (intended for use in the mouth) or dishes that have sharp or jagged edges should not be used;
  2. Imported dishes and imported ceramic dishware or pottery should be certified by the regulatory health authority to meet U.S. standards and to be safe from lead or other heavy metals before they can be used;
  3. Disposable tableware (such as plates, cups, utensils made of heavy weight paper, food-grade medium- weight or BPA- or phthalates-free plastic) should be permitted for single service if they are discarded after use. The facility should not use foam tableware for children under four years of age (1,2);
  4. Single-service articles (such as napkins, paper placemats, paper tablecloths, and paper towels) should be discarded after one use;
  5. Washable bibs, placemats, napkins, and tablecloths, if used, should be laundered or washed, rinsed, and sanitized after each meal. Fabric articles should be sanitized by being machine-washed and dried after each use;
  6. Highchair trays, plates, and all items used in food service that are not disposable should be washed, rinsed, and sanitized. Highchair trays that are used for eating should be washed, rinsed, and sanitized just before and immediately after they are used for eating. Children who eat at tables should have disposable or washed and sanitized plates for their food;
  7. All surfaces in contact with food should be lead-free (3);
  8. Tableware and feeding utensils should be child-sized and developmentally appropriate.

RATIONALE
Clean food service utensils, napkins, bibs, and tablecloths prevent the spread of microorganisms that can cause disease. The surfaces that are in contact with food must be sanitary.

Food should not be put directly on the table surface for two reasons. First, even washed and sanitized tables are more likely to be contaminated than disposable plates or washed and sanitized dishes. Second, eating from plates reduces contamination of the table surface when children put down their partially eaten food while they are eating.

Although highchair trays can be considered tables, they function as plates for seated children. The tray should be washed and sanitized before and after use (4). The use of disposable items eliminates the spread of contamination and disease and fosters safety and injury prevention. Single-service items are usually porous and should not be washed and reused. Items intended for reuse must be capable of being washed, rinsed, and sanitized.

Medium-weight plastic should be chosen because lighter-weight plastic utensils are more likely to have sharp edges and break off small pieces easily. Sharp-edged plastic spoons can cut soft oral tissues, especially when an adult is feeding a child and slides the spoon out of the child’s closed mouth. Older children can cut their mouth tissues in the same way.

Foam can break into pieces that can become choking hazards for young children.

Imported dishware may be improperly fired and may release toxic levels of lead into food. U.S. government standards prevent the marketing of domestic dishes with lead in their glazes. There is no safe level of lead in dishware.

COMMENTS
Ideally, food should not be placed directly on highchair trays, as studies have shown that highchair trays can be loaded with infectious microorganisms. If the highchair tray is made of plastic, is in good repair, and is free from cracks and crevices, it can be made safe if it is washed and sanitized before placing a child in the chair for feeding and if the tray is washed and sanitized after each child has been fed. Food must not be placed directly on highchair trays made of wood or metal, other than stainless steel, to prevent contamination by infectious microorganisms or toxicity from metals.

If there is a question about whether tableware is safe and sanitary, consult the regulatory health authority or local health department.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.9.0.9 Cleaning Food Areas and Equipment
5.2.9.9 Plastic Containers and Toys
REFERENCES
  1. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Center for Disease Control and Prevention. 2017. Lead. https://www.cdc.gov/nceh/lead/.
  3. Safer Chemicals, Healthy Families. 2017. Styrene and styrofoam 101. 
    http://saferchemicals.org/2014/05/26/styrene-and-styrofoam-101-2/
  4. Eco-Healthy Child Care. 2016. Plastics & plastic toys. http://cehn.org/wpcontent/uploads/2015/12/Plastics_Plastic_Toys_6_16.pdf.

Standard 4.8.0.7: Ventilation Over Cooking Surfaces

In centers using commercial cooking equipment to prepare meals, ventilation should be equipped with an exhaust system in compliance with the applicable building, mechanical, and fire codes. These codes may vary slightly with each locale, and centers are responsible to ensure their facilities meet the requirements of these codes (1-2).

All gas ranges in centers should be mechanically vented and fumes filtered prior to discharge to the outside. All vents and filters should be maintained free of grease build-up and food spatters, and in good repair.

RATIONALE
Properly maintained vents and filters control odor, fire hazards, and fumes.

An exhaust system must collect fumes and grease-laden vapors properly at their source.

COMMENTS
The center should refer to the owner’s manual of the exhaust system for a description of capture velocity. Commercial cooking equipment refers to the type of equipment that is typically found in restaurants and other food service businesses.

Proper construction of the exhaust system duct-work assures that grease and other build-up can be easily accessed and cleaned.

If the odor of gas is present when the pilot lights are on, turn off gas and immediately call a qualified gas technician, commercial gas provider, or local gas, electric or utility provider. Never use an open flame to locate a gas leak.

TYPE OF FACILITY
Center
REFERENCES
  1. Clark, J. 2003. Commercial kitchen ventilation design: What you need to know. http://www.esmagazine.com/Articles/Feature_Article/229549b01fca8010VgnVCM100000f932a8c0.
  2. American Society of Heating, Refrigeration and Air Conditioning Engineers. 2007. ASHRAE handbook: HVAC applications. Atlanta, GA: ASHRAE.

Standard 4.8.0.8: Microwave Ovens

Microwave ovens should be inaccessible to all children, with the exception of school-age children under close adult supervision. Any microwave oven in use in a child care facility should be manufactured after October 1971 and should be in good condition. While the microwave is being used, it should not be left unattended.

If foods need to be heated in a microwave:

  1. Avoid heating foods in plastic containers;
  2. Avoid transferring hot foods/drinks into plastic containers;
  3. Do not use plastic wrap or aluminum foil in the microwave;
  4. Avoid plastics for food and beverages labeled “3” (PVC), “6” (PS), and “7” (polycarbonate);
  5. Stir food before serving to prevent burns from hot spots.

RATIONALE
Young children can be burned when their faces come near the heat vent. The issues involved with the safe use of microwave ovens (such as no metal and steam trapping) make use of this equipment by preschool-age children too risky. Older ovens made before the Federal standard went into effect in October 1971 can expose users or passers-by to microwave radiation. If adults or school-age children use a microwave, it is recommended that they do not heat food in plastic containers, plastic wrap or aluminum foil due to concerns of releasing toxic substances even if the container is specified for use in a microwave (1).
COMMENTS
If school-age children are allowed to use a microwave oven in the facility, this use should be closely supervised by an adult to avoid injury. See Standard 4.3.1.9 for prohibition of use of microwave ovens to warm infant feedings.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys
REFERENCES
  1. Institute for Agriculture and Trade Policy (IATP), Food and Health Program. 2005. Smart plastics guide: Healthier food uses of plastics for parents and children. Minneapolis, MN: IATP.

Standard 4.9.0.13: Method for Washing Dishes by Hand

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.9.0.13

Date: 8/19/2012

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.9.0.13: Methods for Washing Dishes by Hand

Question:
I am hoping to get some clarification on the amount of bleach to use when washing dishes in a three compartment sink. I see in Appendix J the chart indicates 1 tablespoon of bleach + 1 gallon of cool water as a sanitizing solution. While the standard says:

 
If the facility does not use a dishwasher, reusable food service equipment and eating utensils should be first scraped to remove any leftover food, washed thoroughly in hot water containing a detergent solution, rinsed, and then sanitized by one of the following methods:

a.    Immersion for at least two minutes in a lukewarm (not less than 75°F) chemical sanitizing solution (bleach solution of at least 100 parts per million by mixing 1 1/2 teaspoons of domestic bleach per gallon of water). The sanitized items should be air-dried;
 
Can you clarify which measurement needs to be used in the three compartment sink method?
 

Answer:
The sanitizing solution referenced in Standard 4.9.0.13 (1 ½ Teaspoons of bleach per gallon of water, ) is from the 2009 Food Code and this section has remained the same in the 2011 Food Code which came out after the publication of CFOC 3.  The key words in the above Standard are “at least.”  If you were to use the sanitizing solution referenced in Appendix J (1 Tablespoon of bleach per gallon of water) you would still be meeting this requirement since that solution is 200 parts per million.  Using a higher concentration of bleach is not a problem as the 2011 Food Code requires “at least” 100 parts per million but does not provide an upper limit.

Content in the STANDARD was modified on 8/6/2013.

If the facility does not use a dishwasher, reusable food service equipment and eating utensils should be first scraped to remove any leftover food, washed thoroughly in hot water containing a detergent solution, rinsed, and then sanitized by one of the following methods:

  1. Immersion for at least two minutes in a lukewarm (not less than 75°F) chemical sanitizing solution. Bleach may be used as a sanitizing solution when diluted according to manufacturer's instructions. The sanitized items should be air-dried; or
  2. Immersed in an EPA-registered sanitizer following the manufacturer’s instructions for preparation and use; or
  3. Complete immersion in hot water and maintenance at a temperature of 170 °F for not less than thirty seconds. The items should be air-dried (1);
  4. Or, other methods if approved by the health department.

RATIONALE
These procedures provide for proper sanitizing and control of bacteria (2-4).
COMMENTS
To manually sanitize dishes and utensils in hot water at 170°F, a special hot water booster is usually required. To avoid burning the skin while immersing dishes and utensils in this hot water bath, special racks are required. Therefore, if dishes and utensils are being washed by hand, the chemical sanitizer method will be a safer choice.

Often, sponges are used in private homes when washing dishes. The structure of natural and artificial sponges provides an environment in which microorganisms thrive. This may contribute to the microbial load in the wash water. Nevertheless, the rinsing and sanitizing process should eliminate any pathogens contributed by a sponge. When possible, a cloth that can be laundered should be used instead of a sponge.

The concentration of bleach used for sanitizing dishes is much more diluted than the concentration recommended for disinfecting surfaces elsewhere in the facility. After washing and rinsing the dishes, the amount of infectious material on the dishes should be small enough so that the two minutes of immersion in the bleach solution (or treatment with an EPA-registered sanitizer) combined with air-drying will reduce the number of microorganisms to safe levels.

Air-drying of surfaces that have been sanitized using bleach leaves no residue, since chlorine evaporates when the solution dries. However, other sanitizers may need to be rinsed off to remove retained chemical from surfaces.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.9.0.12 Dishwashing in Small and Large Family Child Care Homes
REFERENCES
  1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  2. Bryan, F. L., G. H. DeHart. 1975. Evaluation of household dishwashing machines, for use in small institutions. J Milk Food Tech 38:509-15.
  3. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
  4. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
NOTES

Content in the STANDARD was modified on 8/6/2013.

V. Facilities, Supplies, and Equipment

A. Location, Layout, and Construction

Standard 5.1.1.2: Inspection of Buildings

Newly constructed, renovated, remodeled, or altered buildings should be inspected by a public inspector to assure compliance with applicable building and fire codes before the building can be made accessible to children (1).

RATIONALE
Building codes are designed to ensure that a building is safe for occupants. Environmental health recommendations are designed to ensure the building and property are free of health hazards for children and workers. Existing buildings may contain potentially toxic or hazardous construction materials (e.g., lead paint, asbestos) that may be released during renovation work. Assessing the presence of such materials enables the management of potential exposures through removal, containment, or by other means (2).
COMMENTS
Any building not used for child care for a period of time should be inspected for compliance with applicable building and fire codes. A thorough review of former uses of the building(s) should be completed to determine if there may be lingering hazardous exposures from past contamination that might require mitigation. The indoor, air, water, paint, building materials and/or other furnishings in the buildings need to be assessed for contaminant levels prior to siting. Collecting a sample of indoor air, water, paint, and building materials may also be necessary. A review of environmental health hazards by county or city public health environmental offices can help to meet safety requirements. 
TYPE OF FACILITY
Center
RELATED STANDARDS
5.1.1.3 Compliance with Fire Prevention Code
5.1.1.5 Environmental Audit of Site Location
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.6.1 Water Supply
5.2.6.7 Cross-Connections
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.2.9.13 Testing for Lead
5.2.9.15 Construction and Remodeling
REFERENCES
  1. Somers, T.S., Harvey, M.L., Rusnak, S.M. 2011. Making child care centers SAFER: A non-regulatory approach to improving child care center siting. Public Health Reports 126(Suppl 1): 34–40. Accessible at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072901/

  2. 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.

Standard 5.1.1.5: Environmental Audit of Site Location

Frequently Asked Questions/CFOC3 Clarifications

Reference: 5.1.1.5

Date: 10/13/2011

Topic & Location:
Chapter 5
Facilities
Standard 5.1.1.5: Environmental Audit of Site Location

Question:
Has the recommendation for minimum distance between a playground site and hazards, such as electrical transformers and high voltage power lines changed since the CFOC, 2nd Ed., which stated 30 feet?

Answer:
Yes, specific distances are no longer recommended as distances may differ according to local municipalities and states.
Please consult your local ordinance for appropriate information.

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

 

An environmental audit should be conducted before construction of a new building; renovation or occupation of an older building; or after a natural disaster, to properly evaluate and, where necessary, remediate or avoid sites where children’s health could be compromised (1,2,3).

The environmental audit should include assessments of:

  1. Previous uses of the site or nearby sites;
  2. Potential air, soil, and water contamination on child care facility sites and outdoor play spaces;
  3. Potential toxic or hazardous materials in building construction; 
  4. Potential environmental and safety hazards in the community surrounding the site; and 
  5. Potential noise hazards in the community surrounding the site. 

A written environmental audit report that includes any remedial action taken should be kept on file, along with appropriate follow-up assessment measures of noise, air, water and soil quality, and post-remediation to show compliance with local and federal environmental health standards. 

RATIONALE
Evaluation of potential health and safety risks associated with the physical site location of a child care facility will identify any remedial action required or whether the site should be avoided if children’s health could be compromised.
 
Children have higher exposures to some harmful substances than adults due to their unique behavior, such as crawling and hand-to-mouth activity. They also eat, drink, and breathe more than adults do relative to their body size.  In addition, children are much more vulnerable to harm from exposures to contaminated materials than adults because their bodies and organ systems are still developing. Disruption of this development could result in permanent damage with life-long health and developmental consequences (4).
 
Awareness of remedial action required or sites to avoid will reduce exposure to conditions that cause injury or adversely affect health and development.
 
Epidemiological studies indicate a relationship between outdoor air pollution and adverse respiratory effects on children (5). Air pollution sources can be stationary, such as nearby dry cleaning or nail salon business, gas stations, or industrial facilities. Proximity to high traffic roadways is an important factor to avoid in siting a child care facility. The previous uses of sites may also have contaminated the air if environmental hazards were not properly remedied.
 
The soil in play areas should not contain hazardous levels of any toxic chemical or substance. Soil contaminated with toxic materials can poison children. For example, ensuring that soil in play areas is free of dangerous levels of lead helps prevent lead poisoning (6-8).
 
Research indicates that children exposed to chronic noise pollution experience increased difficulties with learning and cognitive performance, resulting in impaired academic achievement (9).
COMMENTS
Potential safety hazards in the community surrounding the site location of a child care facility may include:
  1. Proximity to hazardous industrial air emissions;
  2. Proximity to toxic or hazardous substances in adjacent or nearby property;
  3. Proximity to agricultural plots where industrial pesticides are sprayed;
  4. Proximity to transportation hazards (e.g., local automobile traffic, major roadways, airports, railroads);
  5. Proximity to utilities (e.g., drinking water reservoirs or storage tanks, electrical sub-stations, high-voltage power transmission lines, pressurized gas transmission lines);
  6. Proximity to explosive or flammable products (e.g., propane tanks).

Possible options for reducing exposure to potential safety hazards in the community may include:

  1. Locating the site of a child care facility at a safe distance from the hazard; and/or
  2. Providing a physical barrier to prevent children from being exposed to the safety hazards (e.g., fencing).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.1.2 Inspection of Buildings
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.3.1 Noise Levels
5.2.6.1 Water Supply
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.6.4 Water Test Results
5.2.6.6 Water Handling and Treatment Equipment
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.2.9.13 Testing for Lead
REFERENCES
  1. U.S. Environmental Protection Agency. Human health risk assessment. http://www.epa.gov/risk/health-risk.htm.
  2. Zhua Y., W. C. Hinds, S. Kim, S. Shen, C. Sioutas. 2002. Study of ultrafine particles near a major highway with heavy-duty diesel traffic. Atmospheric Environment 36:4323–35.
  3. Zhou Y., J. I. Levy. 2007. Factors influencing the spatial extent of mobile source air pollution impacts: A meta-analysis. BMC Public Health 7:89. http://www.biomedcentral.com/content/pdf/1471-2458-7-89.pdf.
  4. Boothe V. L., D. G. Shendell. 2008. Potential health effects associated with residential proximity to freeways and primary roads: Review of scientific literature, 1999-2006. J Environmental Health 70:33-41, 55-56.
  5. Stansfeld, S., Clark, C. 2015. Health effects of noise exposure in children. Curr Envir Health Rpt. 2: 171. http://link.springer.com/article/10.1007/s40572-015-0044-1
  6. Burke, P., J. Ryan. 2001. Providing solutions for a better tomorrow: Reducing the risks associated with lead in soil. Washington, DC: U.S. Environmental Protection Agency. http://www.epa.gov/nrmrl/pubs/600f01014/600f01014.pdf.
  7. U.S. Environmental Protection Agency. 2010. The lead-safe certified guide to renovate right. http://www.epa.gov/lead/pubs/renovaterightbrochure.pdf.
  8. American Academy of Pediatrics, Committee on Environmental Health. 2004. Policy statement: Ambient air pollution: Health hazards to children. Pediatrics 114:1699-1707.
  9. U.S. Environmental Protection Agency. 2014. Siting of school facilities. https://www.epa.gov/schools/school-siting-guidelines.
  10. Somers, T.S., Harvey, M.L., Rusnak, S.M. 2011. Making child care centers SAFER: A non-regulatory approach to improving child care center siting. Public Health Reports 126(Suppl 1): 34–40. Accessible at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072901/
  11. Etzel, R. A., S. J. Balk, eds. 2011. Pediatric environmental health. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics Council on Environmental Health.
NOTES

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

 

Standard 5.1.1.6: Structurally Sound Facility

Every exterior wall, roof, and foundation should be structurally sound, weather-tight, and water-tight to ensure protection from weather and natural disasters.

Every interior floor, wall, and ceiling should be structurally sound and should be finished in accordance with local building codes to control exposure of the occupants to levels of toxic fumes, dust, and mold.

RATIONALE
Both the design of structures and the lack of maintenance can lead to exposure of children to physical injury, mold, dust, pests, and toxic materials (1).
COMMENTS
Child care operations sometimes use older buildings or buildings designed for purposes other than child care.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.1.2 Inspection of Buildings
5.1.1.5 Environmental Audit of Site Location
5.7.0.7 Structure Maintenance

Standard 5.1.1.7: Use of Basements and Below Grade Areas

Finished basements or areas that are partially below grade may be used for children who independently ambulate and who are two years of age or older, if the space is in compliance with applicable building and fire codes. Environmental health factors may be reviewed with county or city public health departments.

RATIONALE
Basement and partially below grade areas can be quite habitable and should be usable as long as building, fire safety (1), and environmental quality is satisfactory.
COMMENTS
To “independently ambulate” means that children are able to walk from place to place with or without the use of assistive devices.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.1.8 Buildings of Wood Frame Construction
5.1.2.1 Space Required per Child
5.1.2.2 Floor Space Beneath Low Ceiling Heights
5.1.4.1 Alternate Exits and Emergency Shelter
5.1.4.2 Evacuation of Children with Special Health Care Needs and Children with Disabilities
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.2.1 Levels of Illumination
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
REFERENCES
  1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.1.1.9: Unrelated Business in a Child Care Area

Child care areas should not be used for any business or purpose unrelated to providing child care when children are present in these areas.

If unrelated business is conducted in child care areas when the child care facility is not in operation, activities associated with such business should not leave any residue in the air or on the surfaces, or leave behind materials or equipment, that could be harmful to children.

RATIONALE
Some activities that leave a harmful residue are smoking, ammunition reloading, soldering, woodworking, and welding (1). Examples of materials or equipment that could be harmful are small screws, nails, and electric tools with sharp blades. Child care requires child-oriented, child-safe areas where the child’s needs are primary.
COMMENTS
Employers should inform caregivers/teachers about harmful residues or equipment that may potentially remain from unrelated business activity so that such residues or equipment can be removed.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.1.11 Separation of Operations from Child Care Areas
5.2.1.5 Ventilation of Recently Carpeted or Paneled Areas
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
5.2.9.10 Prohibition of Poisonous Plants
5.2.9.15 Construction and Remodeling
5.7.0.2 Removal of Hazards From Outdoor Areas
5.7.0.4 Inaccessibility of Hazardous Equipment
REFERENCES
  1. U.S. Environmental Protection Agency, U.S. Consumer Product Safety Commission. 2010. The inside story: A guide to indoor air quality. http://www.epa.gov/iaq/pubs/insidest.html.

Standard 5.1.1.11: Separation of Operations from Child Care Areas

Rooms or spaces that are used for the following activities or operations should be separated from the child care areas and the egress route should not pass through such spaces:

  1. Commercial-type kitchen;
  2. Boiler, maintenance shop;
  3. Janitor closet and storage areas for cleaning products, pesticides, and other chemicals;
  4. Laundry and laundering supplies;
  5. Woodworking shop;
  6. Flammable or combustible storage;
  7. Painting operation;
  8. Rooms that are used for any purpose involving the presence of toxic substances;
  9. Area for medication storage.

Areas that have combustibles should be protected by fire-resistant barriers. The egress route and the fire-resistant separation should be approved by the appropriate regulatory agencies responsible for building and fire inspections. In small and large family child care homes, a fire-resistant separation should not be required where the food preparation kitchen contains only a domestic cooking range and the preparation of food does not result in smoke or grease-laden vapors escaping into indoor areas. Where separation is provided between the egress route and the hazardous area, it should be safe to use such route, but egress should not require passage through the hazardous area.

RATIONALE
Hazards and toxic substances must be kept separate in a locked closet or room from space used for child care to prevent children’s and staff members’ exposure to injury (1).

Cleaning agents must be inaccessible to children (out of reach and behind locked doors). Food preparation surfaces must be separate from diaper changing areas including sinks for handwashing. Children must be restricted from access to the stove when cooking surfaces are hot.

COMMENTS
In small family child care homes, mixed use of rooms is common (2). Some combined use of space for food preparation, storage of cleaning equipment and household tools, laundry, and diaper changing requires that each space within a room be defined according to its purpose and that exposure of children to hazards be controlled. Food preparation should be separate from all exposure to possible cross-contamination.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.
  2. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 5.1.3.1: Weather-Tightness and Water-Tightness of Openings

Each window, exterior door, and basement or cellar hatchway should be weather-tight and water-tight when closed.

RATIONALE
Children’s environments must be protected from exposure to moisture, dust, and temperature extremes.
TYPE OF FACILITY
Center, Large Family Child Care Home

B. Quality of Outdoor and Indoor Equipment

Standard 5.1.3.3: Screens for Ventilation Openings

All openings used for ventilation should be screened against insect entry.

RATIONALE
Screens prevent the entry of insects, which may bite, sting, or carry disease.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.3.2 Possibility of Exit from Windows

Standard 5.2.1.1: Ensuring Access to Fresh Air Indoors

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

 

As much fresh outdoor air as possible should be provided in rooms occupied by children. Screened windows should be opened whenever weather and the outdoor air quality permits or when children are out of the room (1). When windows are not kept open, rooms should be ventilated, as specified in Standards 5.2.1.1-5.2.1.6. The specified rates at which outdoor air must be supplied to each room within the facility range from fifteen to sixty cubic feet per minute per person (cfm/p). The rate depends on the activities that normally occur in that room. Indoor air should be kept as free from unnecessary chemicals as possible, including those emitted from air fresherners and other fragrances, cleaning products containing chemicals, aerosol sprays, and some furnishings.


RATIONALE

The health and well-being of both the staff and the children can be greatly affected by indoor air quality. The air people breathe inside a building is contaminated with micorbes shared among occupants, chemicals emitted from common consumer products and furnishings, and migration of polluted outdoor air into the facility. Sometimes the indoor air is more polluted than the outdoor air.

 

Air quality significantly impacts people's health. The health impacts from exposure to air pollution (indoor and outdoor) can include: decreased lung function, asthma, bronchitis, emphysema, learning and behavioral disabilities, and even some types of cancer. Children are particularly vulnerable to air pollution because their organ systems (respiratory, central nervous system, etc.) are still developing and they also breathe in more air relative to their weight than adults do. Indoor air pollution is often greater than outdoor levels of air pollution due to a general lack of adequate air filtration and ventilation, and lingering and build up of air contaminants emitted from certain long-term furnishings (2). The presence of dirt, moisture, and warmth encourages the growth of mold and other contaminants, which can trigger allergic reactions and asthma (3). Children who spend long hours breathing contaminated or polluted indoor air are more likely to develop respiratory problems, allergies, and asthma (2,4,5). 

 

Although insultation of a building is important in reducing heating or cooling costs, it is unwise to try to seal the building completely. Air circulation is essential to clear infectious disease agents, odors, and toxic substances in the air. Levels of carbon dioxide are an indicator of the quality of ventilation. Air circulation can be adjusted by a properly installed and adjusted heating, ventilation, air conditioning, and cooling (HVAC) system as well as by using fans and open windows. 

COMMENTS
For further information on air quality and on ventilation standards related to type of room use, contact the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), the U.S. Environmental Protection Agency (EPA) Public Information Center, the American Gas Association (AGA), the Edison Electric Institute (EEI), the American Lung Association (ALA), the U.S. Consumer Product Safety Commission (CPSC), and the Safe Building Alliance (SBA).

For child care, ANSI/ASHRAE 62.1-2007 calls for 10 cfm/person plus 0.18 cfm/sq.ft. of space. ANSI/ASHRAE 62-1989 or ASHRAE Standard 55-2007 is information on Thermal Environmental Conditions for Human Occupancy.

Qualified engineers can ensure heating, ventilation, air conditioning (HVAC) systems are functioning properly and that applicable standards are being met. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) Website (http://www.ashrae.org) includes the qualifications required of its members and the location of the local ASHRAE chapter. The contractor who services the child care HVAC system should provide evidence of successful completion of ASHRAE or comparable courses. Caregivers/teachers should understand enough about codes and standards to be sure the facility’s building is a healthful place to be.

Indoor air quality is important to all children and early care and education staff. A checklist from the National Heart, Lung and Blood Institute, How Asthma Friendly is your Child Care Setting? (available at http://www.nhlbi.nih.gov/health/public/lung/asthma/chc_chk.pdf), can help caregivers/teachers create a more asthma-friendly environment.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.2 Playing Outdoors
3.1.3.3 Protection from Air Pollution While Children Are Outside
5.2.1.2 Indoor Temperature and Humidity
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
5.2.1.4 Ventilation When Using Art Materials
5.2.1.5 Ventilation of Recently Carpeted or Paneled Areas
5.2.1.6 Ventilation to Control Odors
5.2.9.5 Carbon Monoxide Detectors
REFERENCES
  1. Daneault, S., M. Beusoleil, K. Messing. 1992. Air quality during the winter in Quebec day-care centers.Am J Public Health 82:432-34.
  2. American Lung Association, American Lung Association, U.S. Consumer Product Safety Commission, U.S. Environmental Protection Agency (EPA). 1994. Indoor air pollution: An introduction for health professionals. Cincinnati: EPA National Service Center for Environmental Publications. http://www.epa.gov/iaq/pdfs/indoor_air_pollution.pdf.
  3. U.S. Environmental Protection Agency, Consumer Product Safety Commission. 2010. The inside story: A guide to indoor air quality. http://www.epa.gov/iaq/pubs/insidest.html.
  4. U.S. Environmental Protection Agency (EPA). 2008. Care for your air: A guide to indoor air quality. Washington, DC: EPA. http://www.epa.gov/iaq/pdfs/careforyourair.pdf.
  5. U.S. Environmental Protection Agency. IAQ tools for schools program. http://www.epa.gov/iaq/schools/.
  6. American Society of Heating, Refrigeration and Air-conditioning Engineers (ASHRAE), American Institute of Architects, Illuminating Engineering Society of North America, U.S. Green Building Council, U.S. Department of Energy. 2008. Advanced energy design guide for K-12 school buildings, 148. Atlanta, GA: ASHRAE.
NOTES

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

 

Standard 5.2.1.2: Indoor Temperature and Humidity

A draft-free temperature of 68°F to 75°F should be maintained at thirty to fifty percent relative humidity during the winter months. A draft-free temperature of 74°F to 82°F should be maintained at thirty to fifty percent relative humidity during the summer months (1,2). All rooms that children use should be heated and cooled to maintain the required temperatures and humidity.

RATIONALE
These requirements are based on the standards of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), which take both comfort and health into consideration (1,2). High humidity can promote growth of mold, mildew, and other biological agents that can cause eye, nose, and throat irritation and may trigger asthma episodes in people with asthma (3). These precautions are essential to the health and well-being of both the staff and the children. When planning construction of a facility, it is healthier to build windows that open. Some people need filtered air that helps control pollen and other airborne pollutants found in raw outdoor air.
COMMENTS
Simple and inexpensive devices that measure the ambient relative humidity indoors may be purchased in hardware stores or toy stores that specialize in science products. The ASHRAE Website (http://www.ashrae.org) has a list of membership chapters, and membership criteria that help to establish expertise on which caregivers/teachers could rely in selecting a contractor.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
REFERENCES
  1. U.S. Environmental Protection Agency (EPA). 2008. Care for your air: A guide to indoor air quality. Washington, DC: EPA. http://www.epa.gov/iaq/pdfs/careforyourair.pdf.
  2. American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE). 2007. Standard 55-2007: Thermal conditions for human occupancy. Atlanta: ASHRAE.
  3. American Society of Heating, Refrigeration and Air-Conditioning Engineers, American Institute of Architects, Illuminating Engineering Society of North America, U.S. Green Building Council, U.S. Department of Energy. 2008. Advanced energy design guide for K-12 school buildings, 148. Atlanta, GA: ASHRAE.

Standard 5.2.1.3: Heating and Ventilation Equipment Inspection and Maintenance

All heating and ventilating equipment, including heaters, stoves used for heating (or furnaces), stovepipes, boilers, and chimneys, should be inspected and cleaned before each cooling and heating season by a qualified heating/air conditioning contractor, who should verify in writing that the equipment is properly installed, cleaned, and maintained to operate efficiently and effectively. The system should be operated in accordance with operating instructions and be certified that it meets the local building code by a representative of the agency that administers the building code. Documentation of these inspections and certification of safety should be kept on file in the facility.

RATIONALE
Routinely scheduled inspections and proper operation ensure that equipment is working properly. Heating equipment is the second leading cause of ignition in fatal house fires (1). Heating equipment that is kept in good repair is less likely to cause fires.
COMMENTS
Qualified engineers can ensure heating, ventilation, air conditioning (HVAC) systems are functioning properly and that applicable standards are being met. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) Website (http://www.ashrae.org) includes the qualifications required of its members and the location of the local ASHRAE chapter. The contractor who services the child care HVAC system should provide evidence of successful completion of ASHRAE or comparable courses. Caregivers/teachers should understand enough about codes and standards to be sure the facility’s building is a healthful place to be.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.1.8 Maintenance of Air Filters
5.2.9.5 Carbon Monoxide Detectors
REFERENCES
  1. Chowdhury, R., M. Greene, D. Miller. 2008. 2003-2005 residential fire loss estimates. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/fire05.pdf.

Standard 5.2.1.4: Ventilation When Using Art Materials

Areas where arts and crafts activities are conducted should be well-ventilated. Materials that create toxic fumes or gases such as spray adhesives and paints should not be used when children are present.Safety Data Sheets (SDS) should be obtained and kept for all chemicals used.

RATIONALE
Some art and craft supplies contain toxic ingredients, including possible human carcinogens, creating a significant risk to the health and well-being of children. Art supplies containing toxic chemicals can also produce fumes that trigger asthma, allergies, headaches, and nausea (1). 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 D4236-94(2005) (1). Children in grade six and lower should only use non-toxic art and craft materials (1,2). Labels are required on art supplies to identify any hazardous ingredients, risks associated with their use, precautions, first aid, and sources of further information.
COMMENTS
Staff should be educated to the possibility that some children may have special vulnerabilities to certain art materials (such as children with asthma or allergies). Not allowing food and drink near supplies prevents the possible cross contamination of materials and reduces potential injuries from poisoning. For more information on poisoning, contact the poison center at 1-800-222-1222 begin of the skype highlighting 1-800-222-1222 end of the skype highlighting.

See the How Asthma Friendly is Your Child Care Setting? checklist at http://www.nhlbi.nih.gov/health/public/lung/asthma/chc_chk.pdf to learn more about creating an asthma-friendly indoor environment.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.7 Proper Use of Art and Craft Materials
REFERENCES
  1. Art and Creative Materials Institute, Arts, Crafts, and Theater Safety, Inc., National Art Education Association, U.S. Consumer Product Safety Commission (CPSC). Art and craft safety guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015.pdf.
  2. Art and Creative Materials Institute. 2010. Safety - what you need to know. http://www.acminet.org/Safety.htm.

Standard 5.2.1.5: Ventilation of Recently Carpeted or Paneled Areas

Doors and windows should be opened in areas that have been recently carpeted or paneled using adhesives until the odors are no longer present. Window fans, room air conditioners, or other means to exhaust emission to the outdoors should be used.

RATIONALE
Adhesives that contain toxic materials can cause significant symptoms in occupants of buildings where these materials are used. Many carpets contain polybrominated diphenyl ethers (PBDEs) to retard flames. PBDEs are associated with several adverse health effects in animal studies including changes in memory and learning, interference with thyroid function, endocrine disruption, and cancer (2). One study found that toddlers and preschoolers typically had three times more of these compounds in their blood as their mothers (1).
COMMENTS
Facilities should choose carpeting or other flooring options that are PBDE-free. Low-odor, water-based, non-toxic products should be encouraged.

For more information on “safe” levels of home indoor air pollutants, contact the U.S. Environmental Protection Agency (EPA) or the U.S. Consumer Product Safety Commission (CPSC).

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Environmental Protection Agency. Pollution prevention and toxics: Polybrominated diphenylethers (PBDEs). http://www
    .epa.gov/oppt/pbde/.
  2. Lunder, S., A. Jacob. 2008. Fire retardants in toddlers and their mothers: Levels three times higher in toddlers than moms. Environmental Working Group. http://www.ewg.org/reports/pbdesintoddlers/.

Standard 5.2.1.6: Ventilation to Control Odors

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

 

Odors in toilets, bathrooms, diaper changing areas, and other inhabited areas of the facility should be controlled by ventilation and appropriate cleaning and disinfecting. Toilets and bathrooms, janitorial closets, and rooms with utility sinks or where wet mops and chemicals are stored should be mechanically ventilated to the outdoors with local exhaust mechanical ventilation to control and remove odors in accordance with local building codes. Air fresheners or sanitizers (both manmade and natural) should not be used. Adequate ventilation should be maintained during any cleaning, sanitizing, or disinfecting procedure to prevent children and caregivers/teachers from inhaling potentially toxic fumes.

RATIONALE
Air fresheners or sanitizers (both manmade and natural) may cause nausea, an allergic or asthmatic (airway tightening) response in some children (1). Ventilation and sanitation help control and prevent the spread of disease and contamination. 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
The SDS gives legally required information about the presence of Volatile Organic Compounds (VOCs) and the risk of exposure from all the chemicals in the product. The Occupational Safety and Health Administration (OSHA) requires the availability of the SDS to the workers who use chemicals (2). In addition these sheets should be available to anyone who might be exposed to the chemical in the child care facility.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
4.8.0.7 Ventilation Over Cooking Surfaces
REFERENCES
  1. U.S. Occupational Safety and Health Administration. 2009. Hazard communication: Foundation of workplace chemical safety programs. http://www.osha.gov/dsg/hazcom/index.html.
  2. Elliott, L., M. P. Longnecker, G. E. Kissling, S. J. London. 2006. Volatile organic compounds and pulmonary function in the Third National Health and Nutrition Examination Survey, 1988-1994. Environmental Health Perspective 114:1210-14.
NOTES

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

 

Standard 5.2.1.8: Maintenance of Air Filters

Filters in forced-air heating and cooling system equipment should be checked and cleaned or replaced according to the manufacturer’s instructions on a regular basis, at least every three months (and more often if necessary) (1).

RATIONALE
Clogged filters will impede proper air circulation required for heating and ventilation. Poor air flow causes pressure imbalances in the system and can result in the premature failure of equipment. Low air flow can reduce heating and cooling performance of the system and cause cooling coils to freeze up.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Environmental Protection Agency. 2009. Indoor air quality for schools program: Update. http://www.epa.gov/iaq/schools/pdfs/publications/iaqtfs_update17.pdf.

Standard 5.2.1.9: Type and Placement of Room Thermometers

Thermometers that will not easily break and that do not contain mercury should be placed on interior walls in every indoor activity area at children’s height.

RATIONALE
The temperature of the room can vary between the floor and the ceiling. Because heat rises, the temperature at the level where children are playing can be much cooler than at the usual level of placement of interior thermometers (the standing, eye level of adults). Mercury, glass, or similar materials in thermometers can cause injury and poisoning of children and adults. Mercury is a potent neurotoxin that can damage the brain and nervous system (1). Placing a safe digital thermometer at the children’s height allows proper monitoring of temperature where the children are in the room. A thermometer should not break easily if a child or adult bumps into it.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.2 Indoor Temperature and Humidity
REFERENCES
  1. U.S. Environmental Protection Agency. 2010. Mercury: Health effects. http://www.epa.gov/mercury/effects.htm.

Standard 5.2.1.10: Gas, Oil, or Kerosene Heaters, Generators, Portable Gas Stoves, and Charcoal and Gas Grills

Unvented gas or oil heaters and portable open-flame kerosene space heaters should be prohibited. Gas cooking appliances, including portable gas stoves, should not be used for heating purposes. Charcoal grills should not be used for space heating or any other indoor purposes.

Heat in units that involve flame should be vented properly to the outside and should be supplied with a source of combustion air that meets the manufacturer’s installation requirements.

RATIONALE
Due to improper ventilation, worn or faulty parts, or malfunctioning equipment, dangerous gases can accumulate and cause a fire or carbon monoxide poisoning. Carbon monoxide is a colorless, odorless, gas that is formed when carbon-containing fuel is not burned completely and can cause illness or death. See Standard 5.2.9.5 on installation of carbon monoxide detectors.

Many burns have been caused by contact with space heaters and other hot surfaces such as charcoal and gas grills (1). If charcoal grills are used outside, adequate staff ratios must be maintained and the person operating the grill should not be counted in the ratio.

COMMENTS
For more information on carbon monoxide poisoning and poison prevention, contact your local poison center by calling 1-800-222-1222 begin_of_the_skype_highlighting 1-800-222-1222 end_of_the_skype_highlighting.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.13 Barriers/Guards for Heating Equipment and Units
5.2.9.5 Carbon Monoxide Detectors
REFERENCES
  1. Palmieri, T. L., D. G. Greenhalgh. 2002. Increased incidence of heater-related burn injury during a power crisis. Arch Surg 137:1106-8.

Standard 5.2.1.12: Fireplaces, Fireplace Inserts, and Wood/Corn Pellet Stoves

Fireplaces, fireplace inserts, and wood/corn pellet stoves should be inaccessible to children. Fireplaces, fireplace inserts, and wood/corn pellet stoves should be certified to recognized national performance standards such as Underwriters Laboratories (UL) or the American National Standards Institute (ANSI) and Environmental Protection Agency (EPA) standards for air emissions. The front opening should be equipped with a secure and stable protective safety screen. Fireplaces, fireplace inserts, and wood/corn pellet stoves should be installed in accordance with the local or regional building code and the manufacturer’s installation instructions. The facility should clean the chimney as necessary to prevent excessive build-up of burn residues or smoke products in the chimney.

RATIONALE
Fireplaces provide access to surfaces hot enough to cause burns. Children should be kept away from fire because their clothing can easily ignite. Children should be kept away from a hot surface because they can be burned simply by touching it. Improperly maintained fireplaces, fireplace inserts, wood/corn pellet stoves, and chimneys can lead to fire and accumulation of toxic fumes.

A protective safety screen over the front opening of a fireplace will contain sparks and reduce a child’s accessibility to an open flame.

Heating equipment is the second leading cause of ignition of fatal house fires (1). This equipment can become very hot when in use, potentially causing significant burns.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.10 Gas, Oil, or Kerosene Heaters, Generators, Portable Gas Stoves, and Charcoal and Gas Grills
5.2.1.13 Barriers/Guards for Heating Equipment and Units
5.2.9.5 Carbon Monoxide Detectors
REFERENCES
  1. Chowdhury, R., M. Greene, D. Miller. 2008. 2003-2005 residential fire loss estimates. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/fire05.pdf.

Standard 5.2.1.15: Maintenance of Humidifiers and Dehumidifiers

If humidifiers or dehumidifiers are used to maintain humidity, as specified in Standard 5.2.1.2, the facility should follow the manufacturer’s cleaning, drainage, and maintenance instructions to avoid growth of bacteria and mold and subsequent discharge into the air.

RATIONALE
Bacteria and mold often grow in the tanks and drainage hoses of portable and console room humidifiers and can be released in the mist. Breathing dirty mist may cause lung problems ranging from flu-like symptoms to serious infection, and is of special concern to children and staff with allergy or asthma (1). Humidifiers or dehumidifiers may be required to meet American National Standards Institute (ANSI) and Association of Home Appliance Manufacturers (AHAM) humidifier standards and must not introduce additional hazards.
COMMENTS
Improperly maintained humidifiers may become incubators of biological organisms and increase the risk of disease. Film or scum appearing on the water surface, on the sides or bottom of the tank, or on exposed motor parts may indicate that the humidifier tank contains bacteria or mold. Also, increased humidity enhances the survival of dust mites, and many children are allergic to dust mites.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.2 Indoor Temperature and Humidity
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). CPSC issues alert about care of room humidifiers: Safety alert–dirty humidifiers may cause health problems. Document #5046. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/
    5046.html.

Standard 5.2.2.1: Levels of Illumination

Natural lighting should be provided in rooms where children work and play for more than two hours at a time. Wherever possible, windows installed at child’s eye level should be provided to introduce natural lighting. All areas of the facility should have glare-free natural and/or artificial lighting that provides adequate illumination and comfort for facility activities. The following guidelines should be used for levels of illumination:

  1. Reading, painting, and other close work areas: fifty to 100 foot-candles on the work surface;
  2. Work and play areas: thirty to fifty foot-candles on the surface;
  3. Stairs, walkways, landings, driveways, entrances: at least twenty foot-candles on the surface;
  4. Sleeping and napping areas: no more than five foot-candles during sleeping or napping except for infants and children who are resting in the same room that other children are involved with activities.

RATIONALE
These levels of illumination facilitate cleaning, reading, comfort, completion of projects, and safety (3). Too little light, too much glare and confusing shadows are commonly experienced lighting problems. Inadequate artificial lighting has been linked to eyestrain, headache, and non-specific symptoms of illness (1).

Natural lighting is the most desirable lighting of all. Windows installed at children’s eye level not only provide a source of natural light, they also provide a variety of perceptual experiences of sight, sound, and smell, which may serve as learning activities for children and a focus for conversation. The visual stimulation provided by a window is important to a young child’s development (1,2). Natural lighting provided by sky lights exposes children to variations in light during the day that is less perceptually stimulating than eye-level windows, but is still preferable to artificial lighting.

A study on school performance shows that elementary school children seem to learn better in classrooms with substantial daylight and the opportunity for natural ventilation (4).

Lighting levels should be reduced during nap times to promote resting or napping behavior in children. During napping and rest periods, some degree of illumination must be allowed to ensure that staff can continue to observe children. While decreased illumination for sleeping and napping areas is a reasonable standard when all the children are resting, this standard must not prevent support of individualized sleep schedules that are essential for infants and may be required by other children from time to time.

COMMENTS
When providing artificial lighting, consider purchasing energy-efficient bulbs or lamps (e.g., compact fluorescent lights [CFL] or light emitting diode [LED] bulbs) to help benefit our children’s environment (5-7). Saving electricity reduces carbon monoxide emissions, sulfur oxide, and high-level nuclear waste (8). CFLs contain very small amounts of mercury and care should be taken to ensure the lights are not at risk for breaking and are disposed of properly. In rooms that are used for many purposes, providing the ability to turn on and off different banks of lights in a room, or installation of light dimmers, will allow caregivers/teachers to adjust lighting levels that are appropriate to the activities that are occurring in the room.

Contact the lighting or home service department of the local electric utility company to have foot-candles measured.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.2.3 Areas for School-Age Children
REFERENCES
  1. Maine Senate Democrats. 2007. Legislative leaders change to high-efficiency light bulbs. http://www.maine.gov/tools/whatsnew/index.php?topic=Senatedemsall&id=43036&v=Article.
  2. Tanner, C. 2008. Explaining relationships among student outcomes and the school’s physical environment. J Advanced Academics 19:444-71.
  3. Kats, G. 2006. Greening America’s schools: costs and benefits. http://www.usgbc.org/ShowFile.aspx?DocumentID=2908.
  4. Heschong, L. 2002. Daylighting and human performance. ASHRAE J (June): 65-67.
  5. IESNA School and College Lighting Committee. 2000. Recommended practice on lighting for educational facilities. ANSI/IESNA RP-3-00. New York: Illuminating Engineering Society of North America.
  6. Greenman, J. 1998. Caring spaces, learning places: Children’s environments that work. Redmond, WA: Exchange Press.
  7. American Society of Heating, Refrigeration and Air-conditioning Engineers, American Institute of Architects, Illuminating Engineering Society of North America, U.S. Green Building Council, U.S. Department of Energy. 2008. Advanced energy design guide for K-12 school buildings, 148. Atlanta, GA: ASHRAE.
  8. Greiner, D., D. Leduc, eds. 2008. Well beings: A guide to health in child care. 3rd ed. Ottawa, ON: Canadian Paediatric Society.

Standard 5.2.2.3: High Intensity Discharge Lamps, Multi-Vapor, and Mercury Lamps

High intensity discharge lamps, multi-vapor, and mercury lamps should not be used for lighting the interior of buildings unless provided with special bulbs that self-extinguish if the outer glass envelope is broken.

RATIONALE
Multi-vapor and mercury lamps can be harmful when the outer bulb envelope is broken, causing serious skin burns and eye inflammation (1).
COMMENTS
High intensity lamps are not appropriate for internal illumination of child care facilities since the level of lighting generated is generally too strong for the size of a typical room and/or generates too much glare.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.2.1 Levels of Illumination
REFERENCES
  1. Balk, S. J., S. S. Aronson. 2003. Mercury in the environment: A danger to children. Child Care Info Exch (July/Aug): 58-60.

Standard 5.2.3.1: Noise Levels

Measures should be taken in all rooms or areas accommodating children to maintain the decibel (db) level at or below thirty-five decibels for at least 80% of the time as measured by an acoustical engineer or, more practically, by the ability to be clearly heard and understood in a normal conversation without raising one’s voice. These measures include noncombustible acoustical ceiling, rugs, wall covering, partitions, or draperies, or a combination thereof.

RATIONALE
Excessive sound levels can be damaging to hearing, reduce effective communication, and reduce psychosocial well-being. The level of noise that causes hearing loss commonly experienced by children with fluid in their middle ear space is thirty-five decibels (1). This level of hearing loss correlates with decreased understanding of language. By inference, this level of ambient noise may interfere with the ability of children to hear well enough to develop language normally (2,3).

Research on the effects of ambient noise levels in child care settings has focused on a) concern with damage to the child’s auditory system and b) non-auditory effects such as physiological effects (e.g., elevated blood pressure levels), motivational effects, and cognitive effects (3). Although noise sources may be located outside the child care facility, sometimes the noise source is related to the design of the child care spaces within the facility. In the article “Design of Child Care Centers and Effects of Noise on Young Children,” Maxwell states “spaces must allow for the fact that children need to make noise but the subsequent noise levels should not be harmful to them or others in the center” (3).

COMMENTS
When there is new construction or renovation of a facility, consideration should be given to a design that will reduce noise from outside. High ceiling heights may contribute to noise levels. Installing acoustical tile ceilings reduce noise levels as well as curtains or other soft window treatments over windows and wall-mounted cork boards (4).

While carpets can help reduce the level of noise, they can absorb moisture and serve as a place for microorganisms to grow. Area rugs should be considered instead of carpet because they can be taken up and washed often. Area rugs should be secured with a non-slip mat or other method to prevent tripping hazards.

Caregivers/teachers who need extensive help with sound abatement should consult a child care health consultant for additional ideas or with an acoustical engineer to measure noise levels within the facility. For further assistance on finding an acoustical engineer, contact the Acoustical Society of America.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Manlove, E. E., T. Frank. 2001. Why should we care about noise in classrooms and child care settings? Child Youth Care Forum 30:55-64.
  2. Maxwell, L. E., G. W. Evans. Design of child care centers and effects of noise on young children. Design Share. http://www.designshare.com/research/lmaxwell/noisechildren.htm.
  3. Newman, R. 2005. The cocktail party effect in infants revisited: Listening to one’s name in noise. Devel Psych 41:352-62.
  4. Lazaridis, E., J. C. Saunders. 2008. Can you hear me now? A genetic model of otitis media with effusion. J Clin Invest 118:471-74.

Standard 5.2.5.1: Smoke Detection Systems and Smoke Alarms

In centers with new installations, a smoke detection system (such as hard-wired system detectors with battery back-up system and control panel) or monitored wireless battery operated detectors that automatically signal an alarm through a central control panel when the battery is low or when the detector is triggered by a hazardous condition should be installed with placement of the smoke detectors in the following areas:

  1. Each story in front of doors to the stairway;
  2. Corridors of all floors;
  3. Lounges and recreation areas;
  4. Sleeping rooms.

In large and small family child care homes, smoke alarms that receive their operating power from the building electrical system or are of the wireless signal-monitored-alarm system type should be installed. Battery-operated smoke alarms should be permitted provided that the facility demonstrates to the fire inspector that testing, maintenance, and battery replacement programs ensure reliability of power to the smoke alarms and signaling of a monitored alarm when the battery is low and that retrofitting the facility to connect the smoke alarms to the electrical system would be costly and difficult to achieve.

Facilities with smoke alarms that operate using power from the building electrical system should keep a supply of batteries and battery-operated detectors for use during power outages.

RATIONALE
Because of the large number of children at risk in a center, up-to-date smoke detection system technology is needed. Wireless smoke alarm systems that signal and set off a monitored alarm are acceptable. In large and small family child care homes, single-station smoke alarms are acceptable. However, for all new building installations where access to enable necessary wiring is available, smoke alarms should be used that receive their power from the building’s electrical system. These hard-wired detecting systems typically have a battery operated back-up system for times of power outage. The hard-wired and wireless smoke detectors should be interconnected so that occupants receive instantaneous alarms throughout the facility, not just in the room of origin. Single-station batteries are not reliable enough; single-station battery-operated smoke alarms should be accepted only where connecting smoke detectors to existing wiring would be too difficult and expensive as a retrofitted arrangement.
COMMENTS
Some state and local building codes specify the installation and maintenance of smoke detectors and fire alarm systems. For specific information, see the NFPA 101: Life Safety Code (1) and the NFPA 72: National Fire Alarm and Signaling Code from the National Fire Protection Association.

The Federal Emergency Management Agency (FEMA) has an online coloring book that can be printed and used to teach children about fire safety at https://www.usfa.dhs.gov/applications/publications/display.cfm?id=208/.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.1.3 Compliance with Fire Prevention Code
REFERENCES
  1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.2.6.1: Water Supply

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

 

Every facility should be supplied with piped running water under pressure, from a source approved by the Environmental Protection Agency (EPA) and/or the regulatory health authority, to provide an adequate water supply to every fixture connected to the water supply and drainage system. The water should be sufficient in quantity and pressure to supply water for cooking, cleaning, drinking, toilets, and outside uses.

Water supplied by a well or other private source should meet all applicable health and safety federal, state, and local public health standards and should be approved by the local regulatory health authority. Well water should be tested annually for pH (acidity levels to determine whether the water is corrosive) and for bacteria, parasites, viruses, and chemical content (including, but not limited to arsenic, radon, MtBE, lead, nitrates, or other run-off chemicals) or according to local regulatory health authority (1,2). Any facility not served by a public water supply should keep on file documentation of approval, from the local regulatory health authority, of the water supply.

RATIONALE
A water supply that is safe and does not spread disease or filth or contain harmful substances is essential to health (3).
COMMENTS
For more information on water supply standards, contact the local health authority or the EPA.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.6.4 Water Test Results
REFERENCES
  1. U.S. Environmental Protection Agency (EPA). 2015.How contaminated water can affect human health. https://www.epa.gov/privatewells/how-contaminated-water-can-affect-human-health.      
  2. U.S. Environmental Protection Agency (EPA). 2015. Additional information on private wells. https://www.epa.gov/privatewells/additional-information-private-wells#how.      
  3. Centers for Disease Control and Prevention (CDC). 2016. Ground water awareness week is March 6-12, 2016. http://www.cdc.gov/features/groundwaterawareness/index.html.      
NOTES

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

 

Standard 5.2.6.2: Testing of Drinking Water Not From Public System

If the facility’s drinking water does not come from a public water system, or the facility gets the drinking water from a household well, programs should test the water every year or as required by the local health department, for bacteriological quality, nitrates, total dissolved solids, pH levels, and other water quality indicators as required by the local health department. Testing for nitrate is especially important if there are infants under six months of age in care.

RATIONALE
Drinking water sources should be approved by the local health department. If a child care facility does not receive drinking water from a public water system, the child care operator should ensure that the drinking water is safe. Unsafe water supplies may cause illness or other problems (1) and contain bacteria and parasites. Infants below the age of six months who drink water containing nitrate in excess of the maximum concentration limit of ten milligrams per liter could become seriously ill and, if untreated, may die. Symptoms include shortness of breath and blue-baby syndrome (methemoglobinia) (2). Even if a private water supply is safe, regular testing is valuable because it establishes a record of water quality.
COMMENTS
Public water systems are responsible for complying with all regulations, including monitoring, reporting, and performing treatment techniques. Testing of private water supplies should be completed by a state certified laboratory (1). Most testing laboratories or services supply their own sample containers. Samples for bacteriological testing must be collected in sterile containers and under sterile conditions. Laboratories may sometimes send a trained technician to collect the sample. For further information, contact the local health authority or the U.S. Environmental Protection Agency (EPA).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.6.1 Water Supply
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.6.4 Water Test Results
REFERENCES
  1. American Academy of Pediatrics. Policy statement: Drinking water from private wells and risks to children. Pediatrics 123:1599-1605.
  2. U.S. Environmental Protection Agency (EPA). 2005. Home water testing. Washington, DC: EPA, Office of Water. http://www.epa.gov/ogwdw000/faq/pdfs/fs_homewatertesting.pdf.

Standard 5.2.6.3: Testing for Lead and Copper Levels in Drinking Water

Drinking water, including water in drinking fountains, should be tested and evaluated in accordance with the assistance of the local health authority or state drinking water program to determine whether lead and copper levels are safe.

RATIONALE
Lead and copper in pipes can leach into water in harmful amounts and present a potential serious exposure. Lead exposure can cause: lower IQ levels, hearing loss, reduced attention span, learning disabilities, hyperactivity, aggressive behavior, coma, convulsion, and even death (2,3). Copper exposure can cause stomach and intestinal distress, liver or kidney damage, and complications of Wilson’s disease. Children’s bodies absorb more lead and copper than the average adult because of their rapid development (2,3).

It is especially important to test and have safe water at child care facilities because of the amount of time children spend in these facilities.

Caregivers/teachers should always run cold water for fifteen to thirty seconds before using for drinking, cooking, and making infant formula (3). Cold water is less likely to leach lead from the plumbing.

COMMENTS
Lead is not usually found in water that comes from wells or public drinking water supply systems. More commonly, lead can enter the drinking water when the water comes into contact with plumbing materials that contain lead (2,4).

Child care facilities that have their own water supply and are considered non-transient, non-community water systems (NTNCWS) are subject to the Environmental Protection Agency’s (EPA) Lead and Copper Rule (LCR) requirements, which include taking water samples for testing (1,2).

Contact your local health department or state drinking water program for information on how to collect samples and for advice on frequency of testing. See also the EPA references below.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.6.1 Water Supply
5.2.6.2 Testing of Drinking Water Not From Public System
4.2.0.6 Availability of Drinking Water
5.2.6.4 Water Test Results
5.2.9.13 Testing for Lead
REFERENCES
  1. Zhang, Y., A. Griffin, M. Edwards. 2008. Nitrification in premise plumbing: Role of phosphate, pH and pipe corrosion. Environ Sci Tech 42:4280-84.
  2. U.S. Environmental Protection Agency (EPA). 2005. 3Ts for reducing lead in drinking water in child care facilities: Revised guidance. Washington, DC: EPA, Office of Water. http://www.epa.gov/safewater/schools/pdfs/lead/toolkit_leadschools_guide_3ts_childcare.pdf.
  3. U.S. Environmental Protection Agency (EPA). 2005. Lead and copper rule: A quick reference guide for schools and child care facilities that are regulated under the safe Drinking Water Act. Washington, DC: EPA, Office of Water. http://www.epa.gov/safewater/schools/pdfs/lead/qrg_lcr_schools.pdf.
  4. U.S. Environmental Protection Agency (EPA). 2009. Drinking water in schools and child care facilities. http://water.epa.gov/infrastructure/drinkingwater/schools/index.cfm.

Standard 5.2.6.4: Water Test Results

All water test results should be in written form and kept with other required reports and documents in one central location in the facility, ready for immediate viewing by consumers and regulatory personnel. Early care and education programs should maintain photocopies of all water-testing results if the business is required to submit reports to the regulatory authority.

RATIONALE
Consumers and regulatory personnel can determine that testing has been done through written documentation (1).
COMMENTS
Some regulatory authorities prefer to review copies of water test results available for inspection on site; others that do not provide on-site inspections may prefer to have the reports submitted to them.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
9.4.1.6 Availability of Documents to Parents/Guardians
REFERENCES
  1. U.S. Environmental Protection Agency (EPA). 2005. 3Ts for reducing lead in drinking water in child care facilities: Revised guidance. Washington, DC: EPA, Office of Water. http://www.epa.gov/safewater/schools/pdfs/lead/toolkit_leadschools_guide_3ts_childcare.pdf.

Standard 5.2.6.5: Emergency Safe Drinking Water and Bottled Water

Emergency safe drinking water should be supplied during interruption of the regular approved water supply. Bottled water should be certified as chemically and bacteriologically potable by the Food and Drug Administration (FDA), local health department or its designee.

RATIONALE
Children must have constant access to fresh, potable water if the regular approved supply of drinking water is temporarily interrupted.
COMMENTS
The FDA regulates commercially bottled water and has established specific regulations for bottled water in Title 21 of the Code of Federal Regulations (21 CFR) (1). In addition to the FDA, state and local governments also regulate bottled water. Commercially-bottled water is considered to have an indefinite safety shelf life if it is produced in accordance with current good manufacturing practices (CGMP) and quality standard regulations and is stored in an unopened, properly sealed container. Therefore, FDA does not require an expiration date for bottled water. However, long-term storage of bottled water may result in aesthetic defects, such as off-odor and taste. Bottlers may voluntarily put expiration dates on their labels. The materials used to produce plastic containers for bottled water are regulated by the FDA as food contact substances. Food contact substances must be approved under FDA’s food additive regulations. Commercial bottled water containers should not be used for any purpose other than to hold drinking water. Other liquids should not be stored in bottled-water containers. All drinking water containers must be thoroughly washed and sanitized prior to being refilled with drinking water. For information on safe plastics, see Standard 5.2.9.9.

Under FDA labeling rules, bottled water includes products labeled: bottled water, drinking water, artesian water, mineral water, sparkling bottled water, spring water, purified water, distilled, de-mineralized, de-ionized, or reverse osmosis water. Waters with added carbonation, soda water (or club soda), tonic water, and seltzer historically are regulated by FDA as soft drinks (1).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.9.0.8 Supply of Food and Water for Disasters
5.2.9.9 Plastic Containers and Toys
REFERENCES
  1. Posnick, L. M., H. Kim. 2002. Bottled water regulation and the FDA. Food Safety Mag (Aug/Sept).

Standard 5.2.6.6: Water Handling and Treatment Equipment

Newly installed water handling, treatment, filtering, or softening equipment should meet applicable National Sanitation Foundation (NSF) standards and should be approved by the local regulatory health authority.

RATIONALE
Adherence to NSF standards will help ensure a safe water supply. State and local codes vary, but they generally protect against toxins or sewage entering the water supply.
COMMENTS
Model codes are available from the NSF.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. NSF International. 2004. Home water treatment devices. http://www.nsf.org/consumer/drinking_water/dw_treatment.asp.

Standard 5.2.6.7: Cross-Connections

The facility should have no cross-connections that could permit contamination of the potable water supply:

  1. Backflow preventers, vacuum breakers, or strategic air gaps should be provided for all boiler units in which chemicals are used. Backflow preventers should be tested annually;
  2. Vacuum breakers should be installed on all threaded janitorial sink faucets and outdoor/indoor hose bibs;
  3. Non-submersible, antisiphon ballcocks should be provided on all flush tank-type toilets.

RATIONALE
Pressure differentials may allow contamination of drinking water if cross-connections or submerged inlets exist. Water must be protected from cross-connections with possible sources of contamination (1).
COMMENTS
Short hoses are often attached to the faucets of janitorial sinks (and laundry sinks) and often extend below the top edge of the basin. The ends of a hose in a janitorial sink and a garden hose attached to an outside hose bibs are often found in a pool of potentially contaminated water. If the water faucet is not completely closed, a loss of pressure in the water system could result in the contaminated water being drawn up the hose like dirt is drawn into a vacuum cleaner, thus contaminating the drinking water supply.

Vacuum breakers may be installed as part of the plumbing fixture or are available to attach to the end of a faucet of hose bib.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. International Code Council (ICC). 2009. 2009 international plumbing code. Washington, DC: ICC.

Standard 5.2.7.1: On-Site Sewage Systems

A sewage system should be provided and inspected in accordance with state and local regulations. Whenever a public sewer is available, the facility should be connected to it. Where public sewers are not available, an on-site sewage system or other method approved by the local public health department should be installed. Raw or treated wastes should not be discharged on the surface of the ground.

The wastewater or septic system drainage field should not be located within the outdoor play area of a child care program, unless the drainage field has been designed by a sanitation engineer with the presence of an outdoor play area in mind and meets the approval of the local health authority.

The exhaust vent from a wastewater or septic system and drainage field should not be located within the children’s outdoor play area.

RATIONALE
Sewage must not be allowed to contaminate drinking water or ground water. It must be carried from the facility to a place where sanitary treatment equipment is available. Raw sewage is a health hazard and usually has an offensive odor.

The weight of children or the combined weight of children and playground equipment may cause the drainage field to become compacted, resulting in failure of the system. Some structures are anchored in concrete, which adds weight. The legs of some equipment, such as swing sets, can puncture the surface of drainage fields. In areas where frequent rains are coupled with high water tables, poor drainage, and flooding, the surface of drainage fields often becomes contaminated with untreated sewage.

COMMENTS
Whether the presence of an outdoor play area would adversely affect the operation of an on-site sewage system will depend on the type of playground equipment and method of anchoring, the type of resilient surface placed beneath playground equipment to reduce injury from falls, the soil type where the field would be placed (some soils are more compactable than others), the type of ground cover present (a cover of good grass underlain by a good sandy layer is much better than packed clay or some impermeable or slowly impermeable surface layer), and the design of the drainage field itself. Septic systems are now most commonly called “on-site sewage systems” or “on-site systems” because they treat and dispose of household wastewater on the household’s own property (1).

Staff should consult with the local public health department regarding sewage storage and disposal. The national/international organization representing on-site wastewater/sewage interests is the National On-Site Wastewater Recycling Association, Inc. (NOWRA).

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. National Onsite Wastewater Recycling Association (NOWRA). Homeowner’s onsite system guide and record keeping folder. http://www.nowra.org/documents/HomeownerOnsiteSystemGuide.pdf.

Standard 5.2.7.2: Removal of Garbage

Garbage and rubbish should be removed from rooms occupied by children, staff, parents/guardians, or volunteers on a daily basis and removed from the premises at least twice weekly or at other frequencies required by the regulatory health authority.

RATIONALE
This practice provides proper sanitation and protection of health, prevents infestations by rodents, insects, and other pests, and prevents odors and injuries.
COMMENTS
Compliance can be tested by checking for evidence of infestation and odors.
TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 5.2.7.3: Containment of Garbage

Garbage should be kept in containers approved by the regulatory health authority. Such containers should be constructed of durable metal or other types of material, designed and used so wild and domesticated animals and pests do not have access to the contents, and so they do not leak or absorb liquids. Waste containers should be kept covered with tight-fitting lids or covers when stored.

The facility should have a sufficient number of waste and diaper containers to hold all of the garbage and diapers that accumulate between periods of removal from the premises. Plastic garbage bag liners should be used in such containers. Exterior garbage containers should be stored on an easily cleanable surface. Garbage areas should be free of litter and waste that is not contained. Children should not be allowed access to garbage, waste, and refuse storage areas.

If a compactor is used, the surface should be graded to a suitable drain, as approved by the regulatory health authority.

RATIONALE
Containers for garbage attract animals and insects. When trash contains organic material, decomposition creates unpleasant odors. Therefore, child care facilities must choose and use garbage containers that control sanitation risks, pests, and offensive odors. Lining the containers with plastic bags reduces the contamination of the container itself and the need to wash the containers, which hold a concomitant risk of spreading the contamination into the environment.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.8.1 Integrated Pest Management

Standard 5.2.7.6: Storage and Disposal of Infectious and Toxic Wastes

Infectious and toxic wastes should be stored separately from other wastes, and should be disposed of in a manner approved by the regulatory health authority.

RATIONALE
This practice provides for safe storage and disposal of infectious and toxic wastes.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.2.9.7 Proper Use of Art and Craft Materials
5.2.9.8 Use of Play Dough and Other Manipulative Art or Sensory Materials
5.2.9.9 Plastic Containers and Toys
5.2.9.10 Prohibition of Poisonous Plants
5.2.9.11 Chemicals Used to Control Odors
5.2.9.12 Treatment of CCA Pressure-Treated Wood
5.2.9.13 Testing for Lead
5.2.9.14 Shoes in Infant Play Areas
5.2.9.15 Construction and Remodeling

Standard 5.2.8.1: Integrated Pest Management

Facilities should adopt an integrated pest management program (IPM) to ensure long-term, environmentally sound pest suppression through a range of practices including pest exclusion, sanitation and clutter control, and elimination of conditions that are conducive to pest infestations. IPM is a simple, common-sense approach to pest management that eliminates the root causes of pest problems, providing safe and effective control of insects, weeds, rodents, and other pests while minimizing risks to human health and the environment (2,4).

Pest Prevention: Facilities should prevent pest infestations by ensuring sanitary conditions. This can be done by eliminating pest breeding areas, filling in cracks and crevices; holes in walls, floors, ceilings and water leads; repairing water damage; and removing clutter and rubbish on the premises (5).

Pest Monitoring: Facilities should establish a program for regular pest population monitoring and should keep records of pest sightings and sightings of indicators of the presence of pests (e.g., gnaw marks, frass, rub marks).

Pesticide Use: If physical intervention fails to prevent pest infestations, facility managers should ensure that targeted, rather than broadcast applications of pesticides are made, beginning with the products that pose least exposure hazard first, and always using a pesticide applicator who has the licenses or certifications required by state and local laws.

Facility managers should follow all instructions on pesticide product labels and should not apply any pesticide in a manner inconsistent with label instructions. Safety Data Sheets (SDS) are available from the product manufacturer or a licensed exterminator and should be on file at the facility Facilities should ensure that pesticides are never applied when children are present and that re-entry periods are adhered to.

Records of all pesticides applications (including type and amount of pesticide used), timing and location of treatment, and results should be maintained either on-line or in a manner that permits access by facility managers and staff, state inspectors and regulatory personnel, parents/guardians, and others who may inquire about pesticide usage at the facility.

Facilities should avoid the use of sprays and other volatilizing pesticide formulations. Pesticides should be applied in a manner that prevents skin contact and any other exposure to children or staff members and minimizes odors in occupied areas. Care should be taken to ensure that pesticide applications do not result in pesticide residues accumulating on tables, toys, and items mouthed or handled by children, or on soft surfaces such as carpets, upholstered furniture, or stuffed animals with which children may come in direct contact (3).

Following the use of pesticides, herbicides, fungicides, or other potentially toxic chemicals, the treated area should be ventilated for the period recommended on the product label.

Notification: Notification should be given to parents/guardians and staff before using pesticides, to determine if any child or staff member is sensitive to the product. A member of the child care staff should directly observe the application to be sure that toxic chemicals are not applied on surfaces with which children or staff may come in contact.

Registry: Child care facilities should provide the opportunity for interested staff and parents/guardians to register with the facility if they want to be notified about individual pesticide applications before they occur.

Warning Signs: Child care facilities must post warning signs at each area where pesticides will be applied. These signs must be posted forty-eight hours before and seventy-two hours after applications and should be sufficient to restrict uninformed access to treated areas.

Record Keeping: Child care facilities should keep records of pesticide use at the facility and make the records available to anyone who asks. Record retention requirements vary by state, but federal law requires records to be kept for two years (7). It is a good idea to retain records for a minimum of three years.

Pesticide Storage: Pesticides should be stored in their original containers and in a locked room or cabinet accessible only to authorized staff. No restricted-use pesticides should be stored or used on the premises except by properly licensed persons. Banned, illegal, and unregistered pesticides should not be used.

RATIONALE
Children must be protected from exposure to pesticides (1). To prevent contamination and poisoning, child care staff must be sure that these chemicals are applied by individuals who are licensed and certified to do so. Direct observation of pesticide application by child care staff is essential to guide the pest management professional away from surfaces that children can touch or mouth and to monitor for drifting of pesticides into these areas. The time of toxic risk exposure is a function of skin contact, the efficiency of the ventilating system, and the volatility of the toxic substance. Spraying the grounds of a child care facility exposes children to toxic chemicals. Studies and a recent consensus statement address the risk of neurodevelopmental effects from exposure to pesticides (6). Exposure to pesticides has been linked to learning and developmental disorders. Children are more vulnerable as their metabolic, enzymatic, and immunological systems are immature. Pesticides should only be used as an emergency application to eliminate threats to human health (6).
COMMENTS
Manufacturers of pesticides usually provide product warnings that exposure to these chemicals can be poisonous.

Child care staff should ask to see the license of the pest management professional and should be certain that the individual who applies the toxic chemicals has personally been trained and preferably, individually licensed, i.e., not working in the capacity of a technician being supervised by a licensed pest management professional. In some states only the owner of a pest management company is required to have this training, and s/he may then employ unskilled workers. Child care staff should ensure that the pest management professional is familiar with the pesticide s/he is applying.

Child care staff should contact their state pesticide office and request that their child care facility be added to the state pesticide sensitivity list, in states where such a list exists. When a child care facility is placed on the state pesticide sensitivity list, the child care staff will be notified if there are plans for general pesticide application occurring near the child care facility.

For further information about pest control, contact the state pesticide regulatory agency, the Environmental Protection Agency (EPA), or the National Pesticide Information Center. For possible poison exposure, contact the local poison center at 1-800-222-1222.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. South Dakota State University, Department of Plant Science. Restricted use pesticide record keeping: Pesticide recordkeeping is more than just a good idea -- it’s the law! http://www.sdstate.edu/ps/extension/pat/pesticide-record.cfm.
  2. Gilbert, S. G. 2007. Scientific consensus statement on environmental agents associated with neurodevelopmental disorders. Bolinas, CA: Collaborative on Health and the Environment (CHE). http://www.neep.org/uploads/NEEPResources/id27/lddistatement.pdf.
  3. University of California, Agriculture and Natural Resources. UC IPM online: Statewide integrated pest management program. How to manage pests. http://www.ipm.ucdavis.edu.
  4. The IPM Institute of North America. IPM standards for schools. http://ipminstitute.org/school.htm.
  5. U.S. Environmental Protection Agency. Integrated pest management (IPM) in child care.

    http://www.epa.gov/pesticides/controlling/childcare-ipm.htm.

  6. U.S. Environmental Protection Agency. Integrated pest management (IPM) in schools. http://www.epa.gov/pesticides/ipm/index.htm.
  7. Tulve, N. S., P. A. Jones, M. G. Nishioka, R. C. Fortmann, C. W. Croghan, J. Y. Zhou, A. Fraser, C. Cave, W. Friedman. 2006. Pesticide measurements from the First National Environmental Health Survey of Child Care Centers using a multi-residue GC/MS analysis method. Environ Sci Tech 40:6269-74.

Standard 5.2.8.2: Insect Breeding Hazard

No facility should maintain or permit to be maintained any receptacle or pool, whether natural or artificial, containing water in such condition that insects breeding therein may become a public health issue.

RATIONALE
Collection of water in tin cans, children’s toys, flower pots, rain gutters, discarded tires and other refuse, and natural pools of water can provide breeding sites for mosquitoes. Elimination of mosquito breeding sites is one of the basic environmental control methods.

Mosquitoes are responsible for transmitting a variety of diseases. Mosquito-borne viruses such as West Nile virus, eastern equine encephalitis, western equine encephalitis, and St. Louis encephalitis have occurred in the United States and Canada (1). Children can develop allergic reactions to mosquito and fire ant bites and bee and wasp stings.

COMMENTS
Regular surveillance for stinging insect nests is important.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
5.2.8.1 Integrated Pest Management
REFERENCES
  1. Heymann, D. L. 2008. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association.

Standard 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
3.6.3.2 Labeling, Storage, and Disposal of Medications
5.2.8.1 Integrated Pest Management
3.6.3.1 Medication Administration
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks
REFERENCES
  1. 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.
  2. American Academy of Pediatrics Council on Environmental Health. Pesticide exposure in children. Pediatrics. 2012:130(6). http://pediatrics.aappublications.org/content/130/6/e1757.
  3. 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.
  4. 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
  5. 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.
  6. Safe Kids Grand Forks, Altru Health System. 2016. Electronic cigarette safety tips. http://safekidsgf.com/Documents/6053-0375-E-cigaretteSafetyTips.pdf.
  7. 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.
NOTES

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

 

Standard 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.

Standard 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.

Standard 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). 1993. Radon measurement in schools: Revised edition. https://www.epa.gov/sites/production/files/2014-08/documents/radon_measurement_in_schools.pdf.      
  2. 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.
NOTES

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

 

Standard 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. Safe Kids Worldwide.  Home Safety Fact Sheet. http://www.safekids.org/fact-sheet/home-safety-fact-sheet-2015-pdf.
  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. 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.
  4. Tremblay, K. R., Jr. 2006. Preventing carbon monoxide problems. Colorado State University Extension. http://www.ext.colostate.edu/pubs/consumer/09939.html.

Standard 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. 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.
  2. U.S. Consumer Product Safety Commission (CPSC). Asbestos in the home. http://www.cpsc.gov/cpscpub/pubs/453.html.
  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.

Standard 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. U.S. Consumer Product Safety Commission (CPSC). Art and craft safety guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015.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.

Standard 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.

Standard 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. 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.
  2. 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.
  3. 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.
  4. American Academy of Pediatrics. 2007. Technical report: Pediatric exposure and potential toxicity of phthalate plasticizers. Pediatrics 119:1031.
  5. 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.
  6. 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.
  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. 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.
  9. 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.
  10. Kluwe, W. M. 1986. Carcinogenic potential of phthalic acid esters and related compounds: Structure-activity relationships. Environ Health Perspectives 65:271-78.
  11. Huff, J. 1982. Di(2-ethylhexyl) adipate: Condensation of the carcinogenesis bioassay, technical report.Environ Health Perspectives 45:205-7.
  12. 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
  13. Eco-Healthy Child Care. 2010. Plastics and plastic toys. Children’s Environmental Health Network. http://www.cehn.org/files/Plastics_Plastic_Toys_Dec2010.pdf.

Standard 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. 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. American Academy of Pediatrics. 2011. Handbook of common poisonings in children. 4th ed. Elk Grove Village, IL: AAP.

Standard 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. Children’s Environmental Health Network. (March 2016). Fragrances. Retrieved from http://www.cehn.org/our-work/eco-healthy-child-care/ehcc-faqs/fragrances/.
  2. 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.
  3. 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.
  4. 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
  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. 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.  
NOTES

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

 

Standard 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. 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.
  2. 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.
  3. 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.
  4. 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/.
NOTES

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

 

Standard 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. Environmental Protection Agency. 2010. Lead in paint, dust, and soil: Renovation, repair and painting (RRP). http://www.epa.gov/lead/pubs/renovation.htm.
  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. 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.
  4. 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.
  5. 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.
NOTES

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

Standard 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.

Standard 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 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
  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 Agency. 2010. An introduction to indoor air quality: Volatile organic compounds (VOCs). http://www.epa.gov/iaq/voc.html.
NOTES

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

C. General Furnishings/Equipment and Maintenance

Standard 5.3.1.1: Safety of Equipment, Materials, and Furnishings

Equipment, materials, furnishings, and play areas should be sturdy, safe, and in good repair and should meet the recommendations of the U.S. Consumer Product Safety Commission (CPSC) for control of the following safety hazards:

  1. Openings that could entrap a child’s head or limbs;
  2. Elevated surfaces that are inadequately guarded;
  3. Lack of specified surfacing and fall zones under and around climbable equipment;
  4. Mismatched size and design of equipment for the intended users;
  5. Insufficient spacing between equipment;
  6. Tripping hazards;
  7. Components that can pinch, sheer, or crush body tissues;
  8. Equipment that is known to be of a hazardous type;
  9. Sharp points or corners;
  10. Splinters;
  11. Protruding nails, bolts, or other components that could entangle clothing or snag skin;
  12. Loose, rusty parts;
  13. Hazardous small parts that may become detached during normal use or reasonably foreseeable abuse of the equipment and that present a choking, aspiration, or ingestion hazard to a child;
  14. Strangulation hazards (e.g., straps, strings, etc.);
  15. Flaking paint;
  16. Paint that contains lead or other hazardous materials;
  17. Tip-over hazards, such as chests, bookshelves, and televisions.

RATIONALE
The hazards listed in this standard are those found by CPSC to be most commonly associated with injury (1).

A study conducted by the Center for Injury Research and Policy of The Research Institute at Nationwide Children’s Hospital found that from 1990-2007 an average of nearly 15,000 children younger than eighteen years of age visited emergency departments annually for injuries received from furniture tip-overs (2).

COMMENTS
Equipment and furnishings that are not sturdy, safe, or in good repair, may cause falls, entrap a child’s head or limbs, or contribute to other injuries. Disrepair may expose objects that are hazardous to children. Freedom from sharp points, corners, or edges should be judged according to the Code of Federal Regulations, Title 16, Section 1500.48, and Section 1500.49. Freedom from small parts should be judged according to the Code of Federal Regulations, Title 16, Part 1501. To obtain these publications, contact the Superintendent of Documents of the U.S. Government Printing Office. For assistance in interpreting the federal regulations, contact the CPSC; the CPSC also has regional offices.

Used equipment and furnishings should be closely inspected to determine whether they meet this standard before allowing them to be placed in a child care facility. If equipment and furnishings have deteriorated to a state of disrepair, where they are no longer sturdy or safe, they should be removed from all areas of a child care facility to which children have access. Staff should check on a regular basis to ensure that toys and equipment used by children have not been recalled. A list of recalls can be accessed at http://www.cpsc.gov, or facilities can subscribe to an email notification list from the CPSC (see also, RELATED STANDARDS).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.6.1 Strangulation Hazards
5.1.3.5 Finger-Pinch Protection Devices
5.1.6.6 Guardrails and Protective Barriers
5.3.1.2 Product Recall Monitoring
5.4.5.2 Cribs
REFERENCES
  1. Gottesman, B. L., L. B. McKenzie, K. A. Conner, G. A. Smith. 2009. Injuries from furniture tip-overs among children and adolescents in the United States, 1990-2007. Clin Pediatrics 48:851.
  2. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 5.3.1.4: Surfaces of Equipment, Furniture, Toys, and Play Materials

Frequently Asked Questions/CFOC3 Clarifications

Reference: 5.3.1.4

Date: 10/13/2011

Topic & Location:
Chapter 5
Facilities
Standard 5.3.1.4: Surfaces of Equipment, Furniture, Toys, and Play Materials

Question:
Do all pressed wood items contain formaldehyde?

Answer:
All pressed wood items do not contain added formaldehyde; however, all wood naturally contains some formaldehyde. Pressed wood products that have the highest formaldehyde emissions are those that are made with urea-formaldehyde resins. Products designed for interior use, such as hardwood plywood, medium density fiberboard, and particleboard, are more likely to contain urea-formaldehyde than those designed for exterior use such as oriented strand board or structural plywood. However, hardwood plywood, medium density fiberboard, and particleboard don't necessarily contain added formaldehyde; they are sometimes made with no added formaldehyde based resins. Many companies are choosing to make products with no added formaldehyde (NAF) based resins as well as ultra low-emitting formaldehyde (ULEF) based resins both to market their products as green and to comply with California regulations on composite wood products. Some products are currently labeled as made with NAF or ULEF resins under the California regulations, and once EPA regulations are proposed and go into effect, more products will be labeled to inform consumers about formaldehyde content.

Equipment, furnishings, toys, and play materials should have smooth, nonporous surfaces or washable fabric surfaces that are easy to clean and sanitize, or be disposable.

Walls, ceilings, floors, furnishings, equipment, and other surfaces should be suitable to the location and the users. They should be maintained in good repair, free from visible soil and in a clean condition. Programs should choose materials with the least probability of containing materials that off-gas toxic elements such as volatile organic compounds (VOCs), formaldehyde, or toxic flame retardants (polybrominated diphenylethers [PBDE]). Carpets, porous fabrics, and other surfaces that trap soil and potentially contaminated materials should not be used in toilet rooms, diaper change areas, and areas where food handling occurs (1).

Areas used by staff or children who have allergies to dust mites or components of furnishings or supplies should be maintained according to the recommendations of primary care providers.

RATIONALE
Few young children practice good hygiene. Messy play is developmentally appropriate in all age groups, and especially among very young children, the same group that is most susceptible to infectious disease. These factors lead to soiling and contamination of equipment, furnishings, toys, and play materials. To avoid transmission of disease within the group, these materials must be easy to clean and sanitize.

Formaldehyde and toxic flame retardants are the toxins of most concern in household furnishings, as they are both commonly found in furniture and carpets. Formaldehyde is a flammable, colorless gas that has a pungent odor. It is a human carcinogen, an asthma trigger, and a suspected neurological, reproductive, and liver toxin. People are exposed by breathing contaminated air from pressed wood furniture, flooring, and after application of certain paints, fabrics, and household cleaners. Toxic Flame Retardants (PBDEs) are widely used in furniture foam, carpet padding, back coatings for draperies and upholstery, plastics, building materials, and electrical appliances. It is believed that more than 80% of PBDE exposure is from house dust. PBDEs persist in the environment and accumulate in living things. Health concerns associated with PBDE exposure include liver, thyroid, and neurodevelopmental toxicity.

Carpets and porous fabrics are not appropriate for some areas because they are difficult to clean and sanitize. Disease-causing microorganisms have been isolated from carpets. Caregivers/teachers must remove illness-causing materials. Many allergic children have allergies to dust mites, which are microscopic insects that ingest the tiny particles of skin that people shed normally every day. Dust mites live in carpeting and fabric but can be killed by frequent washing and use of a clothes dryer or mechanical, heated dryer. Restricting the use of carpeting and furnishings to types that can be laundered regularly helps. Other children may have allergies to animal products such as those with feathers, fur, or wool, while some may be allergic to latex.

COMMENTS
Toys that can be washed in a mechanical dishwasher that meets the standard for cleaning and sanitizing dishes can save labor, if the facility has a dishwasher. Otherwise, after the children have used them, these toys can be placed in a tub of detergent water to soak until the staff has time to scrub, rinse, and sanitize the surfaces of these items. Except for fabric surfaces, nonporous surfaces are best because porous surfaces can trap organic material and soil. Fabric surfaces that can be laundered provide the softness required in a developmentally appropriate environment for young children. If these fabrics are laundered when soiled, the facility can achieve cleanliness and sanitation. When a material cannot be cleaned and sanitized it should be discarded.

One way to measure compliance with the standard for cleanliness is to wipe the surface with a clean mop or clean rag, and then insert the mop or rag in cold rinse water. If the surface is clean, no residue will appear in the rinse water.

Disposable gloves are commonly made of latex or vinyl. If latex-sensitive individuals are present in the facility, only vinyl or nitrile disposable gloves should be used.

Tips for Reducing Exposure to Formaldehyde and PBDEs:

  1. Avoid wall-to-wall carpets;
  2. Limit use of pressed wood products that are made with adhesives that contain urea-formaldehyde (UF) resins; choose solid-wood furniture;
  3. Do not leave foam exposed (this includes furniture and toys, such as stuffed animals);
  4. Keep dust levels down;
  5. Vacuum often – use a high efficiency particulate air (HEPA) filter vacuum cleaner;
  6. Ventilate while cleaning;
  7. Except in emergency situations, remove shoes prior to going indoors;
  8. Clean area rugs with biodegradable cleaners;
  9. Choose floor coverings that are made with natural fibers (cotton, hemp, and wool) that are naturally fire-resistant and contain fewer chemicals (2).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.15 Construction and Remodeling
REFERENCES
  1. Eco-Healthy Child Care (EHCC). Furniture and carpets. Washington, DC: EHCC. http://www.oeconline.org/resources/publications/factsheetarchive/Furniture and carpets.pdf.
  2. U.S. Environmental Protection Agency. Polybrominated diphenylethers (PBDEs). http://www.epa.gov/oppt/pbde/.

Standard 5.3.1.6: Floors, Walls, and Ceilings

Floors, walls, and ceilings should be in good repair, and easy to clean when soiled. Only smooth, nonporous surfaces should be permitted in areas that are likely to be contaminated by body fluids or in areas used for activities involving food. The hand contact and splash areas of doors and walls should be covered with a finish that is at least as cleanable as an epoxy finish or enamel paint.

Floors should be free from cracks, bare concrete, dampness, splinters, sliding rugs, and uncovered telephone jacks or electrical outlets.

Carpeting should be clean, in good repair, nonflammable, and nontoxic.

Each bathroom, toilet room, and shower room floor and wall should be impervious to water up to a height of five feet and capable of being kept in a clean and sanitary condition.

All public bathrooms should be constructed of materials that are impervious to moisture, bacteria, mold, or fungus growth. The floor-to-wall joints should be constructed to provide a sanitary cove with a minimum radius of three-eighths inch. Flooring material should be appropriate for bathroom use (e.g., vinyl sheet, ceramic tile, fiber-reinforced plastic, epoxy products). All wall surfaces within twenty-four inches of a water closet or urinal should be ceramic tile to a height of forty-eight inches (1).

RATIONALE
Messy play and activities that lead to soiling of floors and walls is developmentally appropriate in all age groups, but especially among very young children, the same group that is most susceptible to infectious disease. These factors lead to soiling and contamination of floors and walls. A smooth, nonporous surface prevents deterioration and mold and is easier to clean and sanitize; therefore, helps prevent the spread of infectious diseases. To avoid transmission of disease within the group, and to maintain an environment that supports learning cleanliness as a value, all surfaces should be kept clean.

Cracked or porous floors cannot be kept clean and sanitary. Dampness promotes the growth of mold. Rugs without friction backing or underlayment and uncovered telephone jacks or electrical outlets in floors are tripping hazards. Damaged floors, walls or ceilings can expose underlying hazardous structural elements and materials. Surface materials must not pose health, safety, or fire hazards.

COMMENTS
Carpeted floors are not smooth, and therefore, carpeting is not consistent with this standard, except for area carpets for activities that do not involve food or contact with body fluids. Many family child care homes and indoor playrooms of centers use wall-to-wall carpeting on the floor. Although carpeted floors may be more comfortable to walk and play on, smooth floor surfaces provide a better environment for children with allergies (2).

Washable rugs can be placed on smooth floor surfaces. By using friction backings or underlayment, removable and washable carpeting can be used on smooth floor surfaces safely.

When facilities use carpeting or sound-absorbing materials on walls and ceilings, these materials must not be used in areas where contamination with body fluids or food is likely because they are difficult to clean. Thus, carpeted walls should not be present around the diaper change areas, in toilet rooms, in food preparation areas, or where food is served.

Obtain ASTM D2859-06 Standard Test Method for Flammability of Finished Textile Floor Covering Materials, for flammability of finished materials from ASTM International. Ask the local fire marshal for fire safety code requirements.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Davis, J. L. Breathe easy: 5 ways to improve indoor air quality. http://www.webmd.com/health-ehome-9/indoor-air-quality.
  2. International Building Code. 2012. Section 1210 Toilet and Bathroom Requirements.http://publicecodes.cyberregs.com/icod/ibc/2012/icod_ibc_2012_12_sec010.htm

Standard 5.4.1.5: Chemical Toilets

Chemical toilets should not be used in child care facilities unless they are provided as a temporary measure in the event that the facility’s normal plumbed toilets are not functioning. Constant supervision should be required for young children using a chemical toilet. In the event that chemical toilets may be required on a temporary basis, the caregiver/teacher should seek approval for use from the regulatory health agency.

RATIONALE
Chemical toilets can pose a safety hazard to young children. Young children climbing on the toilet seat could fall through the opening and into the chemical that is contained in the waste receptacle.
COMMENTS
A chemical toilet is a toilet consisting of a seat or bowl attached to a container holding a chemical solution that changes waste into sludge (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Dictionary.com. 2000. Chemical toilets. The American heritage dictionary of the English language. 4th ed. http://dictionary.reference.com/browse/chemical toilets.

Standard 5.4.2.6: Maintenance of Changing Tables

Changing tables should be nonporous, kept in good repair, and cleaned and disinfected after each use to remove visible soil and germs.

RATIONALE
Many infectious diseases can be prevented through appropriate cleaning and disinfection procedures. It is difficult, if not impossible, to disinfect porous surfaces, broken edges, and surfaces that cannot be completely cleaned. Bacterial cultures of environmental surfaces in child care facilities have shown fecal contamination, which has been used to gauge the adequacy of sanitation and hygiene measures practiced at the facility (1).

One study has demonstrated that “diapering, handwashing, and food preparation equipment that is specifically designed to reduce the spread of infectious agents significantly reduced diarrheal illness among the children and absence as a result of illness among staff in out-of-home child care centers” (2).

COMMENTS
Caregivers/teachers should be reminded that many disinfectants leave residues that can cause skin irritation or other symptoms. Caregivers/teachers should always follow the manufacturer’s instructions for preparation and use.

A U.S. Environmental Protection Agency (EPA)-registered product labeled for use as a disinfectant suitable for the surface material should be used to disinfect the changing table after use. Some bleach products are EPA-registered disinfectants.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red book: 2015 report to the committee of infectious diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. 
  2. Kotch, J. B., P. Isbell, D. J. Weber, V. Nguyen, E. Gunn, S. Fowlkes, J. Virk, J. Allen. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics120: e29-e36.

Standard 5.5.0.5: Storage of Flammable Materials

Content in the STANDARD was modified on 08/2011.

Gasoline, hand sanitizers in volume, and other flammable materials should be stored in a separate building, in a locked area, away from high temperatures and ignition sources, and inaccessible to children.

RATIONALE
Flammable materials such as chemicals and cleaners account for the majority of burns to the head and face of children (1). These materials are also involved in unintentional ingestion by children.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. D’Souza, A. L., N. G. Nelson, L. B. McKenzie. 2009. Pediatric burn injuries treated in US emergency departments between 1990 and 2006. Pediatrics 124:1424-30.
NOTES

Content in the STANDARD was modified on 08/2011.

Standard 5.6.0.4: Microfiber Cloths, Rags, and Disposable Towels and Mops Used for Cleaning

Microfiber cloths should be preferred for cleaning. They should be laundered between each use. If microfiber cloths are not appropriate for use, disposable towels should be preferred for cleaning. If clean reusable rags are used, they should be laundered separately between each one-time use for cleaning. Disposable towels should be sealed in a plastic bag and removed to outside garbage. Cloth rags should be placed in a closed, foot-operated, plastic-lined receptacle until laundering. When a mop is needed, microfiber mops should be considered as a preferred cleaning method over conventional loop mops. Use of sponges in child care facilities for cleaning purposes is not recommended.

RATIONALE
Microfiber cloths are superior at picking up bacteria and holding it in the fibers. The microfiber mopping system offers many health and safety benefits. The microfiber mopping system is as effective as using the traditional loop mop method, yet there is a reduction in the use of and exposure to harsh disinfectant chemicals (2). Additionally, the microfiber mops are lighter and easier to use than conventional mops thus lessening the potential for worker muscle sprains (1). The system leaves only a light film of water on the floor that dries quickly, thus lessening the potential for worker injury for slips and falls on a wet floor. Materials used for cleaning become contaminated in the process and must be handled so they do not spread potentially infectious material (3).
COMMENTS
Sponges generally are contaminated with bacteria and are difficult to clean.

For more detailed information on microfiber cloths and mopping, see Sustainable Hospitals Project EPA Best Practices Publication Using Microfiber Mops in Hospitals, available at http://www.epa.gov/region9/waste/p2/projects/hospital/mops.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Hoyle, M., B. Slezak. 2008. Understanding microfiber’s role in infection. Infection Control Today (May). http://www.infectioncontroltoday.com/articles/2008/11/understanding-microfiber-s-role-in-infection-prev.aspx.
  2. Sustainable Hospitals Project, University of Massachusetts–Lowell. 2003. Are microfiber mops beneficial for hospitals? http://www.sustainablehospitals.org/PDF/MicrofiberMopCS.pdf.
  3. Sustainable Hospitals Project, University of Massachusetts–Lowell. 2003. 10 reasons to use microfiber mopping. http://www.sustainablehospitals.org/PDF/tenreasonsmop.pdf.

Standard 5.7.0.1: Maintenance of Exterior Surfaces

Porches, steps, stairs, and walkways should:

  1. Be maintained free from accumulations of water, ice, or snow;
  2. Have a non-slip surface;
  3. Be kept free of loose objects;
  4. Be in good repair;
  5. Be free of flaking paint.

RATIONALE
Trip surfaces lead to injury. Flaking lead-based paint can be ingested in sufficient quantities to cause lead poisoning (1,2,3).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.13 Testing for Lead
REFERENCES
  1. 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.
  2. Centers for Disease Control and Prevention (CDC). 2005. Preventing lead poisoning in young children. Atlanta, GA: CDC. http://www.cdc.gov/nceh/lead/publications/prevleadpoisoning.pdf.
  3. U.S. Consumer Product Safety Commission (CPSC). What you should know about lead based paint in your home: Safety alert. https://chemlinks.beloit.edu/classes/Chem117/lead/CPSC5054.pdf

Standard 5.7.0.2: Removal of Hazards From Outdoor Areas

All outdoor activity areas should be maintained in a clean and safe condition by removing:

  1. Debris;
  2. Dilapidated structures;
  3. Broken or worn play equipment;
  4. Building supplies and equipment;
  5. Glass;
  6. Sharp rocks;
  7. Stumps and roots;
  8. Branches;
  9. Animal excrement;
  10. Tobacco waste (cigarette butts);
  11. Garbage;
  12. Toxic plants;
  13. Anthills;
  14. Beehives and wasp nests;
  15. Unprotected ditches;
  16. Wells;
  17. Holes;
  18. Grease traps;
  19. Cisterns;
  20. Cesspools;
  21. Unprotected utility equipment;
  22. Other injurious material.

Holes or abandoned wells within the site should be properly filled or sealed. The area should be well-drained, with no standing water.

A maintenance policy for playgrounds and outdoor areas should be established and followed.

RATIONALE
Proper maintenance is a key factor when trying to ensure a safe play environment for children. Each playground is unique and requires a routine maintenance check program developed specifically for that setting.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
6.2.5.2 Inspection of Play Area Surfacing
9.2.6.1 Policy on Use and Maintenance of Play Areas

Standard 5.7.0.3: Removal of Allergen Triggering Materials From Outdoor Areas

Outdoor areas should be kept free of excessive dust, weeds, brush, high grass, and standing water.

RATIONALE
Dust, weeds, brush, and high grass are potential allergens (1). Standing water breeds insects.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Asthma and Allergy Foundation of America. 2005. Allergy overview. http://www.aafa.org/display.cfm?id=9&cont=82/.

Standard 5.7.0.5: Cleaning Schedule for Exterior Areas

A cleaning schedule for exterior areas should be developed and assigned to appropriate staff members. Delegated staff members should actively look for flaking or peeling paint while cleaning the exterior areas. If flaking/peeling paint is found, it should be tested for lead. If the paint is found to contain lead, the area should be covered by latex-based paint to create a barrier between the lead-based paint and the children in care.

RATIONALE
Developing a cleaning schedule that delegates responsibility to specific staff members helps ensure that the child care facility is appropriately cleaned. Proper cleaning reduces the risk of injury and the transmission of disease.

Lead paint chips may be ingested by young children and lead to neurological and behavioral problems. Covering the lead paint with latex paint reduces toxic exposure (1-3).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.13 Testing for Lead
REFERENCES
  1. 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.
  2. 1.    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.
  3. U.S. Consumer Product Safety Commission (CPSC. What you should know about lead based paint in your home: Safety alert.  https://chemlinks.beloit.edu/classes/Chem117/lead/CPSC5054.pdf

Standard 5.7.0.6: Storage Area Maintenance and Ventilation

Storage areas should have appropriate lighting and be kept clean. If the area is a storage room, the area should be mechanically ventilated to the outdoors when chemicals or a janitorial sink are present.

RATIONALE
Spilled items must be removed to promote health and safety. Spilled dry foods could attract rodent and insects. Chemicals and janitorial supplies can build up toxic fumes that can leak into occupied areas if they are not ventilated to the outdoors (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Environmental Protection Agency. An introduction to indoor air quality. http://www.epa.gov/iaq/voc.html.

Standard 5.7.0.7: Structure Maintenance

The structure should be kept in good repair and safe condition.

Each window, exterior door, and basement or cellar hatchway should be kept in sound condition and in good repair.

RATIONALE
Older preschool-age and younger school-age children readily engage in play and explore their environments. The physical structure where children spend each day can present caregivers/teachers with special safety concerns if the structure is not kept in good repair and maintained in a safe condition. For example, peeling paint in an older building may be ingested, floor surfaces in disrepair could cause falls and other injury, and broken glass windows could cause severe cuts or other glass injury (1).

Children’s environments must be protected from exposure to moisture, dust, and excessive temperatures.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.1.6 Structurally Sound Facility
REFERENCES
  1. Whole Building Design Guide Secure/Safe Committee. 2010. Ensure occupant safety and health. National Institute of Building Sciences. http://www.wbdg.org/design/ensure_health.php.

Standard 5.7.0.10: Cleaning of Humidifiers and Related Equipment

Humidifiers, dehumidifiers, and air-handling equipment that involve water should be cleaned and disinfected according to manufacturers’ instructions.

RATIONALE
These appliances provide comfort by controlling the amount of moisture in the indoor air. To get the most benefit, the facility should follow all instructions. If the facility does not follow recommended care and maintenance guidelines, microorganisms may be able to grow in the water and become airborne, which may lead to respiratory problems (1).
COMMENTS
For additional information, contact the U.S. Consumer Product Safety Commission (CPSC) and the Association of Home Appliance Manufacturers (AHAM).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). CPSC issues alert about care of room humidifiers: Safety alert. Dirty humidifiers may cause health problems. http://www.cpsc.gov/PageFiles/121804/5046.pdf.

VI. Play Areas/Playgrounds

Standard 6.1.0.1: Size and Location of Outdoor Play Area

The facility or home should be equipped with an outdoor play area that directly adjoins the indoor facilities or that can be reached by a route that is free of hazards and is no farther than one-eighth mile from the facility. The playground should comprise a minimum of seventy-five square feet for each child using the playground at any one time.

The following exceptions to the space requirements should apply:

  1. A minimum of thirty-three square feet of accessible outdoor play space is required for each infant;
  2. A minimum of fifty square feet of accessible outdoor play space is required for each child from eighteen to twenty-four months of age.

There should be separated areas for play for the following ages of children:

  1. Ages six through twenty-three months
  2. Ages two to five years*
  3. Ages five to twelve years**

*These areas may be further sub-divided into ages two to three years and four to five years.

** These areas may be further sub-divided into grades K-1, 2-3, and 4-6.

The outdoor playground should include an open space for running that is free of other equipment (4).

RATIONALE
Play areas must be sufficient to allow freedom of movement without collisions among active children.

Providing more square feet per child may correspond to a decrease in the number of injuries associated with gross motor play equipment (1). An aggregate size of greater than 4,200 square feet that includes all of a facility’s playgrounds has been associated with significantly greater levels of children’s physical activity (5).

In addition, meeting proposed Americans with Disabilities Act (ADA) outdoor play area requirements for accessible routes, and developing natural, outdoor play yards with variety and shade can only be achieved if sufficient outdoor play space is provided.

The space exceptions are based on early childhood and playground professionals’ experience (2). This follows the developmental ages used for the development of the Standards for play equipment for children.

COMMENTS
Children benefit from being outside as much as possible and it is important to provide sufficient outdoor space to accommodate the full enrollment of children (2). If a facility has less than seventy-five square feet of outdoor space per child, then the facility should augment the outdoor space by providing a large indoor play area (see Standard 6.1.0.2).

Additional space beyond the standard of seventy-five square feet per child may be required to meet ADA outdoor play area requirements, depending on the layout and terrain (3). A Certified Playground Safety Inspector (CPSI) can be utilized for guidance in assisting with outdoor play areas. To locate a CPSI, check the National Park and Recreation Association (NPRA) registry at https://ipv.nrpa.org/CPSI_registry/.

Children may play in older children’s areas if the equipment is appropriate for the youngest child present.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.2 Playing Outdoors
5.1.1.5 Environmental Audit of Site Location
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
6.1.0.2 Size and Requirements of Indoor Play Area
REFERENCES
  1. Dowda, M., W. H. Brown, C. Addy, K. A. Pfeiffer, K. L. McIver, R. R. Pate. 2009. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 123: e261-66.
  2. Brown, W. H., K. A. Pfeiffer, K. L. Mclver, M. Dowda, C. L. Addy, R. R. Pate. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Devel 80:45-58.
  3. Architectural and Transportation Barriers Compliance Board (U.S. Access Board). 2005. Accessible play areas: A summary of accessibility guidelines for play areas. http://www.access-board.gov/play/guide/guide.pdf.
  4. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.
  5. Ruth, L. C. 2008. Playground design and equipment. Whole Building Design Guide. http://www.wbdg.org/resources/
    playground.php.

Standard 6.1.0.2: Size and Requirements of Indoor Play Area

If a facility has less than seventy-five square feet of accessible outdoor space per child or provides active play space indoors for other reasons, a large indoor activity room that meets the requirement for seventy-five square feet per child may be used if it meets the following requirements:

  1. It provides for types of activities equivalent to those performed in an outdoor play space;
  2. The area is ventilated with fresh, temperate air at a minimum of five cubic feet per minute per occupant when open windows are not possible;
  3. The surfaces and finishes are shock-absorbing, as required for outdoor installations in Standard 6.2.3.1;
  4. The play equipment meets the requirements for outdoor installation as stated in Standards 6.2.1.3-6.2.1.6 and Standards 6.2.2.3-6.2.2.4.

There should be separated areas for play for the following ages of children:

  1. Ages six through twenty-three months
  2. Ages two to five years*
  3. Ages five to twelve years**

*These areas may be further sub-divided into ages two to three years and four to five years.

** These areas may be further sub-divided into grades K-1, 2-3, and 4-6.

RATIONALE
This standard provides facilities located in inner-city areas or areas with extreme weather with an alternative that allows gross motor play when outdoor spaces are unavailable or unusable. Indoor gross motor play must provide an experience like outdoor play, with safe and healthful environmental conditions that match the benefits of outdoor play as closely as possible. These spaces may be interior if ventilation is adequate to prevent undue concentration of organisms, odors, carbon dioxide, humidity and other substances consistent with ASHRAE’s “Standard 62: Ventilation for Acceptable Indoor Air Quality.” This follows the developmental ages used for the development of the Standards for play equipment for children (1,2).
COMMENTS
For days in which weather does not permit outdoor play, the facility is encouraged to provide an alternate place for gross motor activities indoors for children of all ages. This space could be a dedicated gross motor room or a gym, a large hallway, or even a classroom in which furniture has been pushed aside. The room should provide adequate space for children to do vigorous activities including running.

Qualified heating and air conditioning contractors should have a meter to measure the rate of airflow. Before indoor areas are used for gross motor activity, a heating and air conditioning contractor should be called in to make airflow measurements.

TYPE OF FACILITY
Center
RELATED STANDARDS
3.1.3.2 Playing Outdoors
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
6.2.1.3 Design of Play Equipment
6.2.1.4 Installation of Play Equipment
6.2.1.5 Play Equipment Connecting and Linking Devices
6.2.1.6 Size and Anchoring of Crawl Spaces
6.2.1.7 Enclosure of Moving Parts on Play Equipment
6.2.1.8 Material Defects and Edges on Play Equipment
6.2.1.9 Entrapment Hazards of Play Equipment
6.2.2.1 Use Zone for Fixed Play Equipment
6.2.2.2 Arrangement of Play Equipment
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
  2. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 6.1.0.7: Shading of Play Area

Children should be provided shade in play areas (not just playgrounds). Shading may be provided by trees, buildings, or shade structures. Metal equipment (especially slides) should be placed in the shade (1,2). Sun exposure should be reduced by timing children’s outdoor play to take place before ten o’clock in the morning or after four o’clock in the afternoon standard time (3).

RATIONALE
The shade will provide comfort and prevent sunburn or burning because the structures or surfacing are hot. Access to sun and shade is beneficial to children while they play outdoors. Light exposure of the skin to sunlight promotes the production of vitamin D that growing children require for bone development and immune system health (8). Additionally, research shows sun may play an important role in alleviating depression. Exposure to sun is needed, but children must be protected from excessive exposure. Individuals who suffer severe childhood sunburns are at increased risk for skin cancer. Practicing sun-safe behavior during childhood is the first step in reducing the chances of getting skin cancer later in life (4). Placing metal equipment (such as slides) in the shade prevents the buildup of heat on play surfaces. Hot play surfaces can cause burns on children (5,7).
COMMENTS
A tent with sides up, awning, or other simple shelter from the sun can be available. Parents/guardians can be encouraged to supply protective clothing and age-appropriate sunscreen with written permission to apply to specified children, as necessary (6).

For more information on appropriate clothing and footwear when playing outdoors, see Standard 9.2.3.1.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.2 Playing Outdoors
3.4.5.1 Sun Safety Including Sunscreen
5.1.3.2 Possibility of Exit from Windows
9.2.3.1 Policies and Practices that Promote Physical Activity
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. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
  3. California Department of Public Health. Skin cancer prevention program. http://www.cdph.ca.gov/programs/SkinCancer/Documents/Skin-Cancer-Mission.pdf.
  4. Hendricks, C. 2005. Healthy Childcare Consultants. Safe fun in the sun. http://www.childhealthonline.org/Safe Fun in the Sun Booklet color.pdf.
  5. U.S. Environmental Protection Agency. 2009. Sunwise kids. http://www.epa.gov/sunwise/kids/index.html.
  6. Healthy Children. 2010. Safety and prevention: Sun safety. American Academy of Pediatrics. http://www.healthychildren.org/english/safety-prevention/at-play/pages/Sun-Safety.aspx.
  7. National Program for Playground Safety. Tips for limiting sun exposure. http://www.playgroundsafety.org/safety/
    sunexposure.htm.

Standard 6.1.0.8: Enclosures for Outdoor Play Areas

The outdoor play area should be enclosed with a fence or natural barriers. Fences and barriers should not prevent the observation of children by caregivers/teachers. If a fence is used, it should conform to applicable local building codes in height and construction. Fence posts should be outside the fence where allowed by local building codes. These areas should have at least two exits, with at least one being remote from the buildings.

Gates should be equipped with self-closing and positive self-latching closure mechanisms. The latch or securing device should be high enough or of a type such that children cannot open it. The openings in the fence and gates should be no larger than three and one-half inches. The fence and gates should be constructed to discourage climbing. Play areas should be secured against inappropriate use when the facility is closed.

Wooden fences and playground structures created out of wood should be tested for chromated copper arsenate (CCA). Wooden fences and playground structures created out of wood that is found to contain CCA should be sealed with an oil-based outdoor sealant annually.

RATIONALE
This standard helps to ensure proper supervision and protection, prevention of injuries, and control of the area (3). An effective fence is one that prevents a child from getting over, under, or through it and keeps children from leaving the fenced outdoor play area, except when supervising adults are present. Although fences are not childproof, they provide a layer of protection for children who stray from supervision. Small openings in the fence (no larger than three and one-half inches) prevent entrapment and discourage climbing (1,2). Fence posts should be on the outside of the fence to prevent injuries from children running into the posts or climbing on horizontal supports (2).

Fences that prevent the child from obtaining a proper toe hold will discourage climbing. Chain link fences allow for climbing when the links are large enough for a foothold. Children are known to scale fences with diamonds or links that are two inches wide. One-inch diamonds are less of a problem.

CCA is a wood preservative and insecticide that is made up of 22% arsenic, a known carcinogen. In 2004, CCA was phased-out for residential uses; however, older, treated wood is a still a health concern, particularly for children. For more information on CCA-treated wood products, see Standard 5.2.9.12.

COMMENTS
Picket fences with V spaces at the top of the fencing are a potential entrapment hazard.

Some fence designs have horizontal supports on the side of the fence that is outside the play area which may allow intruders to climb over the fence. Facilities should consider selecting a fence design that prevents the ability to climb on either side of the fence.

For additional information on fencing, consult the ASTM International “Standard F2049-09b: Standard Guide for Fences/Barriers for Public, Commercial, and Multi-family Residential use Outdoor Play Areas” (2).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.12 Treatment of CCA Pressure-Treated Wood
REFERENCES
  1. ASTM International (ASTM). 2009. Standard guide for fences/barriers for public, commercial, and multi-family residential use outdoor play areas. ASTM F2049-09b. West Conshohocken, PA: ASTM.
  2. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.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.

Standard 6.2.1.1: Play Equipment Requirements

Play equipment and materials in the facility should meet the recommendations of the U.S. Consumer Product Safety Commission (CPSC) and the ASTM International (ASTM) for public playground equipment. Equipment and materials intended for gross-motor (active) play should conform to the recommendations in the CPSC Public Playground Safety Handbook and the provisions in the ASTM “Standard F1487-07ae1: Consumer Safety Performance Specifications for Playground Equipment for Public Use.”

All play equipment should be constructed, installed, and made available to the intended users in such a manner that meets CPSC guidelines and ASTM standards, as warranted by the manufacturers’ recommendations. A Certified Playground Safety Inspector (CPSI) who has been certified by the National Recreation and Park Association (NRPA) should conduct an inspection of playground plans for new installations. Previously installed playgrounds should be inspected at least once each year, by a CPSI or local regulatory agency, and whenever changes are made to the equipment or intended users.

Inspectors should specifically test wooden play equipment structures for chromated copper arsenate (CCA). The wood in many playground sets can contain potentially hazardous levels of arsenic due to the use of CCA as a wood preservative.

Play equipment and materials should be deemed appropriate to the developmental needs, individual interests, abilities, and ages of the children, by a person with at least a master’s degree in early childhood education or psychology, or identified as age-appropriate by a manufacturer’s label on the product package. Enough play equipment and materials should be available to avoid excessive competition and long waits.

The facility should offer a wide variety of age-appropriate portable play equipment (e.g., balls, jump ropes, hoops, ribbons, scarves, push/pull toys, riding toys, rocking and twisting toys, sand and water play toys) in sufficient quantities that multiple children can play at the same time (1-5).

Children should always be supervised when playing on playground equipment.

RATIONALE
The active play areas of a child care facility are associated with frequent and severe injuries (8). Many technical design and installation safeguards are addressed in the ASTM and CPSC standards. Manufacturers who guarantee that their equipment meets these standards and provide instructions for use to the purchaser ensure that these technical requirements will be met under threat of product liability. Certified Playground Safety Inspectors (CPSI) receive training from the NPRA in association with the National Playground Safety Institute (NPSI). Since the training received by CPSIs exceeds that of most child care personnel, obtaining a professional inspection to detect playground hazards before they cause injury is highly worthwhile.

Playgrounds designed for older children might present intrinsic hazards to preschool-age children. Equipment that is sized for larger and more mature children poses challenges that younger, smaller, and less mature children may not be able to meet.

The health effects related to arsenic include: irritation of the stomach and intestines, birth or developmental effects, cancer, infertility, and miscarriages in women. CCA is a wood preservative and insecticide that is made up of 22% arsenic, a known carcinogen. Much of the wood in playground equipment contains high levels of this toxic substance. In 2004, CCA was phased-out for residential uses; however, older, treated wood is a still a health concern, particularly for children (6).

COMMENTS
Compliance should be measured by structured observation.

A general guideline for establishing play equipment heights is one foot per year of age of the intended users. In some states, height limitations for playground equipment are:

  1. Thirty-two inches for infants and toddlers (six months to twenty-three months) (7);
  2. Forty-eight inches for preschoolers (thirty months to five years of age);
  3. Six and one-half feet for school-age children (six through twelve years of age).

Consult with your regulatory health authority for any local or state requirements.

Check the ASTM Website – http://www.astm
.org – for up-to-date standards. To obtain the publications listed above, contact the ASTM or the CPSC.

To locate a CPSI, check the NPRA registry at https://
ipv.nrpa.org/CPSI_registry/.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.3.0.2 Cleaning and Sanitizing Toys
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
2.2.0.1 Methods of Supervision of Children
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. ASTM International (ASTM). 2007. Standard consumer safety performance specification for playground equipment for public use. ASTM F1487-07ae1. West Conshohocken, PA: ASTM.
  3. American Academy of Pediatrics (AAP), Committee on Environmental Health. 2003. Arsenic. In Pediatric environmental health, ed. R. A. Etzel. Elk Grove Village, IL: AAP.
  4. Dowda, M., W. H. Brown, et al. 2009. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 123: e261-66.
  5. Brown, W. H., K. A. Pfeiffer, et al. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Development 80:45-58.
  6. Bower, J. K., D. P. Hales, et al. 2008. The childcare environment and children’s physical activity. Am J Prev Med 34:23-29.
  7. Ammerman, A. S., D. S. Ward, et al. 2007. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care (NAP SACC) theory and design. Prev Chronic Dis 4 (July).
  8. Ammerman, A., S. E. Benjamin, et al. 2004. The nutrition and physical activity self assessment for child care (NAP SACC). Raleigh and Chapel Hill, NC: Division of Public Health, Center for Health Promotion and Disease Prevention.

Standard 6.2.1.8: Material Defects and Edges on Play Equipment

All pieces of play equipment should be free of sharp edges, protruding parts, weaknesses, and flaws in material construction. Sharp edges in wood, metal, or concrete should be rounded on all edges. All corners and edges on rigid materials should have a minimum radius of one-quarter inch unless the material thickness is less than one-half inch, in which case the radius should be half the thickness of the material. This requirement does not apply to swing seats, straps, ropes, chains, connectors, and other flexible components. Wood materials should be free of chromated copper arsenate (CCA), sanded smooth, and should be inspected regularly for splintering.

RATIONALE
Any sharp or protruding surface presents a potential for lacerations and contusions to the child’s body (1-4).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.12 Treatment of CCA Pressure-Treated Wood
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
  2. ASTM International (ASTM). 2007. Standard consumer safety performance specification for playground equipment for public use. ASTM F1487-07ae1. West Conshohocken, PA: ASTM.
  3. ASTM International (ASTM). 2008. Standard consumer safety performance specification for public use play equipment for children 6 months through 23 months. ASTM F2373-08. West Conshohocken, PA: ASTM.
  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.

Standard 6.2.4.1: Sandboxes

The facility should adhere to the following requirements for sand play areas:

  1. Sandboxes should be constructed to permit drainage;
  2. Sandboxes should be covered with a lid or other covering when they are not in use;
  3. Sandboxes should be kept free from cat and other animal excrement;
  4. Sandboxes should be regularly cleaned of foreign matter;
  5. Sandboxes should be located away from prevailing winds, if this is not possible, windbreaks using bushes, trees, or fences should be provided;
  6. Sand used in the box should be washed, free of organic, toxic, or harmful materials, and fine enough to be shaped easily;
  7. Sand should be replaced as often as necessary to keep the sand visibly clean and free of extraneous materials;
  8. Sand play areas should be distinct from landing areas for slides or other equipment;
  9. Sand play area covers should be adequately secured when they are lifted or moved to allow children to play in the sandbox.

RATIONALE
Wet sand can be a breeding ground for insects and can promote mold and bacterial growth (2).

Uncovered sand is subject to contamination and transmission of disease from animal feces (such as toxoplasmosis from cat feces) and insects breeding in sandboxes (1). Replacement of sand may is required to keep it free of foreign material that could cause injury.

There is potential for used sand to contain toxic or harmful ingredients such as tremolite, an asbestos-like substance. Sand that is used as a building material or is harvested from a site containing toxic substances may contain potentially harmful substances. Sand can come from many sources. Caregivers/teachers should be sure they are using sand labeled as a safe play material or sand that is specifically prepared for sandbox use.

COMMENTS
Sand already installed in play areas cannot be safely cleaned without leaving residues that could harm children.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.8.1 Integrated Pest Management
5.2.8.2 Insect Breeding Hazard
3.3.0.2 Cleaning and Sanitizing Toys
REFERENCES
  1. Warren, N. 2007. How to build a sandbox. Articles Base. http://www.articlesbase.com/home-improvement-articles/how-to-build-a-sandbox-115888.html.
  2. Villar, R. G., M. Connick, L. L. Barton, F. J. Meaney, M. F. Davis. 1998. Parent and pediatrician knowledge, attitudes, and practices regarding pet-associated hazards. Arch Pediatr Adolesc Med 152:1035-37.

Standard 6.2.4.2: Water Play Tables

Communal, unsupervised water play tables should be prohibited. Communal water tables should be permitted if children are supervised and the following conditions apply:

  1. The water tables should be filled with fresh potable water immediately before designated children begin a water play activity at the table, and changed when a new group begins a water play activity at the table even if all the child-users are from a single group in the space where the water table is located; or, the table should be supplied with freely flowing fresh potable water during the play activity;
  2. The basin and toys should be washed and sanitized at the end of the day;
  3. If the basin and toys are used by another classroom, the basin and toys should be washed and sanitized prior to use;
  4. Only children without cuts, scratches, and sores on their hands should be permitted to use a communal water play table;
  5. Children should wash their hands before and after they use a communal water play table;
  6. Caregivers/teachers should ensure that no child drinks water from the water table;
  7. Floor/surface under and around the water table should be dried during and after play;
  8. Avoid use of bottles, cups, and glasses in water play, as these items encourage children to drink from them.

As an alternative to a communal water table, separate basins with fresh potable water for each child to engage in water play should be permitted. If separate basins of water are used and placed on the floor, close supervision is crucial to prevent drowning.

RATIONALE
Contamination of hands, toys, and equipment in the room in which play tables are located seems to play a role in the transmission of diseases in child care settings (1,2). Proper handwashing, supervision of children, and cleaning and sanitizing of the water table will help prevent the transmission of disease (3).

Children have drowned in very shallow water (4).

COMMENTS
A designated group of children is defined as the children in a classroom in a center or the children in a family child care setting.

To avoid splashing chemical solutions around the child care environment, the addition of bleach to the water is not recommended.

Keeping the floor/surface dry with towels and/or wiping up water on the floor during and after play is recommended to reduce the potential for children and staff slipping/falling.

Another way to use water play tables is to use the table to hold a personal basin of potable water for each child who is engaged in water play. With this approach, supervision must be provided to be sure children confine their play to their own basin. Wherever a suitable inlet and outlet of water can be arranged, safe communal water play can involve free-flowing potable water by attaching a hose to the table that connects to the water source and attaching a hose to the table’s drain that connects to a water drain or suitable run-off area.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.3.0.2 Cleaning and Sanitizing Toys
6.3.5.2 Water in Containers
REFERENCES
  1. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child-care centers. Infect Dis Clin North Am 11:347-65.
  2. 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.
  3. American Academy of Pediatrics (AAP), Committee on Environmental Health. 2003. Child care centers. In Pediatric environmental health, ed. R. A. Etzel. Elk Grove Village, IL: AAP.
  4. Van, R., A. L. Morrow, R. R. Reves, L. K. Pickering. 1991. Environmental contamination in child day-care centers. Am J Epidemiol 133:460-70.

Standard 6.2.4.3: Sensory Table Materials

All materials used in a sensory table should be nontoxic and should not be of a size or material that could cause choking. Sensory table activities should not be used with children under eighteen months of age. For toddlers, materials should be limited to water, sand and fixed plastic objects. All sensory table activities should be supervised for toddlers and preschool children. When water is used in a sensory table, the requirements of Standard 6.2.4.2, Water Play Tables should be met.

RATIONALE
According to the federal government’s small parts standard on safe-size toys for children under three years of age, a prohibited small part is any object that fits completely into a specially designed test cylinder two and one-quarter inches long by one and one-quarter inches wide, which approximates the size of the fully expanded throat of a child under three-years-old. Since round objects are more likely to choke children because they can completely block a child’s airway, balls and toys with parts that are spheroid, ovoid, or elliptical with a diameter smaller than one and three-quarter inches should be banned for children under three years old (4,5); any part smaller than this is a potential choking hazard (5). Injury and fatality from aspiration of small parts is well-documented (4). Eliminating small parts from children’s environment will greatly reduce this risk.

According to the U.S. Food and Drug Administration (FDA), eating as few as four or five uncooked kidney beans can cause severe nausea, vomiting, and diarrhea. In addition to their toxicity, raw kidney beans are small objects that could be inserted by a child into his nose or ear; beans can potentially get stuck, swell, and be difficult to remove (1). Styrofoam peanuts could cause choking. Flour could be aspirated and affect breathing; if spilled on the floor, flour could cause slipping. If soil is used, it must be free from chemicals such as fertilizer or pesticides.

Sensory table activities/materials are not developmentally appropriate for children under the age of eighteen months; the potential health and safety hazards outweigh the benefits for use with this age group. Supervision is required for toddlers and preschool-age children to ensure that they are using materials appropriately (2,3).

Sand used in sensory tables should be new “sterilized” natural sand that is labeled for use in children’s sandboxes or labeled as play sand. Water used in sensory tables must be potable and clean.

COMMENTS
Children’s hands should be washed before and after using the sensory table. Children with open areas (cuts/sores) should not be allowed to use the sensory table.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.2.4.1 Sandboxes
6.2.4.2 Water Play Tables
3.2.2.1 Situations that Require Hand Hygiene
3.3.0.2 Cleaning and Sanitizing Toys
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
  2. U.S. Consumer Product Safety Commission (CPSC). 2004. CPSC warns parents about choking hazards to young children, announces new recall of toys posing choking hazards. Release #04-216. http://www.cpsc.gov/cpscpub/prerel/prhtml04/04216.html.
  3. Cryer, D., T. Harms, C. Riley. 2004. All about the ITERS-R. Lewisville, NC: Kaplan Early Learning.
  4. Harms, T., D. Cryer, R. M. Clifford. 2006. Infant/toddler environment rating scale. Rev ed. New York: Teachers College Press. http://ers.fpg.unc.edu/
    infanttoddler-environment-rating-scales-iters-r/.
  5. California Childcare Health Program, University of California San Francisco School of Nursing. Health and safety tip. Child Care Health Connections 16:1. http://www.ucsfchildcarehealth.org/pdfs/newsletters/2003/CCHPJul_Aug03.pdf.

Standard 6.3.2.3: Pool Equipment and Chemical Storage Rooms

Pool equipment and chemical storage rooms should be locked, ventilated, and used only for pool equipment and pool chemicals.

RATIONALE
Pool chemicals are kept in concentrated forms that are hazardous to children. Access to these hazards must be carefully controlled (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Environmental Protection Agency (EPA), Office of Solid Waste and Emergency Response. 2001. Chemical safety alert: Safe storage and handling of swimming pool chemicals. https://www.epa.gov/rmp/chemical-safety-alert-safe-storage-and-handling-swimming-pool-chemicals

Standard 6.3.4.1: Pool Water Quality

Water in swimming pools and built-in wading pools that children use should be maintained between pH 7.2 and pH 7.8. The water should be disinfected by available free chlorine between 1.0 ppm and 3.0 ppm, or bromine between 1.0 ppm and 6.0 ppm, or by an equivalent agent approved by the health department. The pool should be cleaned, and the chlorine or equivalent disinfectant level and pH level should be tested every two hours during periods of use.

Equipment should be available to test for and maintain a measurable residual disinfectant content in the water and to check the pH of the water. Water should be sampled and a bacteriological analysis conducted to determine absence of fecal coliforms (e.g., Escherichia coli, Pseudomonas aeruginosa, and Giardia intestinalis) at least monthly or at intervals required by the local health authority.

RATIONALE
This practice provides control of bacteria and algae and enhances the participants’ comfort and safety. Maintaining pH and disinfectant levels within the prescribed range suppresses bacterial growth to tolerable levels.

Bacteriologic water safety must be ensured to prevent the spread of disease via ingestion of pool water. The chemicals a pool needs to maintain the required standards differ from pool to pool – and day to day. Keeping records of the pool chemistry over time can help interpret its characteristics and aid in performing the correct task (1,3).

COMMENTS
If a stabilized chlorine compound is used, the pH should be maintained between 7.2 and 7.7, and the free available chlorine residual should be at least 1.50 ppm.

For further information, see the Model Aquatic Health Code from the Centers for Disease Control and Prevention (2).

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. American Chemistry Council, Chlorine Chemistry Division. Pool treatment 101: Introduction to chlorine sanitizing. http://www.americanchemistry.com/s_chlorine/sec_content.asp?CID=1167&DID=4529&CTYPEID=109/.
  2. Centers for Disease Control and Prevention. 2010. Model aquatic health code. http://www.cdc.gov/healthywater/swimming/pools/mahc/.
  3. Association of Pool and Spa Professionals (APSP), Recreational Water Quality Committee. 2009. Standard for water quality in public pools and spas. ANSI/APSP-11 2009. Alexandria, VA: APSP.

Standard 6.3.4.2: Chlorine Pucks

“Chlorine Pucks” must not be placed in skimmer baskets or placed anywhere in pools when children are present. If pucks are used, they must be dissolved before children enter the pool.

RATIONALE
Although this practice can keep chlorine disinfectant levels high, it can be dangerous because the “puck” is a concentrated form of chlorine and is very caustic. Curious children may take out a puck and handle it, causing serious skin irritations or burns (1). Contact with eyes can cause serious injury. Lung damage can occur if children inhale vapors, or children could ingest the poison.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Environmental Protection Agency. 2010. Swimming pool chemicals, chlorine. http://www.epa.gov/kidshometour/products/cjug.htm.

Standard 6.4.1.2: Inaccessibility of Toys or Objects to Children Under Three Years of Age

Small objects, toys, and toy parts available to children under the age of three years should meet the federal small parts standards for toys. The following toys or objects should not be accessible to children under three years of age:

  1. Toys or objects with removable parts with a diameter less than one and one-quarter inches and a length between one inch and two and one-quarter inches;
  2. Balls and toys with spherical, ovoid (egg shaped), or elliptical parts that are smaller than one and three-quarters inches in diameter;
  3. Toys with sharp points and edges;
  4. Plastic bags;
  5. Styrofoam objects;
  6. Coins;
  7. Rubber or latex balloons;
  8. Safety pins;
  9. Marbles;
  10. Magnets;
  11. Foam blocks, books, or objects;
  12. Other small objects;
  13. Latex gloves;
  14. Bulletin board tacks;
  15. Glitter.

RATIONALE
Injury and fatality from aspiration of small parts is well-documented (1,2). Eliminating small parts from children’s environment will greatly reduce the risk (2). Objects should not be small enough to fit entirely into a child’s mouth.

According to the federal government’s small parts standard on a safe-size toy for children under three years of age, a small part should be at least one and one-quarter inches in diameter and between one inch and two and one-quarter inches long; any part smaller than this has a potential choking hazard.

Magnets generally are small enough to pass through the digestive tract, however, they can attach to each other across intestinal walls, causing obstructions and perforations within the gastrointestinal tract (5).

Glitter, inadvertently rubbed in eyes, has been known to scratch the surface of the eye and is especially hazardous in children under three years of age (3).

Toys can also contain many chemicals of concern such as lead, phthalates found in many polyvinylchloride (PVC) plastics, cadmium, chlorine, arsenic, bromine, and mercury. When children put toys in their mouths, they may be exposed to these chemicals.

COMMENTS
Toys or games intended for use by children three to five years of age and that contain small parts should be labeled “CHOKING HAZARD--Small Parts. Not for children under three.” Because choking on small parts occurs throughout the preschool years, small parts should be kept away from children at least up to three years of age. Also, children occasionally have choked on toys or toy parts that meet federal standards, so caregivers/teachers must constantly be vigilant (2).

The federal standard that applies is Code of Federal Regulations, Title 16, Part 1501 – “Method for Identifying Toys and Other Articles Intended for Use by Children Under 3 Years of Age Which Present Choking, Aspiration, or Ingestion Hazards Because of Small Parts” – which defines the method for identifying toys and other articles intended for use by children under three years of age that present choking, aspiration, or ingestion hazards because of small parts. To obtain this publication, contact the Superintendent of Documents of the U.S. Government Printing Office or access online at http://www.access.gpo.gov/nara/cfr/waisidx_04/16cfr1501_04.html. This information also is described in the U.S. Consumer Product Safety Commission (CPSC) document, “Small Parts Regulations: Toys and Products Intended for Use by Children Under 3 Years Old,” available online at http://www.cpsc.gov/businfo/
regsumsmallparts.pdf. Also note the ASTM International (ASTM) standard “F963-08: Standard Consumer Safety Specification on Toy Safety.” To obtain this publication, contact the ASTM at http://www.astm.org.

CPSC has produced several useful resources regarding safety and toys based on age group, see: “Which Toy for Which Child Ages Birth to Five” at http://www.cpsc.gov/cpscpub/pubs/285.pdf and “Which Toy for Which Child Ages Six through Twelve” at http://www.cpsc.gov/cpscpub/pubs/286.pdf.

New technologies have become smaller and smaller. Caregivers/teachers should be aware of items such as small computer components, batteries in talking books, mobile phones, portable music players, etc. that fall under item a) in the list of prohibited items.

HealthyToys.org is a good resource for information on chemical contents in toys (4).

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Centers for Disease Control and Prevention. 2006. Gastrointestinal injuries from magnet ingestion in children — United States, 2003-2006. MMWR 55:1296-1300.
  2. HealthyStuff.org. Chemicals of concern: Introduction. http://www.healthystuff.org/departments/toys/chemicals.introduction.php.
  3. Southern Daily Echo. 2009. Dr. John Heyworth from Southampton General Hospital warns about festive injuries. http://www.dailyecho.co.uk/news/4814667.City_doctor_warns_about_bizarre_Christmas_injuries/.
  4. Chowdhury, R. T., U.S. Consumer Product Safety Commission. 2008. Toy-related deaths and injuries, calendar year 2007. Washington, DC: CPSC. http://www.cpsc.gov/LIBRARY/toymemo07.pdf.
  5. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

VII. Administration

Standard 9.2.1.1: Content of Policies

The facility should have policies to specify how the caregiver/teacher addresses the developmental functioning and individual or special health care needs of children of different ages and abilities who can be served by the facility, as well as other services and procedures. These policies should include, but not be limited to, the following:

  1. Admissions criteria, enrollment procedures, and daily sign-in/sign-out policies, including authorized individuals for pick-up and allowing parent/guardian access whenever their child is in care;
  2. Inclusion of children with special health care needs;
  3. Nondiscrimination;
  4. Payment of fees, deposits, and refunds;
  5. Termination of enrollment and parent/guardian notification of termination;
  6. Supervision;
  7. Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
  8. A written comprehensive and coordinated planned program based on a statement of principles;
  9. Discipline;
  10. Methods and schedules for conferences or other methods of communication between parents/guardians and staff;
  11. Care of children and staff who are ill;
  12. Temporary exclusion for children and staff who are ill and alternative care for children who are ill;
  13. Health assessments and immunizations;
  14. Handling urgent medical care or threatening incidents;
  15. Medication administration;
  16. Use of child care health consultants and education and mental health consultants;
  17. Plan for health promotion and prevention (e.g., tracking routine child health care, health consultation, health education for children/staff/families, oral health, sun safety, safety surveillance, preventing obesity, etc.);
  18. Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
  19. Security;
  20. Confidentiality of records;
  21. Transportation and field trips;
  22. Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
  23. Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
  24. Sanitation and hygiene;
  25. Presence and care of any animals on the premises;
  26. Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
  27. Evening and night care plan;
  28. Smoking, tobacco use, alcohol, prohibited substances, and firearms;
  29. Human resource management;
  30. Staff health;
  31. Maintenance of the facility and equipment;
  32. Preventing and reporting child abuse and neglect;
  33. Use of pesticides and other potentially toxic substances in or around the facility;
  34. Review and revision of policies, plans, and procedures.

The facility should have specific strategies for implementing each policy. For centers, all of these items should be written. Facility policies should vary according to the ages and abilities of the children enrolled to accommodate individual or special health care needs. Program planning should precede, not follow the enrollment and care of children at different developmental levels and abilities and with different health care needs. Policies, plans, and procedures should generally be reviewed annually or when any changes are made. A child care health consultant can be very helpful in developing and implementing model policies.

RATIONALE
Neither plans nor policies affect quality unless the program has devised a way to implement the plan or policy. Children develop special health care needs and have developmental differences recognized while they are enrolled in child care (2). Effort should be made to facilitate accommodation as quickly as possible to minimize delay or interruption of care (1). For examples of policies see Model Child Care Health Policies at http://www.ecels-healthy
childcarepa.org/content/MHP4thEd Total.pdf and the California Childcare Health Program at http://www
.ucsfchildcarehealth.org. Nutrition and physical activity policies for child care developed by the NAP SACC Program, Center for Health Promotion and Disease Prevention, University of North Carolina are available at http://www
.center-trt.org.
COMMENTS
Reader’s note: Chapter 9 includes many standards containing additional information on specific policies noted above.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.8.2.1 Staff Familiarity with Facility Policies, Plans and Procedures
REFERENCES
  1. Child Care Law Center. 2009. Questions and answers about the Americans with Disabilities Act: A quick reference for child care providers. Updated Version. http://www.childcarelaw.org/docs/
    ADA Q and A 2009 Final 3 09.pdf.
  2. Aronson, S. S., ed. 2002. Model child care health policies. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 9.2.3.10: Sanitation Policies and Procedures

The child care facility should have written sanitation policies and procedures for the following items:

  1. Maintaining equipment used for hand hygiene, toilet use, and toilet learning/training in a sanitary condition;
  2. Maintaining diaper changing areas and equipment in a sanitary condition;
  3. Maintaining toys in a sanitary condition;
  4. Managing animals in a safe and sanitary manner;
  5. Practicing proper handwashing and diapering procedures (the facility should display proper handwashing instruction signs conspicuously);
  6. Practicing proper personal hygiene of caregivers/teachers and children;
  7. Practicing environmental sanitation policies and procedures, such as sanitary disposal of soiled diapers;
  8. Maintaining sanitation for food preparation and food service.

RATIONALE
Many infectious diseases can be prevented through appropriate hygiene and sanitation practices. Bacterial cultures of environmental surfaces in facilities, which are used to gauge the adequacy of sanitation and hygiene practices, have demonstrated evidence of fecal contamination. Contamination of hands, toys, and other equipment in the room has appeared to play a role in the transmission of diseases in child care settings (1). Regular and thorough cleaning of toys, equipment, and rooms helps to prevent transmission of illness (1).

Animals can be a source of illness for people, and people may be a source of illness for animals (1).

The steps involved in effective handwashing (to reduce the amount of bacterial contamination) can be easily forgotten. Posted signs provide frequent reminders to staff and orientation for new staff. Education of caregivers/teachers regarding handwashing, cleaning, and other sanitation procedures can reduce the occurrence of illness in the group of children with whom they work (2).

Illnesses may be spread by way of:

  1. Human waste (such as urine and feces);
  2. Body fluids (such as saliva, nasal discharge, eye discharge, open skin sores, and blood);
  3. Direct skin-to-skin contact;
  4. Touching a contaminated object;
  5. The air (by droplets that result from sneezes and coughs).

Since many infected people carry communicable diseases without symptoms, and many are contagious before they experience a symptom, caregivers/teachers need to protect themselves and the children they serve by carrying out, on a routine basis, standard precautions and sanitation procedures that approach every potential illness-spreading condition in the same way.

Handling food in a safe and careful manner prevents the spread of bacteria, viruses, and fungi. Outbreaks of foodborne illness have occurred in many settings, including child care facilities.

COMMENTS
State health department rules and regulations may also guide the child care provider.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
3.2.2.2 Handwashing Procedure
3.2.2.5 Hand Sanitizers
4.8.0.7 Ventilation Over Cooking Surfaces
4.8.0.8 Microwave Ovens
4.9.0.13 Method for Washing Dishes by Hand
5.4.1.5 Chemical Toilets
5.4.2.6 Maintenance of Changing Tables
5.7.0.6 Storage Area Maintenance and Ventilation
5.7.0.7 Structure Maintenance
5.7.0.10 Cleaning of Humidifiers and Related Equipment
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
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals
4.8.0.1 Food Preparation Area
4.8.0.2 Design of Food Service Equipment
4.8.0.3 Maintenance of Food Service Surfaces and Equipment
4.8.0.4 Food Preparation Sinks
4.8.0.5 Handwashing Sink Separate from Food Zones
4.8.0.6 Maintaining Safe Food Temperatures
4.9.0.1 Compliance with U.S. Food and Drug Administration Food Sanitation Standards, State and Local Rules
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply
4.9.0.4 Leftovers
4.9.0.5 Preparation for and Storage of Food in the Refrigerator
4.9.0.6 Storage of Foods Not Requiring Refrigeration
4.9.0.7 Storage of Dry Bulk Foods
4.9.0.9 Cleaning Food Areas and Equipment
4.9.0.10 Cutting Boards
4.9.0.11 Dishwashing in Centers
4.9.0.12 Dishwashing in Small and Large Family Child Care Homes
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
5.4.1.6 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)
5.4.1.10 Handwashing Sinks
5.4.1.11 Prohibited Uses of Handwashing Sinks
5.4.1.12 Mop Sinks
5.4.2.1 Diaper Changing Tables
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.3 Handwashing Sinks for Diaper Changing Areas in Homes
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.2.5 Changing Table Requirements
5.4.3.1 Ratio and Location of Bathtubs and Showers
5.4.3.2 Safety of Bathtubs and Showers
5.7.0.8 Electrical Fixtures and Outlets Maintenance
5.7.0.9 Plumbing and Gas Maintenance
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Kotch, J., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics 120:e29-36.
  2. Chin, J., ed. 2000. Control of communicable diseases manual. Washington, DC: American Public Health Association.

Standard 9.2.3.15: Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances

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

 

Facilities should have written policies addressing the use and possession of tobacco and electronic cigarette (e-cigarette) products, alcohol, illegal drugs, legal drugs (e.g. medicinal/recreational marijuana, prescribed narcotics, etc.) that have side effects that diminish the ability to properly supervise and care for children or safely drive program vehicles, and other potentially toxic substances. Policies should include that all of these substances are prohibited inside the facility, on facility grounds, and in any vehicles that transport children at all times. Policies should specify that smoking and vaping is prohibited at all times and in all areas (indoor and outdoor) of the program. This includes any vehicles that are used to transport children.

Policies must also specify that use and possession of all substances referred to above are prohibited during all times when caregivers/teachers are responsible for the supervision of children, including times when children are transported, when playing in outdoor play areas not attached to the facility, and during field trips and staff breaks.

Child care centers and large family child care homes should provide information to employees about available drug, alcohol, and tobacco counseling and rehabilitation, and any available employee assistance programs.

RATIONALE
The age, defenselessness, and lack of discretion of the child under care make this prohibition an absolute requirement. 

The hazards of second-hand and third-hand smoke exposure warrant the prohibition of smoking in proximity of child care areas at any time (1-10). Third-hand smoke refers to gases and particles clinging to smokers’ hair and clothing, cushions, carpeting and outdoor equipment after visible tobacco smoke has dissipated (9). The residue includes heavy metals, carcinogens, and even radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or playing on the floor. Residual toxins from smoking at times when the children are not using the space can trigger asthma and allergies when the children do use the space (10). 

Safe child care necessitates sober caregivers/teachers. Alcohol and drug use, including the misuse of prescription, over-the-counter (OTC), or recreational drugs, prevent caregivers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and response time. Off-site use prior to or during work, of alcohol and illegal drugs is prohibited. OTC medications or prescription medications that have not been prescribed for the user or that could impair motor coordination, judgment, and response time is prohibited.

The use of alcoholic beverages and legal drugs in family child care homes when children are not in care is not prohibited, but these items should be stored safely at all times.

COMMENTS
The policies related to smoking and use of prohibited substances should be discussed with staff and parents/guardians. Educational material such as handouts could include information on the health risks and dangers of these prohibited substances and referrals to services for counseling or rehabilitation programs.

It is strongly recommended that, whenever possible, all caregivers/teachers should be non-tobacco and non-electronic cigarette (e-cigarette) users. Family child care homes should be kept smoke-free at all times to prevent exposure of the children who are cared for in these spaces.

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 required 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 helpy in a locked and 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
5.2.9.1 Use and Storage of Toxic Substances
6.5.1.2 Qualifications for Drivers
REFERENCES
  1. 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.
  2. Centers for Disease Control and Prevention. 2016. Health effects of secondhand smoke. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/
  3. American Academy of Pediatrics. Healthychildren.org. 2015. The dangers of secondhand smoke. https://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/Dangers-of-Secondhand-Smoke.aspx
  4. U.S. Department of Health and Human Services. 2007. Children and secondhand smoke exposure. Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
  5. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf
  6. Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, M. F. Hovell, R. C. McMillen. 2009. Beliefs about the health effects of “thirdhand” smoke and home smoking bans. Pediatrics 123: e74-e79.
  7. ADDITIONAL REFERENCES
     
    U.S. Fire Administration. Electronic cigarette fires and explosions. 2014. https://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf.
     
    Campbell. R. Electronic Cigarette Explosions and Fires: The 2015 Experience. 2016. http://www.nfpa.org/news-and-research/fire-statistics-and-reports/fire-statistics/fire-causes/electrical-and-consumer-electronics/electronic-cigarette-explosions-and-fires-the-2015-experience.
     
    National Institute on Drug Abuse. 2016. What is marijuana? https://www.drugabuse.gov/publications/drugfacts/marijuana.
     
    Rapoport, M.J., Lanctôt, K.L., Streiner, D.L., Bédard, M., Vingilis, E., Murray, B., Schaffer, A., Shulman, K.I., Herrmann, N. Benzodiazepine use and driving: A meta-analysis. J Clin Psychiatry. 2009;70(5):663-73. doi:10.4088/JCP.08m04325.
     
    Sansone, R.A., Sansome, L.A. Driving on Antidepressants: Cruising for a crash?. Psychiatry (Edgmont). 2009:6(9): 13–16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766284/.
     
    Volkow, N.D., Baler, R.D., Compton, W.M., R.B. Weiss, S.R.B. Adverse health effects of marijuana use. N Engl J Med 2014:370:2219-2227. DOI: 10.1056/NEJMra1402309.
     
    Lenné MG, Dietze PM, Triggs TJ, Walmsley S, Murphy B, Redman JR. The effects of cannabis and alcohol on simulated arterial driving: Influences of driving experience and task demand. Accid Anal Prev. 2010;42(3):859-866. doi:10.1016/j.aap.2009.04.021.
     
    Hartman RL, Huestis MA. Cannabis effects on driving skills.Clin Chem. 2013;59(3):478-492. doi:10.1373/clinchem.2012.194381.
     
    Verster, J. C., D. S. Veldhuijzen, E. R. Volkerts. 2005. Is it safe to drive a car when treated with anxiolytics? Evidence from on the road driving studies during normal traffic. Current Psychiatry Reviews1:215-25.
     
    Centers for Disease Control and Prevention. 2009. Facts: Preventing residential fire injuries. http://www.cdc.gov/injury/pdfs/Fires2009CDCFactSheet-FINAL-a.pdf
     
    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/.
     
    Children’s Hospital Colorado. 2016. Acute marijuana intoxication. https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/acute-marijuana-intoxication/.
  8. Campaign for Tobacco-Free Kids. Secondhand smoke, kids and cars. 2016. http://www.tobaccofreekids.org/research/factsheets/pdf/0334.pdf.
  9. Hang, B., Sarker, A.H., Havel, C., et al. Thirdhand smoke causes DNA damage in human cells. Mutagenesis. 2013;28(4):381-391. https://www.ncbi.nlm.nih.gov/pubmed/23462851
  10. Dreyfuss, J.H. Thirdhand smoke identified as potent, enduring carcinogen. CA Cancer J Clin. 2010;60(4):203-204. https://www.ncbi.nlm.nih.gov/pubmed/20530799.
  11. U.S. Environmental Protection Agency. Secondhand tobacco smoke and smoke-free homes. 2016. https://www.epa.gov/indoor-air-quality-iaq/secondhand-tobacco-smoke-and-smoke-free-homes.
NOTES

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

 

Standard 9.2.4.3: Disaster Planning, Training, and Communication

Facilities should consider how to prepare for and respond to emergency or natural disaster situations and develop written plans accordingly. All programs should have procedures in place to address natural disasters that are relevant to their location (such as earthquakes, tornados, tsunamis or flash floods, storms, and volcanoes) and all hazards/disasters that could occur in any location including acts of violence, bioterrorism/terrorism, exposure to hazardous agents, facility damage, fire, missing child, power outage, and other situations that may require evacuation, lock-down, or shelter-in-place.

Written Emergency/Disaster Plan:

Facilities should develop and implement a written plan that describes the practices and procedures they use to prepare for and respond to emergency or disaster situations. This Emergency/Disaster Plan should include:

  1. Information on disasters likely to occur in or near the facility, county, state, or region that require advance preparation and/or contingency planning;
  2. Plans (and a schedule) to conduct regularly scheduled practice drills within the facility and in collaboration with community or other exercises;
  3. Mechanisms for notifying and communicating with parents/guardians in various situations (e.g., Website postings; email notification; central telephone number, answering machine, or answering service messaging; telephone calls, use of telephone tree, or cellular phone texts; and/or posting of flyers at the facility and other community locations);
  4. Mechanisms for notifying and communicating with emergency management public officials;
  5. Information on crisis management (decision-making and practices) related to sheltering in place, relocating to another facility, evacuation procedures including how non-mobile children and adults will be evacuated, safe transportation of children including children with special health care needs, transporting necessary medical equipment obtaining emergency medical care, responding to an intruder, etc.;
  6. Identification of primary and secondary meeting places and plans for reunification of parents/guardians with their children;
  7. Details on collaborative planning with other groups and representatives (such as emergency management agencies, other child care facilities, schools, emergency personnel and first responders, pediatricians/health professionals, public health agencies, clinics, hospitals, and volunteer agencies including Red Cross and other known groups likely to provide shelter and related services);
  8. Continuity of operations planning, including backing up or retrieving health and other key records/files and managing financial issues such as paying employees and bills during the aftermath of the disaster;
  9. Contingency plans for various situations that address:
    1. Emergency contact information and procedures;
    2. How the facility will care for children and account for them, until the parent/guardian has accepted responsibility for their care;
    3. Acquiring, stockpiling, storing, and cycling to keep updated emergency food/water and supplies that might be needed to care for children and staff for up to one week if shelter-in-place is required and when removal to an alternate location is required;
    4. Administering medicine and implementing other instructions as described in individual special care plans;
    5. Procedures that might be implemented in the event of an outbreak, epidemic, or other infectious disease emergency (e.g., reviewing relevant immunization records, keeping symptom records, implementing tracking procedures and corrective actions, modifying exclusion and isolation guidelines, coordinating with schools, reporting or responding to notices about public health emergencies);
    6. Procedures for staff to follow in the event that they are on a field trip or are in the midst of transporting children when an emergency or disaster situation arises;
    7. Staff responsibilities and assignment of tasks (facilities should recognize that staff can and should be utilized to assist in facility preparedness and response efforts, however, they should not be hindered in addressing their own personal or family preparedness efforts, including evacuation).

Details in the Emergency/Disaster Plan should be reviewed and updated bi-annually and immediately after any relevant event to incorporate any best practices or lessons learned into the document.

Facilities should identify in advance which agency or agencies would be the primary contact for them regarding child care regulations, evacuation instructions, and other directives that might be communicated in various emergency or disaster situations.

Training:

Staff should receive training on emergency/disaster planning and response. Training should be provided by emergency management agencies, educators, child care health consultants, health professionals, or emergency personnel qualified and experienced in disaster preparedness and response. The training should address:

  1. Why it is important for child care facilities to prepare for disasters and to have an Emergency/Disaster Plan;
  2. Different types of emergency and disaster situations and when and how they may occur;
    1. Natural Disasters;
    2. Terrorism (i.e., biological, chemical, radiological, nuclear);
    3. Outbreaks, epidemics, or other infectious disease emergencies;
  3. The special and unique needs of children, appropriate response to children’s physical and emotional needs during and after the disaster, including information on consulting with pediatric disaster experts;
  4. Providing first aid, medications, and accessing emergency health care in situations where there are not enough available resources;
  5. Contingency planning including the ability to be flexible, to improvise, and to adapt to ever-changing situations;
  6. Developing personal and family preparedness plans;
  7. Supporting and communicating with families;
  8. Floor plan safety and layout;
  9. Location of emergency documents, supplies, medications, and equipment needed by children and staff with special health care needs;
  10. Typical community, county, and state emergency procedures (including information on state disaster and pandemic influenza plans, emergency operation centers, and incident command structure);
  11. Community resources for post-event support such as mental health consultants, safety consultants;
  12. Which individuals or agency representatives have the authority to close child care programs and schools and when and why this might occur;
  13. Insurance and liability issues;
  14. New advances in technology, communication efforts, and disaster preparedness strategies customized to meet children’s needs.

Communicating with Parents/Guardians:

Facilities should share detailed information about facility disaster planning and preparedness with parents/guardians when they enroll their children in the program, including:

  1. Portions of the Emergency/Disaster Plan relevant to parents/guardians or the public;
  2. Procedures and instructions for what parents/guardians can expect if something happens at the facility;
  3. Description of how parents/guardians will receive information and updates during or after a potential emergency or disaster situation;
  4. Situations that might require parents/guardians to have a contingency plan regarding how their children will be cared for in the unlikely event of a facility closure.

Facilities should conduct an annual drill, test, or “practice use” of the communication options/mechanisms that are selected.

RATIONALE
The only way to prepare for disasters is to consider various worst case or unique scenarios, and to develop contingency plans. By brainstorming and thinking through a variety of “what if...” situations and developing records, protocols/procedures, and checklists, facilities will be better able to respond to an unusual emergency or disaster situation.

Providing clear, accurate, and helpful information to parents/guardians as soon as possible is crucial. Sharing written policies with parents/guardians when they enroll their child, informing them of routine practices, and letting them know how they will receive information and updates, will help them understand what to expect. Notifying parents/guardians about emergencies or disaster situations without causing alarm or prompting inappropriate action is challenging. The content of such communications will depend on the situation. Sometimes, it will be necessary to provide information to parents/guardians before all details are known. In a serious situation, the federal government, the governor, or the state or county health official may announce or declare a state of emergency, a public health emergency, or a disaster. If a facility is unsure of what to do, the first point of contact in any situation should be the local health authority. The local health authority, in partnership with emergency personnel and other officials will know how to engage the appropriate public health and other professionals for the situation.

COMMENTS
Disaster planning and response protocols are unique, and they are typically customized to the type of emergency or disaster; geographical area; identified needs and available resources; applicable federal, state, and local regulations; and the incident command structure in place at the time. The U.S. Department of Homeland Security and the Federal Emergency Management Agency (FEMA) operate under a set of principles and authorities described in various laws and the National Response Framework (see http://www.fema.gov/emergency/nrf/ for details). Each state is required to maintain a state disaster preparedness plan and a separate plan for responding to a pandemic influenza. These plans may be developed by separate agencies, and the point person or the key contact for a child care facility can be the State Emergency Coordinator, a representative in the State Department of Health, an individual associated with the agency that licenses child care facilities for that state, or another official. The State Child Care Administrator is a key contact for any facility that receives federal support.

To develop an Emergency/Disaster Plan that is effective and in compliance with state requirements, the facility must identify who their key contact would be (and what the requirements for their program might be in an emergency or disaster situation) in advance of an unexpected situation. Identifying and connecting with the appropriate key contact before a disaster strikes is crucial for many reasons, but particularly because the identified official may not know how to contact or connect with individual child care facilities. In addition, representatives within the local school system (especially school administrators and school nurses) may have effective and more direct connections to the state disaster preparedness and response system. If facilities do not communicate with the schools in their area on a regular basis, staff should consider establishing a direct link to and partnership with school representatives already involved in disaster planning and response efforts.

Certain emergency/disaster situations may result in exceptions being made regarding state or local regulations (either in existing facilities or in temporary facilities). In these situations, facilities should make every effort to meet or exceed the temporary requirements.

Early childhood professionals, child care health and safety experts, child care health consultants, health care professionals, and researchers with expertise in child development or child care may be asked to support the development of or help to implement emergency, temporary, or respite child care. These individuals may also be asked to assist with caring for children in shelters or other temporary housing situations. A “shelter-in-place” refers to “the process of staying where you are and taking shelter, rather than trying to evacuate” (2).

Early education and child care facilities and pediatricians are rarely considered or included in disaster planning or preparedness efforts, and unfortunately the needs of children are often overlooked. Children have important physical, physiological, developmental, and psychological differences from adults that can and must be anticipated in the disaster planning process. Staff, pediatricians, health care professionals, and child advocates can and should prepare to assume a primary mission of advocating for children before, during, and after a disaster (1). These professionals should be open to fulfilling this obligation in whatever manner presents, in whatever capacity is required at the moment.

For additional resources on disaster planning for child care and early education programs, see the following Websites:

http://www.aap.org/disasters/ (American Academy of Pediatrics);

http://www.naccrra.org/for_parents/coping/disaster.php (National Association of Child Care Resource and Referral Agencies);

http://nccic.acf.hhs.gov/emergency/ (National Child Care Information Center);

http://www.ecels-healthychildcarepa.org/article.cfm?contentID=27 (Healthy Child Care Pennsylvania).

A good source on business continuity or operations planning is http://www.ready.gov/business/plan/planning.html.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.3.1 Emergency Procedures
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
4.9.0.8 Supply of Food and Water for Disasters
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
REFERENCES
  1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Task Force on Terrorism. 2006. Policy statement: The pediatrician and disaster preparedness. Pediatrics 117:560-65.
  2. National Association of Child Care Resource and Referral and Save the Children, Domestic Emergencies Unit. 2010. Protecting children in child care during emergencies. http://www.naccrra.org/publications/naccrra-publications/publications/8960503_Disaster Report-SAVE_MECH.pdf.

Standard 9.2.4.5: Emergency and Evacuation Drills/Exercises Policy

The facility should have a policy documenting that emergency drills/exercises should be regularly practiced for geographically appropriate natural disasters and human generated events such as:

  1. Fire, monthly;
  2. Tornadoes, on a monthly basis in tornado season;
  3. Floods, before the flood season;
  4. Earthquakes, every six months;
  5. Hurricanes, annually;
  6. Threatening person outside or inside the facility;
  7. Rabid animal;
  8. Toxic chemical spill;
  9. Nuclear event.

All drills/exercises should be recorded. Please see Standard 9.4.1.16: Evacuation and Shelter-in-Place Drill Record for more information.

A fire evacuation procedure should be approved and certified in writing by a fire inspector for centers, and by a local fire department representative for large and small family child care homes, during an annual on-site visit when an evacuation drill is observed and the facility is inspected for fire safety hazards.

Depending on the type of disaster, the emergency drill may be within the existing facility such as in the case of earthquakes or tornadoes where the drill might be moving to a certain location within the building (basements, away from windows, etc.) Evacuation drills/exercises should be practiced at various times of the day, including nap time, during varied activities and from all exits. Children should be accounted for during the practice.

The facility should time evacuation procedures. They should aim to evacuate all persons in the specific number of minutes recommended by the local fire department for the fire evacuation, or recommended by emergency response personnel.

Cribs designed to be used as evacuation cribs, can be used to evacuate infants, if rolling is possible on the evacuation route(s).

RATIONALE
Regular emergency and evacuation drills/exercises constitute an important safety practice in areas where these natural or human generated disasters might occur. The routine practice of such drills fosters a calm, competent response to a natural or human generated disaster when it occurs (1). The extensive turnover of both staff and children, in addition to the changing developmental abilities of the children to participant in evacuation procedures in child care, necessitates frequent practice of the exercises.
COMMENTS
Fire inspectors or local fire department representatives can contribute their expertise when observing evacuation plans and drills. They also gain familiarity with the facility and the facility’s plans in the event they are called upon to respond in an emergency. In family child care homes, the possibility of infant rooms or napping areas being located on levels other than the main level makes having consideration and written approval from the fire inspector or local fire department representative of the program’s evacuation plan especially important since infants require more assistance compared to other age groups during an evacuation.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.4.3 Disaster Planning, Training, and Communication
5.4.5.2 Cribs
9.2.4.6 Use of Daily Roster During Evacuation Drills
9.4.1.16 Evacuation and Shelter-In-Place Drill 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.

Standard 9.4.1.2: Maintenance of Records

The facility should maintain the following records:

  1. A copy of the facility’s license, insurance coverage, child care regulations or registration, all inspection reports, correction plans for deficiencies, and any legal actions;
  2. Physical health records for any adult who has direct contact with children;
  3. Training records of the caregiver/teacher and any assistants;
  4. Criminal history records and child abuse and neglect records, as required by state licensing regulations;
  5. Results of well-water tests where applicable;
  6. Results of lead tests;
  7. Insurance records;
  8. Child health records;
  9. Attendance records and sign-in/sign-out records, as well as authorization for pick-up;
  10. List of reportable diseases;
  11. Incident reports;
  12. Fire extinguisher records and smoke detector and carbon monoxide detector battery checks;
  13. Evacuation, emergency, and shelter-in-place drill records;
  14. Play area and equipment warranty, maintenance, and inspection records;
  15. Consultation records;
  16. Medication administration logs; and
  17. Nutrition and food service records.

The length of time to maintain records should follow state regulation requirements. A sample of a state regulation is below.

RATIONALE
Operational control to accommodate the health and safety of individual children requires that information regarding each child in care be kept and made available on a need-to-know basis. These records and reports are necessary to protect the health and safety of children in care.

An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided for children in child care. Such an approach requires written plans, policies, and procedures, and record keeping so that there is consistency over time and across staff and an understanding between parents/guardians and caregivers/teachers about concerns for, and attention to, the safety of children.

COMMENTS
A file of all purchased equipment and toys with warranty information and model numbers will help identify items that have hazard warnings or are recalled by the U.S. Consumer Product Safety Commission (CPSC). A photo of the purchased items can be added to the file.

A sample of state regulations for length of time to maintain records is below.

Retention of Records

  1. Documentation of the previous twelve months activity should be available for review. Records should be accessible during the hours the facility is open and operating.
  2. For licensing purposes, children’s information should be kept on file a minimum of one year from date of discharge from the facility.
  3. For licensing purposes, personnel records should be kept on file a minimum of one year from termination of employment from the facility.
  4. For licensing purposes, staff training certificates and continuing education certificates should be kept on file for a minimum of five years for currently employed staff (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.2.3 Orientation Topics
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
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.6.4 Water Test Results
5.2.6.5 Emergency Safe Drinking Water and Bottled Water
5.2.9.13 Testing for Lead
1.2.0.1 Staff Recruitment
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.3.1 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
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
3.6.4.3 Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
9.2.6.2 Reports of Annual Audits/Monthly Maintenance Checks of Play Areas and Equipment
9.2.6.3 Records of Proper Installation and Maintenance of Facility Equipment
9.4.1.1 Facility Insurance Coverage
9.4.1.6 Availability of Documents to Parents/Guardians
9.4.1.8 Records of Illness
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
9.4.1.12 Record of Valid License, Certificate, or Registration of Facility
9.4.1.13 Maintenance and Display of Inspection Reports
9.4.1.14 Written Plan/Record to Resolve Deficiencies
9.4.1.15 Availability of Reports on Inspections of Fire Protection Devices
9.4.1.16 Evacuation and Shelter-In-Place Drill Record
9.4.1.17 Documentation of Child Care Health Consultation/Training Visits
9.4.1.18 Records of Nutrition Service
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
9.4.3.2 Maintenance of Attendance Records for Staff Who Care for Children

Standard 9.4.1.6: Availability of Documents to Parents/Guardians

In an easily available space that parents/guardians are made aware of and able to access, facilities should make available the following items:

  1. The facility’s license, child care regulations, or registration, which also includes information on how to file a complaint and the telephone number for filing complaints with the regulatory agency;
  2. A statement informing parents/guardians about how they may obtain a copy of the licensing or registration requirements from the regulatory agency;
  3. Inspection certificates;
  4. Reports of any legal sanctions and documentation that all required corrections have been completed;
  5. A notice that inspection reports/certificates, legal actions, and compliance letters are available for inspection in the facility;
  6. Accreditation certificates;
  7. Quality rating score, if applicable;
  8. Evacuation route;
  9. Emergency evacuation procedures, including fire evacuation and weather related evacuation procedures, to be posted in each room of the center;
  10. Procedures for the reporting of child abuse and neglect consistent with state law and local law enforcement and child protective service contacts;
  11. Notice announcing the “open-door policy” (parents/guardians may visit at any time and will be admitted without delay);
  12. The action the facility will take to handle a visitor’s request for access if the caregiver/teacher is concerned about the safety of the children;
  13. A current weekly menu of any food or beverage served in the facility to the children for parents/guardians and caregivers/teachers including changes in the menus as they are served; the facility should provide copies of menus to parents/guardians, if requested, and copies of menus served should be kept on file for six months;
  14. A statement of nondiscrimination for programs participating in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP) and for programs who receive Child Care Assistance Child Care Development Block Grant (CCDBG) funds;
  15. Policy manual (health and safety policies, nutrition and oral health policies, etc.);
  16. A copy of the policy and procedures for discipline, including the prohibition of corporal punishment;
  17. Legible safety rules for the use of swimming and built-in wading pools if the facility has such pools (safety rules should be posted conspicuously on the pool enclosure);
  18. Phone numbers and instructions for contacting the fire department, police, emergency medical services, physicians, dentists, rescue and ambulance services, and the poison center, child abuse reporting hotline; the address of the facility; and directions to the facility from major routes north, south, east, and west (this information should be conspicuously posted adjacent to the telephone);
  19. A list of reportable infectious diseases as required by the state and local health authorities;
  20. Employee rights and safety standards as required by the Occupational Safety and Health Administration (OSHA) and/or state agencies;
  21. Breastfeeding policy that includes information and guidance for mothers on how to store and transport human milk;
  22. A notice of what, where and when pesticides have been applied within or around the program’s property (this notice should be put up forty-eight hours in advance of any pesticide use);
  23. Reports of lead concentration and water quality.

RATIONALE
Each local and/or state regulatory agency gives official permission to certain persons to operate child care programs by virtue of their compliance with regulations. Therefore, documents relating to investigations, inspections, and approval to operate should be made available to consumers, caregivers/teachers, concerned persons, and the community. Posting other documents listed in this standard increases access to parents/guardians over having the policies filed in a less accessible location.

Awareness of the child abuse and neglect reporting requirements and procedures is essential to the prevention of child abuse. State requirements may differ, but those for whom the reporting of child abuse and neglect is mandatory usually include child care personnel. Information on how to call and how to report should be readily available to parents/guardians and caregivers/teachers.

The open-door policy may be the single most important method for preventing maltreatment of children in child care (1). When access is restricted, areas observable by the parents/guardians may not reflect the care the children actually receive.

A roster helps parents/guardians see how facility responsibility is assigned and know which children receive care in their child’s group.

Primary caregiver assignments foster and channel meaningful communication between parents/guardians and caregivers/teachers.

Children are offered nutritious foods that help assure that children can meet the minimum daily requirements of nutrients. A child care facility is not responsible for the children receiving all of their nutrients. Parents/guardians need to know what food and beverages their children receive while in child care. Menus filed should reflect last-minute changes so that parents/guardians and any nutritionist/registered dietitian who reviews these documents can get an accurate picture of what was actually served. Food allergies should be posted for caregivers/teachers to view easily while still maintaining confidentiality from the public.

Parents/guardians and caregivers/teachers must have a common basis of understanding about what disciplinary measures are to be used to avoid conflict and promote consistency in approach between caregivers/teachers and parents/guardians. Corporal punishment may be physical abuse or become abusive very easily.

Parents/guardians have a right to see any reports and notices of any legal actions taken against the facility that have been sustained by the court. Since unfounded suits may be filed, knowledge of which could undermine parent/guardian confidence, only actions that result in corrections or judgment needs to be made accessible.

Pool safety requires reminders to users of pool rules. Making pool rules available serves as reminder that all pool rules must be strictly adhered to for the safety of the children.

In an emergency, phone numbers must be immediately accessible.

COMMENTS
Compliance can be measured by asking for the location of documents and how accessible they are.

A sample telephone emergency list is provided in Healthy Young Children from the National Association for the Education of Young Children (NAEYC) at http://www.naeyc.org.

When it is possible to translate documents into the native language of the parents/guardians of children in care, it increases the level of communication between facility and parents/guardians.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.9 Warming Bottles and Infant Foods
5.2.8.1 Integrated Pest Management
9.2.4.3 Disaster Planning, Training, and Communication
9.4.1.2 Maintenance of Records
10.4.3.1 Procedure for Receiving Complaints
10.4.3.2 Whistle-Blower Protection under State Law
3.6.4.3 Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.4 Feeding Human Milk to Another Mother’s Child
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
4.3.1.10 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
9.2.1.6 Written Discipline Policies
9.4.1.12 Record of Valid License, Certificate, or Registration of Facility
9.4.1.13 Maintenance and Display of Inspection Reports
9.4.1.14 Written Plan/Record to Resolve Deficiencies
9.4.1.18 Records of Nutrition Service
2.2.0.4 Supervision Near Bodies of Water
2.2.0.5 Behavior Around a Pool
6.3.1.7 Pool Safety Rules
REFERENCES
  1. 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.

VIII. Licensing and Community Action

Standard 10.3.5.1: Education, Experience and Training of Licensing Inspectors

Licensing inspectors, and others in licensing positions, should be pre-qualified by education and experience to be knowledgeable about the form of child care they are assigned to inspect. Prior to employment or within the first six months of employment, licensing inspectors should receive training in regulatory administration based on the concepts and principles found in the National Association for Regulatory Administration (NARA) Licensing Curriculum through onsite platform training or online coursework (1). In addition, they should receive no less than forty clock hours of orientation training upon employment (1). In addition, they should receive no less than twenty-four clock hours of continuing education each year (1), covering the following topics and other such topics as necessary based on competency needs:

  1. The licensing statutes and rules for child care;
  2. Other applicable state and federal statutes and regulations;
  3. The historical, conceptual, and theoretical basis for licensing, investigation, and enforcement;
  4. Technical skills related to the person’s duties and responsibilities, such as investigative techniques, interviewing, rule-writing, due process, and data management;
  5. Child development, early childhood education principles, child care programming, scheduling, and design of space;
  6. Law enforcement and the rights of licensees;
  7. Center and large or small family child care home management;
  8. Child and staff health in child care;
  9. Detection, prevention, and management of child abuse;
  10. Practical techniques and ADA requirements for inclusion of children with special needs;
  11. Exclusion/inclusion of children who are ill;
  12. Health, safety, physical activity, and nutrition;
  13. Recognition of hazards.

RATIONALE
Licensing inspectors are a point of contact and linkage for caregivers/teachers and sources of technical information needed to improve the quality of child care. This is particularly true for areas not usually within the network of early childhood professionals, such as health and safety expertise. Unless the licensing inspector is competent and able to recognize areas where facilities need to improve their health and safety provisions (for example prevention of infectious disease), the opportunity for such linkages will be lost. To effectively carry out their responsibilities to license and monitor child care facilities, it is critical that licensing inspectors have appropriate, conceptually based professional development in the principles, concepts and practices of child care licensing as well as in the principles and practices of the form or child care to which they are assigned. When developed, it will be important for licensing inspectors to secure NARA Licensing Credentials.
REFERENCES
  1. National Association for Regulatory Administration (NARA). 2000. Phases of licensing. In NARA licensing curriculum. 2000 ed. Lexington, KY: NARA.

Standard 10.5.0.1: State and Local Health Department Role

State and local health departments should play an important role in the identification, prevention and control of injuries, injury risk, and infectious disease in child care settings as well as in using the child care setting to promote health and safety. This role includes the following activities to be conducted in collaboration with the child care licensing agency:

  1. Assisting in the planning of a comprehensive health and safety program for children and child care providers, including promoting and ensuring maintenance of a system of child care health consultation;
  2. Monitoring the occurrence of serious injury events and outbreaks involving children or providers;
  3. Alerting the responsible child care administrators about identified or potential injury hazards and infectious disease risks in the child care setting;
  4. Controlling outbreaks, identifying and reporting infectious diseases in child care settings including:
    1. Methods for notifying parents/guardians, caregivers/teachers, and health care providers of the problem;
    2. Providing appropriate actions for the child care provider to take;
    3. Providing policies for exclusion or isolation of infected children;
    4. Arranging a source and method for the administration of needed medication;
    5. Providing a list of reportable diseases, including descriptions of these diseases. The list should specify where diseases are to be reported and what information is to be provided by the child care provider to the health department and to parents/guardians;
    6. Requiring that all facilities, regardless of licensure status, and all health care providers report certain infectious diseases to the responsible local or state public health authority. The child care licensing authority should require such reporting under its regulatory jurisdiction and should collaborate fully with the health department when the latter is engaged in an enforcement action with a licensed facility;
    7. Determining whether a disease represents a potential health risk to children in out-of-home child care;
    8. Conducting the epidemiological investigation necessary to initiate public health and safety interventions;
    9. Recommending a disease prevention or control strategy that is based on sound public health and clinical practices (such as the use of vaccine, immunoglobulin, or antibiotics taken to prevent an infection);
    10. Verifying reports of infectious diseases received from facilities with the assessment and diagnosis of the disease made by a health care provider and, or the local or state health department;
  5. Designing systems and forms for use by facilities for the care of children who are ill to document the surveillance of cared for illnesses and problems that arise in the care of children in such child care settings;
  6. Assisting in the development of orientation and annual training programs for caregivers/teachers. Such training should include specialized education for staff of facilities that include child who are ill, as well as those in special facilities that serve only children who are ill. Specialized training for staff who care for children who are ill should focus on the recognition and management of childhood illnesses, as well as the care of children with infectious diseases;
  7. Assisting the licensing authority in the periodic review of facility performance related to caring for children who are ill by:
    1. Reviewing written policies developed by facilities regarding inclusion, exclusion, dismissal criteria and plans for health care, urgent and emergency care, and reporting and managing children with infectious disease;
    2. Assisting with periodic compliance reviews for those rules relating to inclusion, exclusion, dismissal, daily health care, urgent and emergency care, and reporting and management of children with infectious disease;
  8. Collaborating in the planning and implementation of appropriate training and educational programs related to health and safety in child care facilities. Such training should include education of parents/guardians, primary care providers, public health and safety workers, licensing inspectors, and employers about how to prevent injury and disease as well as promote health and safety of children and their caregivers/teachers;
  9. Promoting that health care personnel, such as qualified public health nurses, pediatric and family nurse practitioners, and pediatricians serve as child care health consultants;
  10. Ensuring child care programs are included and represented in local and state disaster preparedness and pandemic flu planning.

RATIONALE

A number of studies have described the incidence of injuries in the child care setting (7-10). Although the injuries described have not been serious, these occur frequently, and may require medical or emergency attention. Child care programs need the assistance of local and state health agencies in planning of the safety program that will minimize the risk for serious injury (11). This would include planning for such significant emergencies as fire, flood, tornado, or earthquake (11-13). A community health agency can collect information that can promptly identify an injury risk or hazard and provide an early notice about the risk or hazard (14). An example is the recent identification of un-powered scooters as a significant injury risk for preschool children (15). Once the injury risk is identified, appropriate channels of communication are required to alert the child care administrators and to provide training and educational activities.

Effective control and prevention of infectious diseases in child care settings depends on affirmative relationships among parents/guardians, caregivers/teachers, public health authorities, regulatory agencies, and primary health care providers. The major barriers to productive working relationships between caregivers/teachers and health care providers are inadequate channels of communication and uncertainty of role definition (4). Public health authorities can play a major role in improving the relationship between caregivers/teachers and primary care providers by disseminating information regarding disease reporting laws, prescribed measures for control and prevention of diseases and injuries, and resources that are available for these activities (11). Child care health consultant networks have proven to be effective in improving the health and safety of children in child care settings (16-18).

State and local health departments are legally required to control certain infectious diseases within their jurisdictions (20). All states have laws that grant extraordinary powers to public health departments during outbreaks of infectious diseases (1,11,12). Since infectious disease is likely to occur in child care settings, a plan for the control of infectious diseases in these settings is essential and often legally required. Early recognition and prompt intervention will reduce the spread of infection. Outbreaks of infectious disease in child care settings can have great implications for the general community (2). Programs administered by local health departments have been more successful in controlling outbreaks of hepatitis A than those that rely primarily on private physicians. Programs coordinated by the local health department also provide reassurance to caregivers/teachers, staff, and parents/guardians, and thereby promote cooperation with other disease control policies (3). Infectious diseases in child care settings pose new epidemiological considerations. Only in recent decades has it been so common for very young children to spend most of their days together in groups. Public health authorities should expand their role in studying this situation and designing new preventive health measures (4,5).

Collaboration is necessary to use limited resources most effectively. In small states, a state level task force that includes the Department of Health might be sufficient. In larger or more populous states, local task forces in addition to coordination at the state level may be needed. The collaboration should focus on establishing the role of each agency in ensuring that necessary services and systems exist to prevent and control injuries and infectious diseases in facilities (6,19).

Health departments generally have or should develop the expertise to provide leadership and technical assistance to licensing authorities, caregivers/teachers, parents/guardians, and primary care providers in the development of licensing requirements and guidelines for the management of children who are ill. The heavy reliance on the expertise of local and state health departments in the establishment of facilities to care for children who are ill has fostered a partnership in many states among health departments, licensing authorities, caregivers/teachers, and parents/guardians for the adequate care of children who are ill in child care settings (16-18).

RELATED STANDARDS
3.6.2.5 Caregiver/Teacher Qualifications 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
3.6.4.3 Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
REFERENCES
  1. Grad, F. P. 2004. The public health law manual. 3rd ed. Washington, DC: American Public Health Association.
  2. Ginter, P. M., Wingate, M. S., A. C. Rucks, R. D. Vasconez, L. C. McCormick, S. Baldwin, C. A. Fargason. 2006. Creating a regional pediatric medical disaster preparedness network: Imperative and issues. Maternal Child Health J 10:391-96.
  3. Buttross, S. 2006. Caring for children of caretakers during a disaster. Pediatrics 117: S446-47.
  4. Wilson, S. A., B. J. Temple, M. E. Milliron, C. Vazquez, M. D. Packard, B. S. Rudy. 2008. The lack of disaster preparedness by the public and it’s affect on communities. Internet J Rescue Disaster Med 7 (2): 1.
  5. Murray, J. S. 2009. Disaster care: Public health emergencies and children. Am J Nursing 109: 28-29, 31.
  6. Vollman, D., R. Witsaman, D. R. Comstock, G. A. Smith. 2009. Epidemiology of playground equipment-related injuries to children in the United States, 1996-2005. Clinical Pediatrics 48:66-71.
  7. Gordon, R. A., R. Kaestner, S. Korenman. 2007. The effects of maternal employment on child injuries and infectious disease. Demography 44:307-33.
  8. Jansson, B., A. P. De Leon, N. Ahmed, V. Jansson. 2006. Why does Sweden have the lowest childhood mortality in the world? The role of architecture and public pre-school services. J Public Health Policy 27:146-65.
  9. Gaines, S. K., J. M. Leary. 2004. Public health emergency preparedness in the setting of child care. Family and Comm Health 27:260-65.
  10. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, Task Force on Terrorism. 2006. Policy statement: The pediatrician and disaster preparedness. Pediatrics 117:560-65.
  11. National Association of Child Care Resource and Referral Agencies. Helping families and children cope with trauma in the aftermath of disaster. http://www.naccrra.org/for_parents/coping/trauma.php.
  12. Samet, J. M. 2004. Risk assessment and child health. Pediatrics 113:952-56.
  13. Kubiak, R., T. Slongo. 2003. Unpowered scooter injuries in children. Acta Paediatrics 92:50-54.
  14. Crowley, A. A. and Kulikowich, J. M. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
  15. 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. 
  16. Garrett, A. L., R. Grant, P. Madrid, A. Brito, D. Abramson, I. Redlener. 2007. Children and megadisasters: Lessons learned in the new millennium. Advances Pediatrics 54:189-214.
  17. National Child Care Information and Technical Assistance Center. State and territory emergency preparedness plans. http://nccic.acf.hhs.gov/poptopics/disasterprep.html.
  18. 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.
  19. Heymann, D. L. 2008. Control of communicable diseases manual. 19th ed. Washington, DC: American Public Health Association.
  20. Brady, M. T. 2005. Infectious disease in pediatric out-of-home child care. Am J Infect Control 33:276-85.

Standard 10.6.1.1: Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services

The licensing agency should promote participation in a variety of caregiver/teacher and consumer training and support services as an integral component of its mission to reduce risks to children in out-of-home child care. Such training should emphasize the importance of conducting regular safety checks and providing direct supervision of children at all times. Training plans should include mechanisms for training of prospective child care staff prior to their assuming responsibility for the care of children and for ongoing/continuing education. The higher education institutions providing early education degree programs should be coordinated with training provided at the community level to encourage continuing education and availability of appropriate content in the coursework provide by these institutions of higher education.

Persons wanting to enter the child care field should be able to learn from the regulatory agency about training opportunities offered by public and private agencies. Discussions of these trainings can emphasize critical child care health and safety messages. Some training can be provided online to reinforce classroom education.

Training programs should address the following:

  1. Child growth and development including social-emotional, cognitive, language, and physical development;
  2. Child care programming and activities;
  3. Discipline and behavior management;
  4. Mandated child abuse and neglect reporting;
  5. Health and safety practices including injury prevention, basic first aid and CPR, reporting, preventing and controlling infectious diseases, children’s environmental health and health promotion, and reducing the risk of SIDS and use of safe sleep practices;
  6. Cultural diversity;
  7. Nutrition and eating habits including the importance of breastfeeding and the prevention of obesity and related chronic diseases;
  8. Parent/guardian education;
  9. Design, use and safe cleaning of physical space;
  10. Care and education of children with special health care needs;
  11. Oral health care;
  12. Reporting requirements for infectious disease outbreaks;
  13. Caregiver/teacher health;
  14. Age-appropriate physical activity.

RATIONALE
Training enhances staff competence (1,2,4). 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 (1,2). Most states require limited training for child care staff depending on their functions and responsibilities. Some states do not require completion of a high school degree or GED for various levels of teacher positions (5). Staff members who are better trained are more able to prevent, recognize, and correct health and safety problems. Decisions about management of illness are facilitated by the caregiver’s/teacher’s increased skill in assessing a child’s behavior that suggests illness (2,3). Training should promote increased opportunity in the field and openings to advance through further degree-credentialed education.
RELATED STANDARDS
1.4.2.3 Orientation Topics
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
10.6.2.1 Development of Child Care Provider Organizations and Networks
REFERENCES
  1. National Child Care Information and Technical Assistance Center, National Association for Regulatory Administration (NARA). 2010. The 2008 child care licensing study: Final report. Lexington, KY: NARA. http://www.naralicensing.org/associations/4734/files/1005_2008_Child Care Licensing Study_Full_Report.pdf.
  2. Moon, R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
  3. Kendrick, A. S. 1994. Training to ensure healthy child day-care programs. Pediatrics 94:1108-10.
  4. Aronson, S. S., L. S. Aiken. 1980. Compliance of child care programs with health and safety standards: Impact of program evaluation and advocate training. Pediatrics 65:318-25.
  5. Galinsky, E., C. Howes, S. Kontos, M. Shinn. 1994. The study of children in family child care and relative care. New York: Families and Work Institute.
  6. U.S. General Accounting Office (USGAO); Health, Education, and Human Services Division. 1994. Child care: Promoting quality in family child care. Report to the chairman, subcommittee on regulation, business opportunities, and technology, committee on small business, House of Representatives. Publication no. GAO-HEHS-95-36. Washington, DC: USGAO.

Standard 10.6.1.2: Provision of Training to Facilities by Health Agencies

Public health departments, other state departments charged with professional development for out of home child care providers, and Emergency Medical Services (EMS) agencies should provide training, written information, consultation in at least the following subject areas or referral to other community resources (e.g., child care health consultants, licensing personnel, health care professionals, including school nurses) who can provide such training in:

  1. Immunization;
  2. Reporting, preventing, and managing of infectious diseases;
  3. Techniques for the prevention and control of infectious diseases;
  4. Exclusion and inclusion guidelines and care of children who are acutely ill;
  5. General hygiene and sanitation;
  6. Food service, nutrition, and infant and child-feeding;
  7. Care of children with special health care needs (chronic illnesses, physical and developmental disabilities, and behavior problems);
  8. Prevention and management of injury;
  9. Managing emergencies;
  10. Oral health;
  11. Environmental health;
  12. Health promotion, including routine health supervision and the importance of a medical or health home for children and adults;
  13. Health insurance, including Medicaid and the Children’s Health Insurance Program (CHIP);
  14. Strategies for preparing for and responding to infectious disease outbreaks, such as a pandemic influenza;
  15. Age-appropriate physical activity;
  16. Sudden Infant Death Syndrome (SIDS) and Shaken Baby Syndrome/Abusive Head Trauma.

RATIONALE
Training of child care staff has improved the quality of their health related behaviors and practices. Training should be available to all parties involved, including caregivers/teachers, public health workers, health care providers, parents/guardians, and children. Good quality training, with imaginative and accessible methods of presentation supported by well-designed materials, will facilitate learning.
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
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
10.5.0.1 State and Local Health Department Role
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
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