Special Collection

Caring for Children with Special Health Care Needs

Caring for Children with Special Health Care Needs (CHSCN) in Early Care and Education is a collection of 146 nationally recognized health and safety standards that have an impact on infants, toddlers, and preschoolers with special health care needs in early care and education settings. These materials and the associated six 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 collection of nationally recognized best practice health and safety standards for the early care and education environment.

The CSHCN collection is a compilation of best practices for children with special health care needs in early care and education programs. All CFOC3 standards are applicable to children with special healthcare care needs. However, this collection of standards, when put into practice, is best able to meet the specific needs of this vulnerable population.

Support for this project was provided through a cooperative agreement with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

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 this CFOC3 collection. Twenty individuals, representing seventeen organizations, reviewed and validated the chosen standards. Our sincere appreciation goes to all of our colleagues who willingly gave their time and expertise to the development of this resource.

The intended audiences for this document are:

Table of Contents

I. Staff and Training

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.6 Additional Qualifications for Caregivers/Teachers Serving School-Age Children
1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.3.3.1 General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home
1.4.1.1 Pre-service Training
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
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
1.4.5.2 Child Abuse and Neglect Education
1.5.0.2 Orientation of Substitutes
1.6.0.1 Child Care Health Consultants
1.6.0.2 Frequency of Child Care Health Consultation Visits
1.6.0.3 Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities

II. Program Activities for Healthy Development

2.1.1.1 Written Daily Activity Program and Statement of Principles
2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.1.1.5 Helping Families Cope with Separation
2.1.1.9 Verbal Interaction
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.2.5 Toilet Learning/Training
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.2.0.3 Screen Time/Digital Media Use
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
2.2.0.10 Using Physical Restraint
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
2.3.1.2 Parent/Guardian Visits
2.3.2.1 Parent/Guardian Conferences
2.3.2.2 Seeking Parent/Guardian Input
2.3.2.3 Support Services for Parents/Guardians
2.3.2.4 Parent/Guardian Complaint Procedures
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior
2.3.3.2 Communication from Specialists
2.4.1.1 Health and Safety Education Topics for Children
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
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.3 Care for Animals
3.4.3.1 Emergency Procedures
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.5.0.2 Caring for Children Who Require Medical Procedures
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.2.9 Information Required for Children Who Are Ill
3.6.3.1 Medication Administration
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
3.6.4.5 Death

IV. Nutrition and Food Service

4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.7.0.1 Nutrition Learning Experiences for Children

V. Facilities, Supplies, and Equipment

5.1.1.4 Accessibility of Facility
5.1.1.7 Use of Basements and Below Grade Areas
5.1.2.1 Space Required per Child
5.1.4.2 Evacuation of Children with Special Health Care Needs and Children with Disabilities
5.1.4.3 Path of Egress
5.1.4.7 Access to Exits
5.1.6.5 Areas Used by Children for Wheeled Vehicles
5.2.1.2 Indoor Temperature and Humidity
5.3.1.4 Surfaces of Equipment, Furniture, Toys, and Play Materials
5.3.2.1 Therapeutic and Recreational Equipment
5.3.2.2 Special Adaptive Equipment
5.3.2.3 Storage for Adaptive Equipment
5.3.2.4 Orthotic and Prosthetic Devices
5.4.1.7 Toilet Learning/Training Equipment
5.4.3.2 Safety of Bathtubs and Showers
5.4.6.2 Space for Therapy Services
5.6.0.1 First Aid and Emergency Supplies
5.7.0.3 Removal of Allergen Triggering Materials From Outdoor Areas

VI. Play Areas/Playgrounds

6.1.0.1 Size and Location of Outdoor Play Area
6.2.1.2 Play Equipment and Surfaces Meet ADA Requirements
6.5.1.1 Competence and Training of Transportation Staff
6.5.2.2 Child Passenger Safety

VII. Infectious Diseases

7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers

VIII. Children with Special Health Care Needs and Disabilities

8.2.0.1 Inclusion in All Activities
8.2.0.2 Planning for Inclusion
8.3.0.1 Initial Assessment of the Child to Determine His or Her Special Needs
8.4.0.1 Determining the Type and Frequency of Services
8.4.0.2 Formulation of an Action Plan
8.4.0.3 Determination of Eligibility for Special Services
8.4.0.4 Designation and Role of Staff Person Responsible for Coordinating Care in the Child Care Facility
8.4.0.5 Development of Measurable Objectives
8.4.0.6 Contracts and Reimbursement
8.5.0.1 Coordinating and Documenting Services
8.5.0.2 Written Reports on IFSPs/IEPs to Caregivers/Teachers
8.6.0.1 Reevaluation Process
8.6.0.2 Statement of Program Needs and Plans
8.7.0.1 Facility Self-Assessment
8.7.0.2 Technical Assistance in Developing Plan
8.7.0.3 Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs

IX. Administration

9.2.1.1 Content of Policies
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.1.5 Nondiscriminatory Policy
9.2.1.6 Written Discipline Policies
9.2.2.1 Planning for Child’s Transition to New Services
9.2.2.2 Format for the Transition Plan
9.2.3.2 Content and Development of the Plan for Care of Children and Staff Who Are Ill
9.2.3.4 Written Policy for Obtaining Preventive Health Service Information
9.2.3.5 Documentation of Exemptions and Exclusion of Children Who Lack Immunizations
9.2.3.6 Identification of Child’s Medical Home and Parental Consent for Information Exchange
9.2.3.7 Information Sharing on Therapies and Treatments Needed
9.2.3.9 Written Policy on Use of Medications
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
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.17 Documentation of Child Care Health Consultation/Training Visits
9.4.1.19 Community Resource Information
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records

X. Licensing and Community Action

10.3.2.1 Child Care Licensing Advisory Board
10.3.3.5 Licensing Agency Role in Communicating the Importance of Compliance with Americans with Disabilities Act
10.3.4.1 Sources of Technical Assistance to Support Quality of Child Care
10.3.4.3 Support for Consultants to Provide Technical Assistance to Facilities
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs
10.3.4.7 Technical Assistance to Facilities to Address Diversity in the Community
10.3.5.1 Education, Experience and Training of Licensing Inspectors
10.6.1.2 Provision of Training to Facilities by Health Agencies

Appendices

Appendix A: Signs and Symptoms Chart
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix D: Gloving
Appendix F: Enrollment/Attendance/Symptom Record
Appendix I: Recommendations for Preventive Pediatric Health Care
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix S: Physical Activity: How Much Is Needed?
Appendix X: Adaptive Equipment for Children with Special Health Care Needs
Appendix AA: Medication Administration Packet
Appendix BB: Emergency Information Form for Children with Special Health Care Needs
Appendix CC: Incident Report Form
Appendix FF: Child Health Assessment
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix P: Situations that Require Medical Attention Right Away

I. Staff and Training

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

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

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

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

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

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

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

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

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

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

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

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

COMMENTS

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

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

Unscheduled inspections encourage compliance with this standard.

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

Standard 1.1.1.2: Ratios for Large Family Child Care Homes and Centers

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

Large Family Child Care Homes

Age

Maximum Child:Staff Ratio

Maximum Group Size

     

≤ 12 months

2:1

6

13-23 months

2:1

8

24-35 months

3:1

12

3-year-olds

7:1

12

4- to 5-year-olds

8:1

12

6- to 8-year-olds

10:1

12

9- to 12-year-olds

12:1

12

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

Child Care Centers

Age

Maximum Child:Staff Ratio

Maximum Group Size

     

≤ 12 months

3:1

6

13-35 months

4:1

8

3-year-olds

7:1

14

4-year-olds

8:1

16

5-year-olds

8:1

16

6- to 8-year-olds

10:1

20

9- to 12-year-olds

12:1

24

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

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

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

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

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

RATIONALE

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

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

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

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

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

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

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

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

COMMENTS

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

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

Unscheduled inspections encourage compliance with this standard.

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

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

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

Facilities enrolling children with special health care needs and disabilities should determine, by an individual assessment of each child’s needs, whether the facility requires a lower child:staff ratio.

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

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

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

Standard 1.3.1.1: General Qualifications of Directors

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

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

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

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

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

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

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

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

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

Standard 1.3.2.2: Qualifications of Lead Teachers and Teachers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 1.4.2.1: Initial Orientation of All Staff

All new full-time staff, part-time staff and substitutes should be oriented to the policies listed in Standard 9.2.1.1 and any other aspects of their role. The topics covered and the dates of orientation training should be documented. Caregivers/teachers should also receive continuing education each year, as specified in Continuing Education, Standard 1.4.4.1 through Standard 1.4.6.2.

RATIONALE
Orientation ensures that all staff members receive specific and basic training for the work they will be doing and are informed about their new responsibilities. Because of frequent staff turnover, directors should institute orientation programs on a regular basis (1).

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

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

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

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

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

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

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
1.6.0.1 Child Care Health Consultants
9.2.1.1 Content of Policies
9.4.3.3 Training Record
REFERENCES
  1. National Association for the Education of Young Children (NAEYC). 2008. Leadership and management: A guide to the NAEYC early childhood program standards and related accreditation criteria. Washington, DC: NAEYC.

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

  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  4. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.

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

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

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

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

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

RATIONALE
A basic understanding of developmental disabilities and special care requirements of any child in care is a fundamental part of any orientation for new employees. Training is an essential component to ensure that staff members develop and maintain the needed skills. A comprehensive curriculum is required to ensure quality services. However, lack of specialized training for staff does not constitute grounds for exclusion of children with disabilities (1).

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

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

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

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

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 1.4.3.1: First Aid and CPR Training for Staff

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 1.4.3.2: Topics Covered in First Aid Training

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

  1. Management of a blocked airway and rescue breathing for infants and children with return demonstration by the learner (pediatric CPR);
  2. Abrasions and lacerations;
  3. Bleeding, including nosebleeds;
  4. Burns;
  5. Fainting;
  6. Poisoning, including swallowed, skin or eye contact, and inhaled;
  7. Puncture wounds, including splinters;
  8. Injuries, including insect, animal, and human bites;
  9. Poison control;
  10. Shock;
  11. Seizure care;
  12. Musculoskeletal injury (such as sprains, fractures);
  13. Dental and mouth injuries/trauma;
  14. Head injuries, including shaken baby syndrome/abusive head trauma;
  15. Allergic reactions, including information about when epinephrine might be required;
  16. Asthmatic reactions, including information about when rescue inhalers must be used;
  17. Eye injuries;
  18. Loss of consciousness;
  19. Electric shock;
  20. Drowning;
  21. Heat-related injuries, including heat exhaustion/heat stroke;
  22. Cold related injuries, including frostbite;
  23. Moving and positioning injured/ill persons;
  24. Illness-related emergencies (such as stiff neck, inexplicable confusion, sudden onset of blood-red or purple rash, severe pain, temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method, and looking/acting severely ill);
  25. Standard Precautions;
  26. Organizing and implementing a plan to meet an emergency for any child with a special health care need;
  27. Addressing the needs of the other children in the group while managing emergencies in a child care setting;
  28. Applying first aid to children with special health care needs.

RATIONALE
First aid for children in the child care setting requires a more child-specific approach than standard adult-oriented first aid offers. To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common injuries and life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including pediatric CPR, coupled with a facility that has been designed or modified to ensure the safety of children, can reduce the potential for death and disability. Knowledge of pediatric first aid, including the ability to demonstrate pediatric CPR skills, and the confidence to use these skills, are critically important to the outcome of an emergency situation (1).

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

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

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 1.4.5.2: Child Abuse and Neglect Education

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

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

 

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

 

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

RATIONALE

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

COMMENTS

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

 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.2.1.1 Content of Policies
9.4.3.3 Training Record
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.4.2.1 Health and Safety Education Topics for Staff
REFERENCES
  1. Admon Livny K, Katz C. Schools, families, and the prevention of child maltreatment: lessons that can be learned from a literature review. Trauma Violence Abuse. 2016;pii:1524838016650186

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

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

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

  5. Centers for Disease Control and Prevention. Child abuse and neglect prevention. https://www.cdc.gov/violenceprevention/childmaltreatment/index.html. Updated April 17, 2017. Accessed March 8, 2018

NOTES

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

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 1.6.0.2: Frequency of Child Care Health Consultation Visits

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

The child care health consultant (CCHC) should visit each facility as needed to review and give advice on the facility’s health component and review the overall health status of the children and staff (1-4). Early childhood programs that serve any child younger than three years of age should be visited at least once monthly by a health professional with general knowledge and skills in child health and safety and health consultation. Child care programs that serve children three to five years of age should be visited at least quarterly and programs serving school-age children should be visited at least twice annually. In all cases, the frequency of visits should meet the needs of the composite group of children and be based on the needs of the program for training, support, and monitoring of child health and safety needs, including (but not limited to) infectious disease, injury prevention, safe sleep, nutrition, oral health, physical activity and outdoor learning, emergency preparation, medication administration, and the care of children with special health care needs. Written documentation of CCHC visits should be maintained at the facility.

RATIONALE
Almost everything that goes on in a facility and almost everything about the facility itself affects the health of the children, families, and staff. (1-4). Because infants are developing rapidly, environmental situations can quickly create harm. Their rapid changes in behavior make regular and frequent visits by the CCHC extremely important (2-4). More frequent visits should be arranged for those facilities that care for children with special health care needs and those programs that experience health and safety problems and high turnover rate to ensure that staff have adequate training and ongoing support (2). In one study, 84% of child care directors who were required to have weekly health consultation visits considered the visits critical for children’s health and program health and safety (2). Growing evidence suggests that frequent visits by a trained health consultant improves health policies and health and safety practices  and improves children’s immunization status, access to a medical home, enrollment in health insurance, timely screenings, and potentially reduces the prevalence of obesity with a targeted intervention (5-11). Furthermore, in one state, child care center medication administration regulatory compliance was associated with weekly visits by a trained nurse child care health consultant who delivered a standardized best practice curriculum (12).
COMMENTS
State child care regulations display a wide range of frequency and recommendations in states that require CCHC visits (5,6,13), from as frequently as once a week for programs serving children under three years of age to twice a year for programs serving children three to five years of age (2,5,6,13).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.6.0.1 Child Care Health Consultants
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
10.3.4.3 Support for Consultants to Provide Technical Assistance to Facilities
10.3.4.4 Development of List of Providers of Services to Facilities
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
4.4.0.1 Food Service Staff by Type of Facility and Food Service
4.6.0.2 Nutritional Quality of Food Brought From Home
9.4.1.17 Documentation of Child Care Health Consultation/Training Visits
REFERENCES
  1. National Resource Center for Health and Safety in Child Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/default/assets/File/CCHC%20by%20state%20NOV%202012_FINAL.pdf.
  2. Crowley, A. A. & Rosenthal, M. S. IMPACT: Ensuring the health and safety of Connecticut’s early care and education programs. 2009. Farmington, CT: The Child Health and Development Institute of Connecticut.
  3. Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Improvement of child care programs’ policies, practices, and children’s access to health care linked to child care health consultation. NHSA Dialog: A Research to Practice Journal 2013;16 (2):34-52 (ISSN:1930-1395).
  4. Bryant, D. “Quality Interventions for Early Care and Education.” Early Developments, Spring 2013, http://fpg.unc.edu/sites/default/files/resources/early-developments/FPG_EarlyDevelopments_v14n1.pdf.
  5. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. Nutrition and physical activity self-assessment for child care (NAP SACC): Results from a pilot intervention. Journal of Nutrition Education and Behavior 39(3):142-9.
  6. Nurse Consultant Intervention Improves Nutrition and Physical Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care.  A. Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, V. Ngyuen, J. Kotch. Head Start Research Conference, Washington, DC. June 20, 2012.
  7. 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.
  8. Crowley, A. A. & Kulikowich, J. Impact of training on child care health consultant knowledge and practice. Pediatric Nursing.,2009, 35 (2): 93-100.
  9. 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.
  10. Healthy Child Care Consultant Network Support Center, CHT Resource Group. 2006. The influence of child care health consultants in promoting children’s health and well-being: A report on selected resources. http://hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf.
  11. 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.
  12. 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.
  13. Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
NOTES

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

Standard 1.6.0.3: Early Childhood Mental Health Consultants

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

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

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

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

  1. Developing and implementing classroom curricula regarding conflict resolution, emotional regulation, and social skills development;
  2. Developing and implementing appropriate screening and referral mechanisms for behavioral and mental health needs;
  3. Forming relationships with mental health providers and special education systems in the community;
  4. Providing mental health services, resources and/or referral systems for families and staff;
  5. Helping staff facilitate and maintain mentally healthy environments within the classroom and overall system;
  6. Helping address mental health needs and reduce job stress within the staff;
  7. Improving management of children with challenging behaviors;
  8. Preventing the development of problem behaviors;
  9. Providing a classroom climate that promotes positive social-emotional development;
  10. Recognizing and appropriately responding to the needs of children with internalizing behaviors, such as persistent sadness, anxiety, and social withdrawal;
  11. Actively teaching developmentally appropriate social skills, conflict resolution, and emotional regulation;
  12. Addressing the mental health needs and daily stresses of those who care for young children, such as families and caregivers/teachers;
  13. Helping the staff to address and handle unforeseen crises or bereavements that may threaten the mental health of staff or children and families, such as the death of a caregiver/teacher or the serious illness of a child.

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

Standard 1.6.0.4: Early Childhood Education Consultants

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

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

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

The role of the early childhood education consultant should include:

  1. Review of the curriculum and written policies, plans and procedures of the program;
  2. Observations of the program and meetings with the director, caregivers/teachers, and parents/guardians;
  3. Review of the professional needs of staff and program and provision of recommendations of current resources;
  4. Reviewing and assisting directors in implementing and monitoring evidence based approaches to classroom management;
  5. Maintaining confidences and following all Family Educational Rights and Privacy Act (FERPA) regulations regarding disclosures;
  6. Keeping records of all meetings, consultations, recommendations and action plans and offering/providing summary reports to all parties involved;
  7. Seeking and supporting a multidisciplinary approach to services for the program, children and families;
  8. Following the National Association for the Education of Young Children (NAEYC) Code of Ethics;
  9. Availability by telecommunication to advise regarding practices and problems;
  10. Availability for on-site visit to consult to the program;
  11. Familiarity with tools to evaluate program quality, such as the Early Childhood Environment Rating Scale–Revised (ECERS–R), Infant/Toddler Environment Rating Scale–Revised (ITERS–R), Family Child Care Environment Rating Scale–Revised (FCCERS–R), School-Age Care Environment Rating Scale (SACERS), Classroom Assessment Scoring System (CLASS), as well as tools used to support various curricular approaches.

RATIONALE
The early childhood education consultant provides an objective assessment of a program and essential knowledge about implementation of child development principles through curriculum which supports the social and emotional health and learning of infants, toddlers and preschool age children (1-5). Furthermore, utilization of an early childhood education consultant can reduce the need for mental health consultation when challenging behaviors are the result of developmentally inappropriate curriculum (6,7). Together with the child care health consultant, the early childhood education consultant offers core knowledge for addressing children’s healthy development.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
1.6.0.3 Early Childhood Mental Health Consultants
REFERENCES
  1. Connecticut Department of Public Health. Child day care licensing program. http://www.ct.gov/dph/cwp/view
    .asp?a=3141&Q=387158&dphNav_GID=1823/.
  2. The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org.
  3. Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Rev ed. National Association for the Education of Young Children (NAEYC). Publication no. 234. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
  4. Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. Baltimore, MD: Brookes Publishing.
  5. Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53.
  6. Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics Early Childhood Special Ed 26:131-41.
  7. Dunn, L., K. Susan. 1997. What have we learned about developmentally appropriate practice? Young Children 52:4-13.

Standard 1.6.0.5: Specialized Consultation for Facilities Serving Children with Disabilities

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

  1. A registered nurse, nurse practitioner with pediatric experience, or child care health consultant;
  2. A physician with pediatric experience, especially those with developmental-behavioral training;
  3. A registered dietitian;
  4. A psychologist;
  5. A psychiatrist;
  6. A physical therapist;
  7. An adaptive equipment technician;
  8. An occupational therapist;
  9. A speech pathologist;
  10. An audiologist for hearing screenings conducted on-site at child care;
  11. A vision screener;
  12. A respiratory therapist;
  13. A social worker;
  14. A parent/guardian of a child with special health care needs;
  15. Part C representative/service coordinator;
  16. A mental health consultant;
  17. Special learning consultant/teacher (e.g., teacher specializing in work with visually impaired child or sign language interpreters);
  18. A teacher with special education expertise;
  19. The caregiver/teacher;
  20. Individuals identified by the parent/guardian;
  21. Certified child passenger safety technician with training in safe transportation of children with special needs.

RATIONALE
The range of professionals needed may vary with the facility, but the listed professionals should be available as consultants when needed. These professionals need not be on staff at the facility, but may simply be available when needed through a variety of arrangements, including contracts, agreements, and affiliations. The parent’s participation and written consent in the native language of the parent, including Braille/sign language, is required to include outside consultants (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Cohen, A. J. 2002. Liability exposure and child care health consultation. http://www.ucsfchildcarehealth.org/pdfs/forms/CCHCLiability.pdf.

II. Program Activities for Healthy Development

Standard 2.1.1.1: Written Daily Activity Program and Statement of Principles

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

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

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

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

These principles should address the following elements:

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

 

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

 

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

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

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

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

RATIONALE

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

Early childhood specialists agree on the

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

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

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

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

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

COMMENTS

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

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

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

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

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

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

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

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

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

Parents/guardians should be explicitly invited to:

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

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

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

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

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

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

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

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

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

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

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

Standard 2.1.1.5: Helping Families Cope with Separation

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

For the child, this should be accomplished by:

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

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

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

RATIONALE
In childhood, some separation experiences facilitate psychological growth by mobilizing new approaches for learning and adaptation. Other separations are painful and traumatic. The way in which influential adults provide support and understanding, or fail to do so, will shape the child’s experience (1).

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

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

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

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

Standard 2.1.1.9: Verbal Interaction

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

  1. For infants, these interactions should include responses to, and encouragement of, soft infant sounds, as well as identifying objects, feelings, and desires by the caregiver/teacher.
  2. For toddlers, the interactions should include naming of objects, feelings, listening to the child and responding, along with actions and supporting, but not forcing, the child to do the same.
  3. For preschool and school-age children, interactions should include respectful listening and responses to what the child has to say, amplifying and clarifying the child’s intent, and not reinforcing mispronunciations (e.g., Wambulance instead of Ambulance).
  4. Frequent interchange of questions, comments, and responses to children, including extending children’s utterances with a longer statement, by teaching staff.
  5. For children with special needs, alternative methods of communication should be available, including but not limited to: sign language, assistive technology, picture boards, picture exchange communication systems (PECS), FM systems for hearing aids, etc. Communication through methods other than verbal communication can result in the same desired outcomes.
  6. Profanity should not be used at any time.

RATIONALE
Conversation with adults is one of the main channels through which children learn about themselves, others, and the world in which they live. While adults speaking to children teaches the children facts and relays information, the social and emotional communications and the atmosphere of the exchange are equally important. Reciprocity of expression, response, and the initiation and enrichment of dialogue are hallmarks of the social function and significance of the conversations (1-4).

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

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

Standard 2.1.2.1: Personal Caregiver/Teacher Relationships for Infants and Toddlers

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

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

The caregiver/teacher should:

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

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


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

RATIONALE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NOTES

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

Standard 2.1.2.5: Toilet Learning/Training

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Facilities should provide opportunities for each child to build long-term, trusting relationships with a few caring caregivers/teachers by limiting the number of adults the facility permits to care for any one child in child care to a maximum of eight adults in a given year and no more than three primary caregivers/teachers in a day. Children with special health care needs may require additional specialists to promote health and safety and to support learning; however, relationships with primary caregivers/teachers should be supported.

RATIONALE
Children learn best from adults who know and respect them; who act as guides, facilitators, and supporters within a rich learning environment; and with whom they have established a trusting relationship (1,2). When the facility allows too many adults to be involved in the child’s care, the child does not develop a reciprocal, sustained, responsive, and trusting relationship with any of them.

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

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

Standard 2.2.0.3: Screen Time/Digital Media Use

Frequently Asked Questions/CFOC3 Clarifications

Reference: 2.2.0.3

Date: 3/8/2012

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

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

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

Answer:
Yes.

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

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


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

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

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

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

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

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

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

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

Standard 2.2.0.6: Discipline Measures

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

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

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

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

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

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

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

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

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

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

 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.1.6 Written Discipline Policies
9.4.1.6 Availability of Documents to Parents/Guardians
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
REFERENCES
  1. ADDITIONAL REFERENCES:

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

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

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

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

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

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

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

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

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

  2. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  3. Dunlap, S., L. Fox, M. L. Hemmeter, P. Strain. 2004. The role of time-out in a comprehensive approach for addressing challenging behaviors of preschool children. CSEFEL What Works Series. http://csefel.vanderbilt.edu/briefs/wwb14.pdf.
  4. American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in schools. Pediatrics 118:1266.
  5. Weiss, B., et al. 1992. Some consequences of early harsh discipline: Child aggression and a maladaptive social information processing style. Child Dev 63:1321-35.
  6. Deater-Deckard, K., et al. 1996. Physical discipline among African American and European American mothers: Links to children’s externalizing behaviors. Dev Psychol 32:1065-72.
  7. Straus, M. A., et al. 1997. Spanking by parents and subsequent antisocial behavior of children. Arch Pediatric Adolescent Medicine 151:761-67.
  8. Fraiberg, S. H. 1959. The Magic Years. New York: Charles Scribner’s Sons.
  9. Hodgkin, R. 1997. Why the “gentle smack” should go: Policy review. Child Soc 11:201-4.
  10. Henderlong, J., M. Lepper. 2002 The effects of praise on children’s intrinsic motivation: A review and synthesis. Psychological Bulletin 128:774-95.

Standard 2.2.0.7: Handling Physical Aggression, Biting, and Hitting

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

RATIONALE
Caregiver/teacher intervention protects children and encourages children to exhibit more acceptable behavior (1).
COMMENTS
Biting is a phase. Here are some specific steps to deal with biting:

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

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

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

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

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

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

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

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

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

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

Other important strategies to consider:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 2.2.0.9: Prohibited Caregiver/Teacher Behaviors

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

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

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

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

RATIONALE

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

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

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

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies
2.2.0.10 Using Physical Restraint
REFERENCES
  1. Zolotor AJ. Corporal punishment. Pediatr Clin North Am. 2014;61(5):971–978

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

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

  4. Gershoff ET, Purtell KM, Holas I. Education and advocacy efforts to reduce school corporal punishment. In: Corporal Punishment in U.S. Public Schools: Legal Precedents, Current Practices, and Future Policy. New York, NY: Springer International Publishing; 2015:87–98

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

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

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

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

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

NOTES

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

Standard 2.2.0.10: Using Physical Restraint

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

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

That behavioral care plan should include:

  1. An indication and documentation of the use of other behavioral strategies before the use of restraint and a precise definition of when the child could be restrained;
  2. That the restraint be limited to holding the child as gently as possible to accomplish the restraint;
  3. That such child restraint techniques do not violate the state’s mental health code;
  4. That the amount of time the child is physically restrained should be the minimum necessary to control the situation and be age-appropriate; reevaluation and change of strategy should be used every few minutes;
  5. That no bonds, ties, blankets, straps, car seats, heavy weights (such as adult body sitting on child), or abusive words should be used;
  6. That a designated and trained staff person, who should be on the premises whenever this specific child is present, would be the only person to carry out the restraint.

RATIONALE
A child could be harmed if not restrained properly (1). Therefore, staff who are doing the restraining must be trained. A clear behavioral care plan needs to be in place. And, clear documentation with parent/guardian notification needs to be done after a restraining incident occurs in order to conform with the mental health code.
COMMENTS
If all strategies described in Standard 2.2.0.6 are followed and a child continues to behave in an unsafe manner, staff need to physically remove the child from the situation to a less stimulating environment. Physical removal of a child is defined according the development of the child. If the child is able to walk, staff should hold the child’s hand and walk him/her away from the situation. If the child is not ambulatory, staff should pick the child up and remove him/her to a quiet place where s/he cannot hurt themselves or others. Staff need to remain calm and use a calm voice when directing the child. Certain procedures described in Standard 2.2.0.6 can be used at this time, including not giving a lot of attention to the behavior, distracting the child and/or giving a time-out to the child. If the behavior persists, a plan needs to be made with parental/guardian involvement. This plan could include rewards or a sticker chart and/or praise and attention for appropriate behavior. Or, loss of privileges for inappropriate behavior can be implemented, if age-appropriate. Staff should request or agree to step out of the situation if they sense a loss of their own self-control and concern for the child.

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

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

Standard 2.3.1.1: Mutual Responsibility of Parents/Guardians and Staff

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 2.3.1.2: Parent/Guardian Visits

Content in the STANDARD was modified on 8/28/2018

 

Parents/guardians are welcome any time their child is in attendance. Caregivers/teachers should inform all parents/guardians that they may visit the site at any time when their child is there and that they will be asked to follow the facility’s sign-in procedures (see Standard 9.2.4.7) and admitted without delay. This open-door policy should be part of the “admission agreement” or other contract between the parent/guardian and the facility and caregiver/teacher (1). Parents/guardians should be welcomed and encouraged to speak freely to staff about concerns and suggestions.

Parents/guardians must be informed what appropriate and inappropriate parental/guardian behavior is and the consequences for inappropriate behavior. Caregivers/teachers should not release a child to a parent/guardian who appears impaired. Caregivers/teachers should not attempt to handle an unstable (e.g., intoxicated) parent/guardian who wants to be admitted but whose behavior poses a risk to the children and adults in the facility. The director should consult local police or the local child protection agency about their recommendations for how staff can obtain support from law enforcement authorities and train caregivers/teachers accordingly.


To ensure the safety of the children and staff, all visitors, including authorized individuals and parents/guardians should check in with the facility staff every visit.

 

RATIONALE

When access is restricted, areas observable by the parents/guardians may not reflect the care the children actually receive. Strong relationships between families and early care and education staff can contribute to positive outcomes for children and families. Positive, mutually respectful, and collaborative relationships can enhance family engagement in early care and education programs, family well-being, and home–school connections. There is also some evidence that these relationships can have a positive effect on children’s school readiness (2).

COMMENTS

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

 

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
9.2.1.1 Content of Policies
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
9.2.4.7 Sign-In/Sign-Out System
2.1.1.7 Communication in Native Language Other Than English
2.3.2.1 Parent/Guardian Conferences
2.3.2.2 Seeking Parent/Guardian Input
2.3.2.3 Support Services for Parents/Guardians
2.3.2.4 Parent/Guardian Complaint Procedures
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior
REFERENCES
  1. Porter T, Bromer J, Forry N. Assessing Quality in Family and Provider/Teacher Relationships: Using the Family and Provider Teacher Relationships Quality (FPTRQ) Measures in Conjunction with Strengthening Families and the Head Start Parent, Family and Community Engagement Frameworks and their Self-Assessment Tools. OPRE Report 2015-56. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, US Department of Health and Human Services; 2015. https://www.acf.hhs.gov/sites/default/files/opre/assessing_quality_in_family_provider_teacher_relationships_a.pdf. Accessed June 26, 2018

  2. Child Care Aware of Missouri. What to look for. http://mo.childcareaware.org/parents-families/what-to-look-for/. Accessed June 29, 2018

NOTES

Content in the STANDARD was modified on 8/28/2018

Standard 2.3.2.1: Parent/Guardian Conferences

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 2.3.2.2: Seeking Parent/Guardian Input

At least twice a year, each caregiver/teacher should seek the views of parents/guardians about the strengths and needs of the indoor and outdoor learning/play environment and their satisfaction with the services offered. Caregivers/teachers should honor parents’/guardians’ requests for more frequent reviews. Anonymous surveys can be offered as a way to receive parent/guardian input without parents/guardians feeling concerned if they have negative comments or concerns about the facility or practices within a facility.

RATIONALE
Parents/guardians and caregiver/teacher alike recognize that parents/guardians have essential rights in helping to shape the kind of child care service their children receive (1).
COMMENTS
Asking parents/guardians about their concerns and observations is essential so they can share issues and engage with staff in collaborative problem-solving. Small and large family child care homes should have group meetings of all parents/guardians once or twice a year. This standard avoids mention of procedures that are inappropriate to small family child care, as it does not require any explicit mechanism (such as a parent/guardian advisory council) for obtaining or offering parental/guardian input. Individual or group meetings with parents/guardians would suffice to meet this standard. Seeking consumer input is a cornerstone of facility planning and evaluation. Centers can offer parents/guardians the chance to respond in writing. Accreditation organizations such as the National Association for the Education of Young Children (NAEYC) or the National Association for Family Child Care (NAFCC) have guidance on conducting parent/guardian surveys.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. National Association of Child Care Resource and Referral Agencies. It’s a win-win situation: When parents and providers work together. Child Care Aware. http://ccaapps.childcareaware.org/en/subscriptions/dailyparent/volume.php?id=29.

Standard 2.3.2.3: Support Services for Parents/Guardians

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

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

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

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

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

Standard 2.3.2.4: Parent/Guardian Complaint Procedures

Facilities should have in place complaint resolution procedures to jointly resolve with parents/guardians any problems that may arise. Arrangements for hearing (or receiving) the complaint and the actions (or discussion) resulting in resolution should be documented along with dates and people involved. Facilities should develop mechanisms for holding formal and informal meetings between staff and groups of parents/guardians. Substantiated complaints and their resolution(s) should be posted in a prominent location. Facilities should post the complaint and resolution procedure where parents/guardians can easily see (or view) them.

RATIONALE
Coordination between the facility and the parents/guardians is essential to promote their respective child care roles and to avoid confusion or conflicts surrounding values. In addition to routine meetings, special meetings can deal with crises and unique problems. Complaint and resolution documentation records can help program directors assess problem areas of the facility, staff, and services.
COMMENTS
Special meetings could identify facility needs, assist in developing resources, and recommend facility and policy changes to the governing body. It is most helpful to document the proceedings of these meetings to facilitate future communications and to ensure continuity of service delivery. Facility-sponsored activities could take place outside facility hours and at other venues.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.8.2.5 Handling Complaints About Caregivers/Teachers
10.4.3.1 Procedure for Receiving Complaints
9.1.0.1 Governing Body of the Facility
9.1.0.2 Written Delegation of Administrative Authority
9.4.1.4 Access to Facility Records

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

The facility should ask parents/guardians for information regarding the child’s health, nutrition, level of physical activity, and behavioral status upon registration or when there has been an extended gap in the child’s attendance at the facility. The child’s health record should be updated if s/he have had any changes in their health or immunization status. Parents/guardians should be encouraged to sign a release of information/agreement so that child care workers can communicate directly with the child’s medical home/primary care provider.

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

Standard 2.3.3.2: Communication from Specialists

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

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

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

Standard 2.4.1.1: Health and Safety Education Topics for Children

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

 

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

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

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

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

     d. Expression and identification of feelings

     e.Self-esteem and self-awareness

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

     g. Healthy sleep habits

     h. Outdoor learning/play

     i. Fitness and age-appropriate physical activity

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

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

     l. Conflict management, violence prevention, and bullying prevention

     m. Age-appropriate first aid concepts

     n.Healthy and safe behaviors

     o. Poisoning prevention and poison safety

     p. Awareness of routine preventive care

     q. Care of children with special health care needs

     r. Health risks of secondhand and third-hand smoke

     s. Appropriate use of medications

     t. Handling food safely

     u. Preventing choking and falls

RATIONALE

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

COMMENTS

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

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

ADDITIONAL RESOURCES

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

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

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

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

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

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

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

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

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

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

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

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

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

NOTES

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

 

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
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.4.1 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
1.4.5.2 Child Abuse and Neglect Education
1.6.0.1 Child Care Health Consultants
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.2.0.6 Discipline Measures
2.4.1.1 Health and Safety Education Topics for Children
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.4.3.3 CPR Training for Swimming and Water Play
1.4.5.1 Training of Staff Who Handle Food
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
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
2.2.0.4 Supervision Near Bodies of Water
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
2.1.1.5 Helping Families Cope with Separation
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
2.4.1.1 Health and Safety Education Topics for Children
9.4.1.19 Community Resource Information
REFERENCES
  1. 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 3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical Activity

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

Caregivers/teachers should promote children’s active play and participate in children’s active games at times when they can safely do so. Caregivers/teachers should

     a. Lead structured activities to promote children’s activities 2 or more times per day.

     b. Wear clothing and footwear that permits easy and safe movement (1). 

     c. Provide prompts for children to be active (2,3). (eg, “Good throw!”).

     d. Encourage children’s physical activities that are appropriate and safe in the setting (eg, do not prohibit running on the playground when it is safe to run).

     e.Have orientation and annual training opportunities to learn about age-appropriate gross motor activities and games that promote children’s physical activity (2,4).

     f. Not sit during active play.

     g. Limit screen time and other digital media as outlined in Standard 2.2.0.3.

Caregivers/teachers should consider incorporating structured activities into the curriculum indoors or after children have been on the playground for 10 to 15 minutes. Caregivers/teachers should communicate with parents/guards about their use of screen time/digital media in the home.

RATIONALE

Children learn from the adult modeling of healthy and safe behavior. Caregivers/teachers may not be comfortable promoting active play, perhaps due to inhibitions about their own physical activity skills or lack of training. Caregivers/teachers may also assume their sole role on the playground is to supervise and keep children safe, rather than to promote physical activity. Continuing education activities are useful in disseminating knowledge about effective games to promote physical activity in early care and education while keeping children safe (4).

Children exposed to less screen time/digital media in early care and education settings engage in more moderate-to-vigorous physical activity compared with children who are exposed to more screen time (5).  This gives caregivers/teachers the opportunity to model the limitation of screen time/digital media use and to educate parents/guardians about alternative activities that families can do with their children (2). 

Additional Resource:

American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.2.0.3 Screen Time/Digital Media Use
3.1.3.2 Playing Outdoors
3.1.3.1 Active Opportunities for Physical Activity
9.2.3.1 Policies and Practices that Promote Physical Activity
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43

  2. Tandon PS, Saelens BE, Copeland KA. A comparison of parent and childcare provider's attitudes and perceptions about preschoolers' physical activity and outdoor time. Child Care Health Dev. 2017;43(5):679–686

  3. Tandon PS, Walters KM, Igoe BM, Payne EC, Johnson DB. Physical activity practices, policies and environments in Washington state child care settings: results of a statewide survey. Matern Child Health J. 2017;21(3):571–582

  4. Copeland KA, Khoury JC, Kalkwarf HJ. Child care center characteristics associated with preschoolers’ physical activity. Am J Prev Med. 2016;50(4):470–479

  5. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272

NOTES

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

Standard 3.2.1.5: Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants 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, 8/23/2016 and 10/16/2018.

The following changing procedure for soiled disposable training pants, underwear and clothing should be posted in the changing area, followed for all changes, and used as part of staff evaluation of caregivers/teachers who change disposable training pants, underwear and clothing. The signage  should be simple and in multiple languages if caregivers/teachers who speak multiple languages are involved in changing disposable training pants or underwear. All employees who will change disposable training pants, 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 may also be used. Changing tables that are a comfortable height for caregivers help reduce the risk of back injury for the adults, which 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 a fragrance-free bleach that is US Environmental Protection Agency (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 if hands have been contaminated since the last time hand hygiene was performed (3), gather, and bring supplies to the changing area.

  1. Nonabsorbent paper liner large enough to cover the changing surface
  2. Unused disposable training pants, underwear, clean clothes (if you need them)
  3. Readily available wipes, dampened cloths, or wet paper towels for cleaning the child’s genitalia and buttocks
  4. A plastic bag for any soiled clothes, including underwear, or disposable training pants
  5. Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or disposable training pants; remove them before handling clean disposable training pants, 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 his or her shirt, sweater, etc., up above the 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 clothespins that can be washed and sanitized to keep the clothing out of the way.
    3. If disposable training pants 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, a dampened cloth, or a 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, cloth, or paper towels into the soiled disposable training pants 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 changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.
      1. Check for spills under the child. If there are any, use the corner of 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.
      2. If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can.
      3. 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 clean disposable training pants or clean underwear and clothing, if necessary.

      1. Assist the child, as needed, in putting on clean disposable training pants or underwear, and then in re-dressing (1).
        1. Note and plan to report any skin problems such as redness, cracks, or bleeding.
        2. 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.

Use soap and warm water, between 60°F and 120°F (16°C and 49°C), at a sink to wash the child’s hands, if you can.

Step 6: Clean and disinfect the changing surface.

Dispose of the disposable paper liner used on the changing surface in a plastic-lined, hands-free covered can.

If clothing was soiled, securely tie the plastic bag used to store the clothing and send the bag home.

Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, and then rinse.

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.

Put away the disinfectant. Some types of disinfectants may require rinsing the changing table surface with fresh water afterward.

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.

In the daily log, record what was in the disposable training pants or underwear and any problems (e.g., a loose stool, an unusual odor, blood in the stool, any skin irritation) and report as necessary (4).

RATIONALE

Children who are learning to use the toilet may still wet/soil their disposable training pants,  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 (5, 6). Posting the multistep 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 re-soiled.

Children’s hands often stray into the changing area (the area of the child’s body covered by the soiled disposable training pants or underwear) during the changing 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 disposable training pants 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 disposable training pants, 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 disposable training pants 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 on 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) (7).

Changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils. Additionally, changing tables that are a comfortable height for caregivers help reduce the risk of back injury for the adults, which may occur from lifting the child onto the table (1).

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-aged 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 typical 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 typically 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 about 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, Small Family Child Care Home
RELATED STANDARDS
2.1.2.5 Toilet Learning/Training
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. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster. Reaffirmed April 2018. Accessed June 26, 2018

  2. University of California, San Francisco School of Nursing Institute for Health and Aging; University of California, Berkeley Center for Environmental Research and Children’s Health; Informed Green Solutions. 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. Published 2013. Accessed June 26, 2018

  3. American Academy of Pediatrics. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018
  4. National Association for the Education of Young Children. Healthy Young Children: A Manual for Programs. Aronson SS, ed. 5th ed. Washington, DC: National Association for the Education of Young Children; 2012
  5. American Academy of Pediatrics. Managing infectious diseases in child care and schools: A quick reference guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL; 2017.
  6. Children’s Environmental Health Network. 2016. Household chemicals. https://sharemylesson.com/teaching-resource/household-chemicals-fact-sheet-298286.

  7. Early Childhood Education Linkage Systems, Healthy Child Care Pennsylvania. Changing soiled underwear. http://www.ecels-healthychildcarepa.org/publications/fact-sheets/item/116-changing-soiled-underwear?highlight=WyJzb2lsZWQiXQ. Published 2016. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, 8/23/2016 and 10/16/2018.

Standard 3.4.2.1: Animals that Might Have Contact with Children and Adults

The following domestic animals may have contact with children and adults if they meet the criteria specified in this standard:

  1. Dog;
  2. Cat;
  3. Ungulate (e.g., cow, sheep, goat, pig, horse);
  4. Rabbit;
  5. Rodent (e.g., mice, rats, hamsters, gerbils, guinea pigs, chinchillas).

Fish are permissible but must be inaccessible to children.

Any animal present at the facility, indoors or outdoors, should be trained/adapted to be with young children, in good health, show no evidence of carrying any disease, fleas or ticks, be fully immunized, and be maintained on an intestinal parasite control program. A current (time-specified) certificate from each animal’s attending veterinarian should be on file in the facility, stating that all animals on the facility premises meet these conditions and meet local and state requirements.

Only animals that do not pose a health or safety risk will be allowed on the premises of the facility.

The caregiver/teacher should instruct children on the humane and safe procedures to follow when in close proximity to animals (for example, not to provoke or startle animals or touch them when they are near food).

All contact between animals and children should be supervised by a caregiver/teacher who is close enough to remove the child immediately if the animal shows signs of distress (e.g., growling, baring teeth, tail down, ears back) or the child shows signs of treating the animal inappropriately.

Children should not be allowed to feed animals directly from their hands.

No food and beverages should be allowed in animal areas. In addition, adults and children should not carry toys, use pacifiers, cups, and infant bottles in animal areas.

The animals should be housed within some “barrier” that protects them from competition by other animals while being fed which would also provide protection for the children yet they could still observe the animals eating. Animal food dishes should not be placed in areas accessible to children during hours when children are present.

Children should be discouraged from “kissing” animals or having them in close contact with their faces.

All children and caregivers/teachers who handle animals or animal-related equipment (e.g., leashes, dishes, toys, etc.) should be instructed to use hand hygiene immediately after handling.

Immunocompromised children, such as children with organ transplants, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), or currently receiving cancer chemotherapy or radiation therapy, and/or children with allergies, should have an individualized health care plan in place that specifies if there are precautionary measures to be taken before the child has direct or indirect contact with animals or equipment.

Uncaged animals, such as dogs and cats, should wear a proper collar, harness, and/or leash when on the facility premises and the owner or responsible adult should stay with the animal at all times. Animals should not be permitted in food preparation or service areas at any time.

RATIONALE
The risk of injury, infection, and aggravation of allergy from contact between children and animals is significant. The staff must plan carefully when having an animal in the facility and when visiting a zoo or local pet store (5,9,10). Children should be brought into direct contact only with animals known to be friendly and comfortable in the company of children.

Dog bites to children under four years of age usually occur at home, and the most common injury sites are the head, face, and neck (1-4). Many human illnesses can be acquired from animals (5,7,8,11). Many allergic children have symptoms when they are around animals.

Special precautions may be needed to minimize the risk of disease transmission to immunocompromised children (13).

When animals are taken out of their natural environment and are in situations unusual to them, the stress that the animals experience may cause them to act aggressively or attempt to escape (the “flight or fight” phenomenon). Appropriate restraint devices will allow the holder to react quickly, prevent harm to children and/or the escape of the animal (9).

Pregnant women need to be aware of a potential risk associated with contact with cats’ feces (stool). Toxoplasmosis is an infection caused by a parasite called Toxoplasma gondii. This parasite is carried by cats and is passed in their feces. Toxoplasmosis can cause problems with pregnancy, including abortion (8). The CDC advises pregnant women to avoid pet rodents because of the risk of lymphocytic choriomeningitis virus (6,12).

COMMENTS
Bringing animals and children together has both risks and benefits. Animals teach children about how to be gentle and responsible, about life and death, and about unconditional love (9). Nevertheless, animals can pose serious health and safety risks.

Special accommodations for children with allergies may be necessary. Cleaning air filters more often if animals are in childcare areas may be helpful in reducing animal dander.

Some dogs complete training and are certified as part of “dog-assisted therapy programs.” Certification requires that dogs meet specific criteria, complete screening/training, and be a member of Therapy Dogs International for liability purposes. Although these programs are typically based in hospitals, certified therapy animals also help with disaster relief and other efforts. Facilities that want to offer educational information to staff or hands-on learning opportunities for children may find it helpful to contact their local hospital to identify a trainer for dog-assisted therapy programs. For more information on this program and resources, contact Therapy Dogs International at http://www.tdi-dog.org.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
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
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals
REFERENCES
  1. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to nontraditional pets at home and to animals in public settings: risks to children. Pediatrics 122:876-86.
  2. Massachusetts Department of Public Health Division of Epidemiology and Immunization. 2001. Recommendations for petting zoos, petting farms, animal fairs, and other events and exhibits where contact between animals and people is permitted. http://www.mass.gov/Eeohhs2/docs/dph/cdc/rabies/reduce_zoos
    _risk.pdf.
  3. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
    ab1007.pdf.
  4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Pregnant women and Toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm.
  5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2000. Compendium of measures to control Chlamydia psittaci infection among humans (psittacosis) and pet birds (avian chlamydiosis). MMWR 49:3-17.
  6. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.
  7. Hemsworth, S., B. Pizer. 2006. Pet ownership in immunocompromised children – A review of the literature and survey of existing guidelines. Eur J Oncol Nurs 10:117-27.
  8. Centers for Disease Control and Prevention. 2010. Lymphocytic choriomeningitis (LCMV). http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/lcmv.htm.
  9. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13.
  10. Bernardo, L. M., M. J. Gardner, R. L. Rosenfield, B. Cohen, R. Pitetti. 2002. A comparison of dog bite injuries in younger and older children treated in a pediatric emergency department. Pediatric Emergency Care 18:247-49.
  11. Information from Your Family Doctor. 2004. Dog bites: Teaching your child to be safe. Am Family Physician 69:2653.
  12. Reisner, I. R., F. S. Shofer. 2008. Effects of gender and parental status on knowledge and attitudes of dog owners regarding dog aggression toward children. J Am Vet Med Assoc 233:1412-19.
  13. Gilchrist, J., J. J. Sacks, D. White, M. J. Kresnow. 2008. Dog bites: Still a problem? Injury Prevention 14:296-301.

Standard 3.4.2.3: Care for Animals

The facility should care for all animals as recommended by the health department and in consultation with licensed veterinarian. When animals are kept on the premises, the facility should write and adhere to procedures for their humane care and maintenance. When animals are kept in the child care facility, the following conditions should be met:

Humane Care: An environment will be maintained in which animals experience:

  1. Good health;
  2. Are able to effectively cope with their environment;
  3. Are able to express a diversity of species specific behaviors.

Health Care: Proof of appropriate current veterinary certificate meeting local and state health requirement is kept on file at the facility for each animal kept on the premises or visiting the child care facility.

Animal care: Specific areas should be designated for animal contact.

Live animals should be prohibited from:

  1. Food preparation, food storage, and dining areas;
  2. The vicinity of sinks where children wash their hands;
  3. Clean supply rooms;
  4. Areas where children routinely play or congregate (e.g., sandboxes, child care facility playgrounds).

The living quarters of animals should be enclosed and kept clean of waste to reduce the risk of human contact with this waste.

Animal food supplies should be kept out of reach of children.

Animal litter boxes should not be located in areas accessible to children. Children and food handlers should not handle or clean up any form of animal waste (feces, urine, blood, etc).

All animal waste and litter should be removed immediately from children’s areas and will be disposed of in a way where children cannot come in contact with the material, such as in a plastic bag or container with a well-fitted lid or via the sewage waste system for feces.

Used fish tank water should be disposed of in sinks that are not used for food preparation or used for obtaining water for human consumption.

Disposable gloves should be used when cleaning aquariums and hands should be washed immediately after cleaning is finished. Eye and oral contamination by splashing of contaminated water during the cleaning process should be prevented. Children should not be involved in the cleaning of aquariums.

Areas where feeders, water containers, and cages are cleaned should be disinfected after cleaning activity is finished.

Pregnant persons should not handle cat waste or litter. Cat litter boxes should be cleaned daily.

All persons who have contact with animals, animal products, or animal environments should wash their hands immediately after the contact.

RATIONALE
Animals, including pets, are a source of illness for people; likewise, people may be a source of illness for animals (1). All contact with animals, and animal wastes should occur in a fashion that minimizes staff and children’s risk of injury, infection and aggravation of allergy (2,4,5). Hand hygiene is the most important way to reduce the spread of infection. Unwashed or improperly washed hands are primary carriers of germs which may lead to infections.

Just as food intended for human consumption may become contaminated, an animal’s food can become contaminated by standing at room temperature, or by being exposed to animals, insects, or people.

Pregnant woman can acquire toxoplasmosis from infected cat waste. The infection can be transmitted to her unborn child. Congenital toxoplasmosis infection can lead to miscarriage or an array of malformations of the developing child prior to birth. Cat litter boxes should be cleaned daily since it takes one to five days for feces containing toxoplasma oocysts to become infectious with toxoplasmosis (3).

COMMENTS
Ensuring animal welfare is a human responsibility that includes consideration for all aspects of animal well-being, inclusive of secure housing, suitable temperature, adequate exercise and proper diet, disease prevention and treatment, humane handling, and, when necessary, humane euthanasia (6). Animal well-being also includes continued care of animals during the days that child care is not in session and in the event of an emergency evacuation.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.2.1 Animals that Might Have Contact with Children and Adults
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
3.4.2.2 Prohibited Animals
REFERENCES
  1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections transmitted from animals. Infect Dis Clin North Am 5:649-61.
  2. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13.
  3. Centers for Disease Control and Prevention (CDC). Pregnant women and toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm.
  4. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
    ab1007.pdf.
  5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.
  6. American Veterinary Medical Association. Animal welfare principles. https://www.avma.org/public/animalwelfare/pages/default.aspx.

Standard 3.4.3.1: Emergency Procedures

When an immediate emergency medical response is required, the following emergency procedures should be utilized:

  1. First aid should be employed and an emergency medical response team should be called such as 9-1-1 and/or the poison center if a poison emergency (1-800-222-1222);
  2. The program should implement a plan for emergency transportation to a local emergency medical facility;
  3. The parent/guardian or parent/guardian’s emergency contact person should be called as soon as practical;
  4. A staff member should accompany the child to the hospital and will stay with the child until the parent/guardian or emergency contact person arrives. Child to staff ratio must be maintained, so staff may need to be called in to maintain the required ratio.

Programs should develop contingency plans for emergencies or disaster situations when it may not be possible or feasible to follow standard or previously agreed upon emergency procedures (see also Standard 9.2.4.3, Disaster Planning, Training, and Communication). Children with known medical conditions that might involve emergent care require a Care Plan created by the child’s primary care provider. All staff need to be trained to manage an emergency until emergency medical care becomes available.

RATIONALE
The staff must know how to carry out the written disaster and emergency plans as described in Standard 9.2.4.3 to help prevent or minimize severe injury to children and other staff. The staff should review and practice the emergency plan regularly (1).
COMMENTS
First aid instructions are available from the American Academy of Pediatrics (AAP) and the American Red Cross.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.4.3 Disaster Planning, Training, and Communication
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. Aronson, S. 2005. Pediatric first aid for caregivers and teachers. Sudbury, MA: Jones and Bartlett; Elk Grove Village, IL: American Academy of Pediatrics.

Standard 3.4.4.4: Care for Children Who Have Experienced Abuse/Neglect

Content in the STANDARD was modified on 08/28/2018

Caregivers/teachers should have access to specialized training and expert advice when caring for children with behavioral challenges related to abuse or neglect.

RATIONALE

All children who have experienced abuse or neglect have had their physical and emotional boundaries violated. With this violation often comes a breach of the child’s sense of security and trust. Children who have experienced abuse and neglect may come to believe that the world is not a safe place and that adults are not trustworthy. These children may have more emotional needs and may require more individual staff time and attention than children who have not experienced maltreatment.

Children who have experienced abuse or neglect may display varying levels of developmental delay, physical symptoms, or behavioral concerns such as avoidant or anxious behavior, fearfulness, sadness/depression, or impulsive, oppositional, aggressive, and sexualized behavior (1).

These problems may persist long after the maltreatment occurred and may have significant psychiatric and medical consequences into adulthood. In particular, children who have experienced abuse or neglect or have been exposed to violence, including domestic violence, often have excessive responses to environmental stress. Caregivers/teachers are better equipped in responding to a child’s behavior when provided with training and information about the dynamics of abuse, mental health consultation to explore trauma-informed strategies to support and keep the child safe, and data on long-term outcomes of child maltreatment (2). Child care staff may need to work closely with the child’s primary health care provider, therapist, social worker, and parents/guardians to formulate a more personalized behavior management plan.

COMMENTS

Centers serving children with a history of maltreatment-related behavior problems may require staff trained in trauma-informed practices and/or assistance from a child care mental health consultant. Care may be facilitated by having an intentional, written behavioral care plan. Resources on caring for a child who has experienced abuse or neglect are available from the following agencies:

TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
REFERENCES
  1. Center for Early Childhood Mental Health Consultation, Georgetown University Center for Child and Human Development. Trauma signs and symptoms. https://www.ecmhc.org/tutorials/trauma/mod3_1.html. Accessed June 26, 2018

  2. Van Toledo A, Seymour F. Caregiver needs following disclosure of child sexual abuse. J Child Sex Abus. 2016;25(4):403–414. http://www.tandfonline.com/doi/full/10.1080/10538712.2016.1156206. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 08/28/2018

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 3.5.0.2: Caring for Children Who Require Medical Procedures

A facility that enrolls children who require the following medical procedures: tube feedings, endotracheal suctioning, supplemental oxygen, postural drainage, or catheterization daily (unless the child requiring catheterization can perform this function on his/her own), checking blood sugars or any other special medical procedures performed routinely, or who might require special procedures on an urgent basis, should receive a written plan of care from the primary care provider who prescribed the special treatment (such as a urologist for catheterization). Often, the child’s primary care provider may be able to provide this information. This plan of care should address any special preparation to perform routine and/or urgent procedures (other than those that might be required in an emergency for any typical child, such as cardiopulmonary resuscitation [CPR]). This plan of care should include instructions for how to receive training in performing the procedure, performing the procedure, a description of common and uncommon complications of the procedure, and what to do and who to notify if complications occur. Specific/relevant training for the child care staff should be provided by a qualified health care professional in accordance with state practice acts. Facilities should follow state laws where such laws require RN’s or LPN’s under RN supervision to perform certain medical procedures. Updated, written medical orders are required for nursing procedures.

RATIONALE
The specialized skills required to implement these procedures are not traditionally taught to early childhood caregivers/teachers, or educational assistants as part of their academic or practical experience. Skilled nursing care may be necessary in some circumstances.
COMMENTS
Parents/guardians are responsible for supplying the required equipment. The facility should offer staff training and allow sufficient staff time to carry out the necessary procedures. Caring for children who require intermittent catheterization or maintaining supplemental oxygen is not as demanding as it first sounds, but the implication of this standard is that facilities serving children who have complex medical problems need special training, consultation, and monitoring.

Before enrolling a child who will need this type of care, caregivers/teachers can request and review fact sheets, instructions, and training by an appropriate health care professional that includes a return demonstration of competence of the caregivers/teachers for handling specific procedures. Often, the child’s parents/guardians or clinicians have these materials and know where training is available. If possible, parents/guardians should be present and take part in the training. The primary care provider is responsible for providing the health care plan for the child; the plan can be communicated to the caregiver/teacher by the parent/guardian with the help of the child care health consultant who can then assist in training the staff. When the specifics are known, caregivers/teachers can make a more responsible decision about what would be required to serve the child. A caregiver/teacher should not assume care for a child with special medical needs unless comfortable with training received and approved for that role by the child care health consultant or consulting primary care provider.

Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (1). 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) (1).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.3.1 First Aid and CPR Training for Staff
1.6.0.1 Child Care Health Consultants
3.5.0.1 Care Plan for Children with Special Health Care Needs
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.

Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children

Content in the STANDARD was modified on 04/16/2015, on 8/2015, and on 4/4/2017.

(Adapted from: 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.)

Preparing for managing illness:

Caregivers/teachers should:

  1. With a child care health consultant, develop protocols and procedures for handling children’s illnesses, including care plans and an inclusion/exclusion policy.
  2. Review with all families the inclusion/exclusion criteria. Clarify that the program staff (not the families) will make the final decision about whether children who are ill may attend. The decision will be based on the program’s inclusion/exclusion criteria and their ability to care for the child who is ill without compromising the care of other children in the program.
  3. Encourage all families to have a backup plan for child care in the event of short- or long-term exclusion.
  4. Consider the family’s description of the child’s behavior to determine whether the child is well enough to return, unless the child’s status is unclear from the family’s report.
  5. A primary health care provider’s note may be required to readmit a child to determine whether the child is a health risk to others, or if guidance is needed about any special care the child requires.

Daily health checks as described in Standard 3.1.1.1 should be performed upon arrival of each child each day. Staff should objectively determine if the child is ill or well. Staff should determine which children with mild illnesses can remain in care and which need to be excluded.
Staff should notify the parent/guardian when a child develops new signs or symptoms of illness. Parent/guardian notification should be immediate for emergency or urgent issues.
Staff should notify parents/guardians of children who have symptoms that require exclusion and parents/guardians should remove the child from the child care setting as soon as possible.
For children whose symptoms do not require exclusion, verbal or written notification of the parent/guardian at the end of the day is acceptable.
Most conditions that require exclusion do not require a primary health care provider visit before reentering care.

Conditions/symptoms that do not require exclusion:

  1. Common colds, runny noses (regardless of color or consistency of nasal discharge)
  2. A cough not associated with fever, rapid or difficult breathing, wheezing or cyanosis (blueness of skin or mucous membranes)
  3. Pinkeye (bacterial conjunctivitis) indicated by pink or red conjunctiva with white or yellow eye mucous drainage and matted eyelids after sleep.  This may be thought of as a cold in the eye. Exclusion is no longer required for this condition. Health professionals may vary on whether or not to treat pinkeye with antibiotic drops. The role of antibiotics in treatment and preventing spread of conjunctivitis is unclear. Most children with pinkeye get better after 5 or 6 days without antibiotics. Parents/guardians should discuss care of this condition with their child’s primary care provider, and follow the primary care provider’s advice. Some primary care providers do not think it is necessary to examine the child if the discussion with the parents/guardians suggests that the condition is likely to be self-limited. If no treatment is provided, the child should be allowed to remain in care.  If the child’s eye is painful, a health care [provider should examine the child.  If 2 or more children in a group develop pinkeye in the same period, the program should seek advice from the program’s health consultant or a public health agency.
  4. Watery, yellow or white discharge or crusting eye discharge without fever, eye pain, or eyelid redness
  5. Yellow or white eye drainage that is not associated with pink or red conjunctiva (i.e., the whites of the eyes)
  6. Fever without any signs or symptoms of illness in children who are older than four months regardless of whether acetaminophen or ibuprofen was given. For this purpose, fever is defined as temperature above 101 degrees F (38.3 degrees C) by any method. These temperature readings do not require adjustment for the location where they are made. They are simply reported with the temperature and the location, as in “101 degrees in the armpit/axilla";
Fever is an indication of the body’s response to something, but is neither a disease nor a serious problem by itself. Body temperature can be elevated by overheating caused by overdressing or a hot environment, reactions to medications, and response to infection. If the child is behaving normally but has a fever, the child should be monitored, but does not need to be excluded for fever alone. For example, an infant with a fever after an immunization who is behaving normally does not require exclusion.

  1. Rash without fever and behavioral changes. Exception: call EMS (911) for rapidly spreading bruising or small blood spots under the skin.
  2. Impetigo lesions should be covered, but treatment may be delayed until the end of the day. As long as treatment is started before return the next day, no exclusion is needed;
  3. Lice or nits treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed;
  4. Ringworm treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed;
  5. Scabies treatment may be delayed until the end of the day. As long as treatment is started before returning the next day, no exclusion is needed;
  6. Molluscum contagiosum (does not require covering of lesions);
  7. Thrush (i.e., white spots or patches in the mouth or on the cheeks or gums);
  8. Fifth disease (slapped cheek disease, parvovirus B19) once the rash has appeared;
  9. Methicillin-resistant Staphylococcus aureus, or MRSA, without an infection or illness that would otherwise require exclusion. Known MRSA carriers or colonized individuals should not be excluded;
  10. Cytomegalovirus infection;
  11. Chronic hepatitis B infection;
  12. Human immunodeficiency virus (HIV) infection;
  13. Asymptomatic children who have been previously evaluated and found to be shedding potentially infectious organisms in the stool. Children who are continent of stool or who are diapered with formed stools that can be contained in the diaper may return to care. For some infectious organisms, exclusion is required until certain guidelines have been met. Note: These agents are not common and caregivers/teachers will usually not know the cause of most cases of diarrhea;
  14. Children with chronic infectious conditions that can be accommodated in the program according to the legal requirement of federal law in the Americans with Disabilities Act. The act requires that child care programs make reasonable accommodations for children with disabilities and/or chronic illnesses, considering each child individually.

Key criteria for exclusion of children who are ill:
When a child becomes ill but does not require immediate medical help, a determination must be made regarding whether the child should be sent home (i.e., should be temporarily “excluded” from child care). Most illnesses do not require exclusion. The caregiver/teacher should determine if the illness:

  1. Prevents the child from participating comfortably in activities;
  2. Results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;
  3. Poses a risk of spread of harmful diseases to others. 

If any of the above criteria are met, the child should be excluded, regardless of the type of illness. Decisions about caring for the child while awaiting parent/guardian pick-up should be made on a case-by-case basis providing care that is comfortable for the child considering factors such as the child's age, the surroundings, potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in their usual care setting while awaiting pick-up, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children not previously in close contact with the child. All who have been in contact with the ill child must wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and disinfected after the child leaves.
Temporary exclusion is recommended when the child has any of the following conditions:

  1. The illness prevents the child from participating comfortably in activities;
  2. The illness results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;
  3. A severely ill appearance - this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash;
  4. Fever (temperature above 101°F [38.3°C] by any method) with a behavior change in infants older than 2 months of age. For infants younger than 2 months of age, a fever (above 100.4°F [38°C] by any method) with or without a behavior change or other signs and symptoms (e.g., sore throat, rash, vomiting, diarrhea) requires exclusion and immediate medical attention;
  5. Diarrhea is defined by stools that are more frequent or less formed than usual for that child and not associated with changes in diet. Exclusion is required for all diapered children whose stool is not contained in the diaper and toilet-trained children if the diarrhea is causing ”accidents”. In addition, diapered children with diarrhea should be excluded if the stool frequency exceeds two stools above normal for that child during the time in the program day, because this may cause too much work for the caregivers/teachers, or those whose stool contains blood or mucus. Readmission after diarrhea can occur when diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children are not having “accidents” and when stool frequency is no more than 2 stools above normal for that child during the time in the program day;

Special circumstances that require specific exclusion criteria include the following (2):
A health care provider must clear the child or staff member for readmission for all cases of diarrhea with blood or mucus. Readmission can occur following the requirements of the local health department authorities, which may include testing for a diarrhea outbreak in which the stool culture result is positive for Shigella, Salmonella serotype Typhi and Paratyphi, or Shiga toxin–producing E coli. Children and staff members with Shigella should be excluded until diarrhea resolves and test results from at least 1 stool culture are negative (rules vary by state). Children and staff members with Shiga toxin–producing E coli (STEC) should be excluded until test results from 2 stool cultures are negative at least 48 hours after antibiotic treatment is complete (if prescribed). Children and staff members with Salmonella serotype Typhi and Paratyphi are excluded until test results from 3 stool cultures are negative. Stool should be collected at least 48 hours after antibiotics have stopped. State laws may govern exclusion for these conditions and should be followed by the health care provider who is clearing the child or staff member for readmission.

  1. Vomiting more than two times in the previous twenty-four hours, unless the vomiting is determined to be caused by a non-infectious condition and the child remains adequately hydrated;
  2. Abdominal pain that continues for more than two hours or intermittent pain associated with fever or other signs or symptoms of illness;
  3. Mouth sores with drooling that the child cannot control unless the child’s primary care provider or local health department authority states that the child is noninfectious;
  4. Rash with fever or behavioral changes, until the primary care provider has determined that the illness is not an infectious disease;
  5. Active tuberculosis, until the child’s primary care provider or local health department states child is on appropriate treatment and can return;
  6. Impetigo, only if child has not been treated after notifying family at the end of the prior program day. Exclusion is not necessary before the end of the day as long as the lesions can be covered;
  7. Streptococcal pharyngitis (i.e., strep throat or other streptococcal infection), until the child has two doses of antibiotic (one may be taken the day of exclusion and the second just before returning the next day);
  8. Head lice, only if the child has not been treated after notifying the family at the end of the prior program day.  (note: exclusion is not necessary before the end of the program day);
  9. Scabies, only if the child has not been treated after notifying the family at the end of the prior program day. (note: exclusion is not necessary before the end of the program day);
  10. Chickenpox (varicella), until all lesions have dried or crusted (usually six days after onset of rash and no new lesions have appeared for at least 24 hours);
  11. Rubella, until seven days after the rash appears;
  12. Pertussis, until five days of appropriate antibiotic treatment;
  13. Mumps, until five days after onset of parotid gland swelling;
  14. Measles, until four days after onset of rash;
  15. Hepatitis A virus infection, until one week after onset of illness or jaundice if the child’s symptoms are mild or as directed by the health department. (Note: Protection of the others in the group should be checked to be sure everyone who was exposed has received the vaccine or receives the vaccine immediately.);
  16. Any child determined by the local health department to be contributing to the transmission of illness during an outbreak.

Procedures for a child who requires exclusion:
The caregiver/teacher will:

  1. Make decisions about caring for the child while awaiting parent/guardian pick-up on a case-by-case basis providing care that is comfortable for the child considering factors such as the child’s age, the surroundings, potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. If symptoms allow the child to remain in their usual care setting while awaiting pick-up, the child should be separated from other children by at least 3 feet until the child leaves to help minimize exposure of staff and children not previously in close contact with the child. All who have been in contact with the ill child must wash their hands. Toys, equipment, and surfaces used by the ill child should be cleaned and  disinfected after the child leaves;
  2. Discuss the signs and symptoms of illness with the parent/guardian who is assuming care. Review guidelines for return to child care. If necessary, provide the family with a written communication that may be given to the primary care provider. The communication should include onset time of symptoms, observations about the child, vital signs and times (e.g., temperature 101.5°F at 10:30 AM) and any actions taken and the time actions were taken (e.g., one children’s acetaminophen given at 11:00 AM). The nature and severity of symptoms and or requirements of the local or state health department will determine the necessity of medical consultation. Telephone advice, electronic transmissions of instructions are acceptable without an office visit;
  3. If the child has been seen by their primary health provider, follow the advice of the  provider for return to child care;
  4. If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for further information from the health professional when the child returns to care. Children who had been excluded from care do not necessarily need to have an in-person visit with a health care provider;
  5. Contact the local health department if there is a question of a reportable (harmful) infectious disease in a child or staff member in the facility. If there are conflicting opinions from different primary care providers about the management of a child with a reportable infectious disease, the health department has the legal authority to make a final determination;
  6. Document actions in the child’s file with date, time, symptoms, and actions taken (and by whom); sign and date the document;
  7. In collaboration with the local health department, notify the parents/guardians of contacts to the child or staff member with presumed or confirmed reportable infectious infection.

The caregiver/teacher should make the decision about whether a child meets or does not meet the exclusion criteria for participation and the child’s need for care relative to the staff’s ability to provide care. If parents/guardians and the child care staff disagree, and the reason for exclusion relates to the child’s ability to participate or the caregiver’s/teacher’s ability to provide care for the other children, the caregiver/teacher should not be required to accept responsibility for the care of the child.
Reportable conditions:
The current list of infectious diseases designated as notifiable in the United States at the national level by the Centers for Disease Control and Prevention (CDC) are listed at https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/infectious-diseases/.
The caregiver/teacher should contact the local health department:

  1. When a child or staff member who is in contact with others has a reportable disease;
  2. If a reportable illness occurs among the staff, children, or families involved with the program;
  3. For assistance in managing a suspected outbreak. Generally, an outbreak can be considered to be two or more unrelated (e.g., not siblings) children with the same diagnosis or symptoms in the same group within one week. Clusters of mild respiratory illness, ear infections, and certain dermatological conditions are common and generally do not need to be reported.

Caregivers/teachers should work with their child care health consultants to develop policies and procedures for alerting staff and families about their responsibility to report illnesses to the program and for the program to report diseases to the local health authorities.

RATIONALE
Most infections are spread by children who do not have symptoms. Excluding children with mild illnesses is unlikely to reduce the spread of most infectious agents (germs) caused by bacteria, viruses, parasites and fungi. Exposure to frequent mild infections helps the child’s immune system develop in a healthy way. As a child gets older s/he develops immunity to common infectious agents and will become ill less often. Since exclusion is unlikely to reduce the spread of disease, the most important reason for exclusion is the ability of the child to participate in activities and the staff to care for the child.
The terms contagious, infectious and communicable have similar meanings. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts. Hand and personal hygiene is paramount in preventing transmission of these organisms. Written notes should not be required for return to child care for common respiratory illnesses that are not specifically listed in the excludable condition list above.
For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 4th Edition has educational handouts that can be copied and distributed to parents/guardians, health professionals, and caregivers/teachers. This publication is available from the American Academy of Pediatrics (AAP) at http://www.aap.org.
For more detailed rationale regarding inclusion/exclusion, return to care, when a health visit is necessary, and health department reporting for children with specific symptoms, please see Appendix A: Signs and Symptoms Chart.
State licensing law or code defines the conditions or symptoms for which exclusion is necessary. States are increasingly using the criteria defined in Caring for Our Children and the Managing Infectious Diseases in Child Care and Schools publications. Usually, the criteria in these two sources are more detailed than the state regulations so can be incorporated into the local written policies without conflicting with state law.
COMMENTS
When taking a child’s temperature, remember that:
  1. The amount of temperature elevation varies at different body sites;
  2. The height of fever does not indicate a more or less severe illness. The child’s activity level and sense of well-being are far more important that the temperature reading;
  3. If a child has been in a very hot environment and heatstroke is suspected, a higher temperature is more serious;
  4. The method chosen to take a child’s temperature depends on the need for accuracy, available equipment, the skill of the person taking the temperature, and the ability of the child to assist in the procedure;
  5. Oral temperatures are difficult to take for children younger than four years of age;
  6. Rectal temperatures should be taken only by persons with specific health training in performing this procedure and permission given by parents/guardians, however this method is not generally practiced due to concerns about proper procedure and risk of accusations of sexual abuse;
  7. Axillary (armpit) temperatures are accurate only when the thermometer remains within the closed armpit for the time period recommended by the device;
  8. Any device used improperly may give inaccurate results; and
  9. Only digital thermometers, not mercury thermometers, should be used.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.1.1 Conduct of Daily Health Check
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.1.4 Infectious Disease Outbreak Control
Appendix A: Signs and Symptoms Chart
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 122-123

  2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
  3. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 140-141

NOTES

Content in the STANDARD was modified on 04/16/2015, on 8/2015, and on 4/4/2017.

Standard 3.6.1.2: Staff Exclusion for Illness

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

Please note that if a staff member has no contact with the children, or with anything with which the children has come into contact, this standard does not apply to that staff member.

A facility should not deny admission to or send home a staff member or substitute with illness unless one or more of the following conditions exists:

  1. Influenza, until fever free for 24 hours. (Health care providers can use a test to determine whether an ill person has influenza rather than other symptoms. However, it is not practical to test all ill staff members to determine whether they have common cold viruses or influenza infection. Therefore, exclusion decisions are based on the symptoms of the staff member);
  2. Chickenpox, until all lesions have dried and crusted, which usually occurs by six days;
  3. Shingles, only if the lesions cannot be covered by clothing or a dressing until the lesions have crusted;
  4. Rash with fever or joint pain, until diagnosed not to be measles or rubella;
  5. Measles, until four days after onset of the rash (if the staff member or substitute has the capacity to develop an immune response following exposure);
  6. Rubella, until six days after onset of rash;
  7. Diarrheal illness, stool frequency exceeds two or more stools above normal for that individual or blood in stools, until diarrhea resolves, or until a primary care provider determines that the diarrhea is not caused by a germ that can be spread to others in the facility; For all cases of bloody diarrhea and diarrhea caused by Shiga toxin–producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi  I, exclusion must continue until the person is cleared to return by the primary health care provider. Exclusion is warranted for STEC, until results of 2 stool cultures are negative (at least 48 hours after antibiotic treatment is complete (if prescribed)); for Shigella species, until at least 1 stool culture is negative (varies by state); and for Salmonella serotype Typhi, until 3 stool cultures are negative. Stool samples need to be collected at least 48 hours after antibiotic treatment is complete. Other types of Salmonella do not require negative test results from stool cultures. Vomiting illness, two or more episodes of vomiting during the previous twenty-four hours, until vomiting resolves or is determined to result from non-infectious conditions;
  8. Hepatitis A virus, until one week after symptom onset or as directed by the health department;
  9. Pertussis, until after five days of appropriate antibiotic therapy or until 21 days after the onset of cough if the person is not treated with antibiotics;
  10. Skin infection (such as impetigo), until treatment has been initiated; exclusion should continue if lesion is draining AND cannot be covered;
  11. Tuberculosis, until noninfectious and cleared by a health department official or a primary care provider;
  12. Strep throat or other streptococcal infection, until twenty-four hours after initial antibiotic treatment and end of fever;
  13. Head lice, from the end of the day of discovery until after the first treatment;
  14. Scabies, until after treatment has been completed;
  15. Haemophilus influenzae type b (Hib), prophylaxis, until cleared by the primary health care provider;
  16. Meningococcal infection, until cleared by the primary health care provider;
  17. Other respiratory illness, if the illness limits the staff member’s ability to provide an acceptable level of child care and compromises the health and safety of the children. This includes a respiratory illness in which the staff member is unable to consistently manage respiratory secretions using proper cough and sneeze etiquette.
Caregivers/teachers who have herpes cold sores should not be excluded from the child care facility, but should:
1. Cover and not touch their lesions;
2. Carefully observe hand hygiene policies; and
3. Not kiss any children.

RATIONALE
Most infections are spread by children who do not have symptoms.
The terms contagious, infectious and communicable have similar meanings. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts.
Adults are as capable of spreading infectious disease as children (1,2). Hand and personal hygiene is paramount in preventing transmission of these organisms. 
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.3.2 Cough and Sneeze Etiquette
3.6.1.4 Infectious Disease Outbreak Control
REFERENCES
  1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
  2. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 138-146


NOTES

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

Standard 3.6.2.9: Information Required for Children Who Are Ill

For each day of care in a special facility that provides care for children who are ill, the caregiver/teacher should have the following information on each child:

  1. The child’s specific diagnosis and the individual providing the diagnosis (primary care provider, parent/guardian);
  2. Current status of the illness, including potential for contagion, diet, activity level, and duration of illness;
  3. Health care, diet, allergies (particularly to foods or medication), and medication and treatment plan, including appropriate release forms to obtain emergency health care and administer medication;
  4. Communication with the parent/guardian on the child’s progress;
  5. Name, address, and telephone number of the child’s source of primary health care;
  6. Communication with the child’s primary care provider.

Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (2). 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) (2).

RATIONALE
The caregiver/teacher must have child-specific information to provide optimum care for each child who is ill and to make appropriate decisions regarding whether to include or exclude a given child. The caregiver/teacher must have contact information for the child’s source of primary health care or specialty health care (in the case of a child with asthma, diabetes, etc.) to assist with the management of any situation that arises.
COMMENTS
For school-age children, documentation of the care of the child during the illness should be provided to the parent to deliver to the school health program upon the child’s return to school. Coordination with the child’s source of health care and school health program facilitates the overall care of the child (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
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. Beierlein, J. G., J. E. Van Horn. 1995. Sick child care. National Network for Child Care. http://www.nncc.org/eo/emp.sick.child
    .care.html.

Standard 3.6.3.1: Medication Administration

The administration of medicines at the facility should be limited to:

  1. Prescription or non-prescription medication (over-the-counter [OTC]) ordered by the prescribing health professional for a specific child with written permission of the parent/guardian. Written orders from the prescribing health professional should specify medical need, medication, dosage, and length of time to give medication;
  2. Labeled medications brought to the child care facility by the parent/guardian in the original container (with a label that includes the child’s name, date filled, prescribing clinician’s name, pharmacy name and phone number, dosage/instructions, and relevant warnings).

Facilities should not administer folk or homemade remedy medications or treatment. Facilities should not administer a medication that is prescribed for one child in the family to another child in the family.

No prescription or non-prescription medication (OTC) should be given to any child without written orders from a prescribing health professional and written permission from a parent/guardian. Exception: Non-prescription sunscreen and insect repellent always require parental consent but do not require instructions from each child’s prescribing health professional.

Documentation that the medicine/agent is administered to the child as prescribed is required.

“Standing orders” guidance should include directions for facilities to be equipped, staffed, and monitored by the primary care provider capable of having the special health care plan modified as needed. Standing orders for medication should only be allowed for individual children with a documented medical need if a special care plan is provided by the child’s primary care provider in conjunction with the standing order or for OTC medications for which a primary care provider has provided specific instructions that define the children, conditions and methods for administration of the medication. Signatures from the primary care provider and one of the child’s parents/guardians must be obtained on the special care plan. Care plans should be updated as needed, but at least yearly.

RATIONALE
Medicines can be crucial to the health and wellness of children. They can also be very dangerous if the wrong type or wrong amount is given to the wrong person or at the wrong time. Prevention is the key to prevent poisonings by making sure medications are inaccessible to children.

All medicines require clear, accurate instruction and medical confirmation of the need for the medication to be given while the child is in the facility. Prescription medications can often be timed to be given at home and this should be encouraged. Because of the potential for errors in medication administration in child care facilities, it may be safer for a parent/guardian to administer their child’s medicine at home.

Over the counter medications, such as acetaminophen and ibuprofen, can be just as dangerous as prescription medications and can result in illness or even death when these products are misused or unintentional poisoning occurs. Many children’s over the counter medications contain a combination of ingredients. It is important to make sure the child isn’t receiving the same medications in two different products which may result in an overdose. Facilities should not stock OTC medications (1).

Cough and cold medications are widely used for children to treat upper respiratory infections and allergy symptoms. Recently, concern has been raised that there is no proven benefit and some of these products may be dangerous (2,3,5). Leading organizations such as the Consumer Healthcare Products Association (CHPA) and the American Academy of Pediatrics (AAP) have recommended restrictions on these products for children under age six (4-7).

If a medication mistake or unintentional poisoning does occur, call your local poison center immediately at 1-800-222-1222.

Parents/guardians should always be notified in every instance when medication is used. Telephone instructions from a primary care provider are acceptable if the caregiver/teacher fully documents them and if the parent/guardian initiates the request for primary care provider or child care health consultant instruction. In the event medication for a child becomes necessary during the day or in the event of an emergency, administration instructions from a parent/ guardian and the child’s prescribing health professional are required before a caregiver/teacher may administer medication.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.2.9 Information Required for Children Who Are Ill
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.3.2 Labeling, Storage, and Disposal of Medications
REFERENCES
  1. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medications in children. Pediatrics 121:783-87.
  2. American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.
  3. Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/10_11_07_OralInfantMedicines.aspx.
  4. Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.
  5. American Academy of Pediatrics. 2008. AAP Urges caution in use of over-the-counter cough and cold medicines. http://www.generaterecords.net/PicGallery/AAP_CC.pdf
  6. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Slone Survey. Pediatrics 122: e323-29.
  7. U.S. Department of Health and Human Services, Food and Drug Administration. 2008. Public Health advisory: FDA recomends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm051137.htm

Standard 3.6.3.3: Training of Caregivers/Teachers to Administer Medication

Any caregiver/teacher who administers medication should complete a standardized training course that includes skill and competency assessment in medication administration. The trainer in medication administration should be a licensed health professional. The course should be repeated according to state and/or local regulation. At a minimum, skill and competency should be monitored annually or whenever medication administration error occurs. In facilities with large numbers of children with special health care needs involving daily medication, best practice would indicate strong consideration to the hiring of a licensed health care professional. Lacking that, caregivers/teachers should be trained to:

  1. Check that the name of the child on the medication and the child receiving the medication are the same;
  2. Check that the name of the medication is the same as the name of the medication on the instructions to give the medication if the instructions are not on the medication container that is labeled with the child’s name;
  3. Read and understand the label/prescription directions or the separate written instructions in relation to the measured dose, frequency, route of administration (ex. by mouth, ear canal, eye, etc.) and other special instructions relative to the medication;
  4. Observe and report any side effects from medications;
  5. Document the administration of each dose by the time and the amount given;
  6. Document the person giving the administration and any side effects noted;
  7. Handle and store all medications according to label instructions and regulations.

The trainer in medication administration should be a licensed health professional: Registered Nurse, Advanced Practice Registered Nurse (APRN), MD, Physician’s Assistant, or Pharmacist.

RATIONALE
Administration of medicines is unavoidable as increasing numbers of children entering child care take medications. National data indicate that at any one time, a significant portion of the pediatric population is taking medication, mostly vitamins, but between 16% and 40% are taking antipyretics/analgesics (5). Safe medication administration in child care is extremely important and training of caregivers/teachers is essential (1).

Caregivers/teachers need to know what medication the child is receiving, who prescribed the medicine and when, for what purpose the medicine has been prescribed and what the known reactions or side effects may be if a child has a negative reaction to the medicine (2,3). A child’s reaction to medication can be occasionally extreme enough to initiate the protocol developed for emergencies. The medication record is especially important if medications are frequently prescribed or if long-term medications are being used (4).

COMMENTS
Caregivers/teachers need to know the state laws and regulations on training requirements for the administration of medications in out-of-home child care settings. These laws may include requirements for delegation of medication administration from a primary care provider. Training on medication administration for caregivers/teachers is available in several states. Model Child Care Health Policies, 2nd Ed. from Healthy Child Care Pennsylvania is available at http://www.ecels-healthychildcarepa.org/publications/manuals-pamphlets-policies/item/248-model-child-care-health-policies and contains sample polices and forms related to medication administration.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
9.2.3.9 Written Policy on Use of Medications
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix AA: Medication Administration Packet
REFERENCES
  1. Vernacchio, L., J. P. Kelly, D. W. Kaufman, A. A. Mitchell. 2009. Medication use among children <12 years of age in the United States: Results from the Slone Survey. Pediatrics 124:446-54.
  2. Calder, J. 2004. Medication administration in child care programs. Health and Safety Notes. Berkeley, CA: California Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/medadminEN102004_adr.pdf.
  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  4. Qualistar Early Learning. 2008. Colorado Medication Administration Curriculum. 5th ed. http://www.qualistar.org/medication-administration.html.
  5. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and administration in child care settings: A case study. Policy, Politics, and Nursing Practice 6:86-98.

Standard 3.6.4.5: Death

Each facility should have a plan in place for responding to any death relevant to children enrolled in the facility and their families. The plan should describe protocols the program will follow and resources available for children, families, and staff.

If a facility experiences the death of a child or adult, the following should be done:

  1. If a child or adult dies while at the facility:
    1. The caregiver/teacher(s) responsible for any children who observed or were in the same room where the death occurred, should take the children to a different room, while other staff tend to appropriate response/follow-up. Minimal explanations should be provided until direction is received from the proper authorities. Supportive and reassuring comments should be provided to children directly affected;
    2. Designated staff should:
    3. Immediately notify emergency medical personnel;
    4. Immediately notify the child’s parents/guardians or adult’s emergency contact;
    5. Notify the Licensing agency and law enforcement the same day the death occurs;
    6. Follow all law enforcement protocols regarding the scene of the death:
      1. Do not disturb the scene;
      2. Do not show the scene to others;
      3. Reserve conversation about the event until having completed all interviews with law enforcement.
    7. Provide age-appropriate information for children, parents/guardians and staff;
    8. Make resources for support available to staff, parents and children;
  2. For a suspected Sudden Infant Death Syndrome (SIDS) death or other unexplained deaths:
    1. Seek support and information from local, state, or national SIDS resources;
    2. Provide SIDS information to the parents/guardians of the other children in the facility;
    3. Provide age-appropriate information to the other children in the facility;
    4. Provide appropriate information for staff at the facility;
  3. If a child or adult known to the children enrolled in the facility dies while not at the facility:
    1. Provide age-appropriate information for children, parents/guardians and staff;
    2. Make resources for support available to staff, parents and children.

Facilities may release specific information about the circumstances of the child or adult’s death that the authorities and the deceased member’s family agrees the facility may share.

If the death is due to suspected child maltreatment, the caregiver/teacher is mandated to report this to child protective services.

Depending on the cause of death (SIDS, suffocation or other infant death, injury, maltreatment etc.), there may be a need for updated education on the subject for caregivers/teachers and/or children as well as implementation of improved health and safety practices.

RATIONALE
Following the steps described in this standard would constitute prudent action (1-3). Accurate information given to parents/guardians and children will help them understand the event and facilitate their support of the caregiver/teacher (4-7).
COMMENTS
It is important that caregivers/teachers are knowledgeable about SIDS and that they take proper steps so that they are not falsely accused of child abuse and neglect. The licensing agency and/or a SIDS agency support group (e.g., CJ Foundation for SIDS at http://www.cjsids.org, the National Action Partnership to Promote Safe Sleep (NAPPSS) at http://nappss.org, and First Candle at http://www.firstcandle.org) can offer support and counseling to caregivers/teachers.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
REFERENCES
  1. Knapp, J., D. Mulligan-Smith, Committee on Pediatric Emergency Medicine. 2005. Death of a child in the emergency department. Pediatrics 115:1432-37.
  2. Trozzi, M. 1999. Talking with children about Loss: Words, strategies, and wisdom to help children cope with death, divorce, and other difficult times. New York: Berkley Publishing Group.
  3. Rivlin, D. The good grief program of Boston Medical Center: What do children need? Boston Medical Center. http://www.wayland.k12.ma.us/claypit_hill/GoodGriefHandout.pdf.
  4. Boston Medical Center. Good grief program. http://www.bmc.org/pediatrics-goodgrief.htm.
  5. Moon, R. Y., L. Kotch, L. Aird. 2006. State child care regulations regarding infant sleep environment since the Healthy Child Care America – Back to Sleep Campaign. Pediatrics 118:73-83.
  6. Moon, R. Y., K. M. Patel, S. J. M. Shaefer. 2000. Sudden infant death syndrome in child care settings. Pediatrics 106:295-300.
  7. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.

IV. Nutrition and Food Service

Standard 4.2.0.8: Feeding Plans and Dietary Modifications

Content in the STANDARD was modified on 11/9/2017. 

 

Before a child enters an early care and education facility, the facility should obtain a written history that contains any special nutrition or feeding needs for the child, including use of human milk or any special feeding utensils. The staff should review this history with the child’s parents/guardians, clarifying and discussing how the parents’/guardians’ home feeding routines may differ from the facility’s planned routine. The child’s primary health care provider should provide written information to the parent/guardian about any dietary modifications or special feeding techniques that are required at the early care and education program so they can be shared with and implemented by the program.

If dietary modifications are indicated, based on a child’s medical or special dietary needs, caregivers/teachers should modify or supplement the child’s diet to meet the individual child’s specific needs. Dietary modifications should be made in consultation with the parents/guardians and the child’s primary health care provider. Caregivers/teachers can consult with a nutritionist/registered dietitian.

A child’s diet may be modified because of food sensitivity, a food allergy, or many other reasons. Food sensitivity includes a range of conditions in which a child exhibits an adverse reaction to a food that, in some instances, can be life-threatening. Modification of a child’s diet may also be related to a food allergy, an inability to digest or to tolerate certain foods, a need for extra calories, a need for special positioning while eating, diabetes and the need to match food with insulin, food idiosyncrasies, and other identified feeding issues, including celiac disease, phenylketonuria, diabetes, and severe food allergy (anaphylaxis). In some cases, a child may become ill if he/she is unable to eat, so missing a meal could have a negative consequence, especially for children with diabetes.

For a child with special health care needs who requires dietary modifications or special feeding techniques, written instructions from the child’s parent/guardian and the child’s primary health care provider should be provided in the child’s record and carried out accordingly. Dietary modifications should be recorded. These written instructions must identify
 
a.  The child’s full name and date of instructions
b.  The child’s special health care needs
c.   Any dietary restrictions based on those special needs
d.  Any special feeding or eating utensils
e.  Any foods to be omitted from the diet and any foods to be substituted
f.    Any other pertinent information about the child’s special health care needs
g.  What, if anything, needs to be done if the child is exposed to restricted foods
 
The written history of special nutrition or feeding needs should be used to develop individual feeding plans and, collectively, to develop facility menus. Health care providers with experience in disciplines related to special nutrition needs, including nutrition, nursing, speech therapy, occupational therapy, and physical therapy, should participate when needed and/or when they are available to the facility. If available, the nutritionist/registered dietitian should approve menus that accommodate needed dietary modifications.

The feeding plan should include steps to take when a situation arises that requires rapid response by the staff, such as a child choking during mealtime or a child with a known history of food allergies demonstrating signs and symptoms of anaphylaxis (severe allergic reaction), such as difficulty breathing and severe redness and swelling of the face or mouth. The completed plan should be on file and accessible to staff and available to parents/guardians on request.

RATIONALE

Children with special health care needs may have individual requirements related to diet and swallowing, involving special feeding utensils and feeding needs that will necessitate the development of an individual plan prior to their entry into the facility (1). Many children with special health care needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent feeding skills. Food, eating style, food utensils, and equipment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (2,3,).

Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. Others, such as those with diabetes, may need to have their diet matched to their medication (e.g., insulin, if they are on a fixed dose of insulin). Some children are unable to tolerate certain foods because of their allergy to the food or their inability to digest it. The 8 most common foods to cause anaphylaxis in children are cow’s milk, eggs, soy, wheat, fish, shellfish, peanuts, and tree nuts (3). Staff members must know ahead of time what procedures to follow, as well as their designated roles, during an emergency.

As a safety and health precaution, staff should know in advance whether a child has food allergies, inborn errors of metabolism, diabetes, celiac disease, tongue thrust, or special health care needs related to feeding, such as requiring special feeding utensils or equipment, nasogastric or gastric tube feedings, or special positioning. These situations require individual planning prior to the child’s entry into an early care and education program and on an ongoing basis (2).

In some cases, dietary modifications are based on religious or cultural beliefs. Detailed information on each child’s special needs, whether stemming from dietary, feeding equipment, or cultural needs, is invaluable to the facility staff in meeting the nutritional needs of all the children in their care.

COMMENTS
Close collaboration between families and the facility is necessary for children on special diets. Parents/guardians may have to provide food on a temporary, or even permanent, basis, if the facility, after exploring all community resources, is unable to provide the special diet.

Programs may consider using the American Academy of Pediatrics (AAP) Allergy and Anaphylaxis Emergency Plan, which is included in the AAP clinical report, Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan (4).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.5.0.1 Care Plan for Children with Special Health Care Needs
4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.5.0.10 Foods that Are Choking Hazards
REFERENCES
  1. Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
  2. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  3. Kaczkowski CH, Caffrey C. Pediatric nutrition. In: Blanchfield DS, ed. The Gale Encyclopedia of Children's Health: Infancy Through Adolescence. Vol 3. 3rd ed. Farmington Hills, MI: Gale; 2016:2063–2066
  4. Samour PQ, King K. Pediatric Nutrition. 4th ed. Sunbury, MA: Jones and Bartlett Learning; 2010
NOTES

Content in the STANDARD was modified on 11/9/2017. 

 

Standard 4.2.0.9: Written Menus and Introduction of New Foods

Content in the STANDARD was modified on 11/9/2017. 

 

Facilities should develop, at least one month in advance, written menus that show all foods to be served during that month and should make the menus available to parents/guardians. The facility should date and retain these menus for 6 months, unless the state regulatory agency requires a longer retention time. The menus should be amended to reflect any and all changes in the food actually served. Any substitutions should be of equal nutrient value.

Caregivers/teachers should use or develop a take-home sheet for parents/guardians on which caregivers/teachers record the food consumed each day or, for breastfed infants, the number of times they are fed and other important notes. Caregivers/teachers should continue to consult with each infant’s parent/guardian about foods they have introduced and are feeding to the infant. In this way, caregivers/teachers can follow a schedule of introducing new foods one at a time and more easily identify possible food allergies or intolerances. Caregivers/teachers should let parents/guardians know what and how much their infants eat each day.

To avoid problems of food sensitivity in infants younger than 12 months, caregivers/teachers should obtain from infants’ parents/guardians a list of foods that have already been introduced (without any reaction) and serve those items when appropriate. As new foods are considered for serving, caregivers/teachers should share and discuss these foods with parents/guardians prior to their introduction.

RATIONALE
Planning menus in advance helps to ensure that food will be on hand. Posting menus in a prominent area and distributing them to parents/guardians helps to inform parents/guardians about proper nutrition Parents/guardians need to be informed about food served in the facility to know how to complement it with the food they serve at home. If a child has difficulty with any food served at the facility, parents/guardians can address this issue with appropriate staff members. Some regulatory agencies require menus as a part of the licensing and auditing process (1).

Consistency between home and the early care and education setting is essential during the period of rapid change when infants are learning to eat age-appropriate solid foods (1-3).
COMMENTS
Caregivers/teachers should be aware that new foods may need to be offered between 8 and 15 times before they may be accepted (2,4). Sample menus and menu planning templates are available from most state health departments and the US Department of Agriculture (5) and its Child and Adult Care Food Program (6).

Good communication between caregivers/teachers and parents/guardians is essential for successful feeding, in general, including when introducing age-appropriate solid foods (complementary foods). The decision to feed specific foods should be made in consultation with the parents/guardians. It is recommended that caregivers/teachers be given written instructions on the introduction and feeding of foods from the parents/guardians and the infants’ primary health care providers. 
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.5.0.8 Experience with Familiar and New Foods
REFERENCES
  1. American Academy of Pediatrics Committee on Nutrition. Childhood nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 20, 2017
  2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). https://www.fns.usda.gov/cacfp/child-and-adult-care-food-program. Published March 29, 2017. Accessed September 20, 2017
  3. US Department of Agriculture. Menu planning tools for child care providers. https://healthymeals.fns.usda.gov/menu-planning/menu-planning-tools/menu-planning-tools-child-care-providers. Accessed September 20, 2017
  4. Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: conception to adolescence. J Law Med Ethics. 2007;35(1):22–34
  5. Coulthard H, Sealy A. Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite. 2017;113:84–90
  6. Benjamin SE, Copeland KA, Cradock A, et al. Menus in child care: a comparison of state regulations with national standards. J Am Diet Assoc. 2009;109(1):109–115
NOTES

Content in the STANDARD was modified on 11/9/2017. 

 

Standard 4.2.0.10: Care for Children with Food Allergies

Content in the STANDARD was modified on 11/9/2017.

 

When children with food allergies attend an early care and education facility, here is what should occur.
a.  Each child with a food allergy should have a care plan prepared for the facility by the child’s primary health care provider, to include
     1.  A written list of the food(s) to which the child is allergic and instructions for steps that need to be taken to avoid that food.
     2.  A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan should include specific symptoms that would indicate the need to administer one or more medications.

b.  Based on the child’s care plan, the child’s caregivers/teachers should receive training, demonstrate competence in, and implement measures for
     1.  Preventing exposure to the specific food(s) to which the child is allergic
     2.  Recognizing the symptoms of an allergic reaction
     3.  Treating allergic reactions

c.   Parents/guardians and staff should arrange for the facility to have the necessary medications, proper storage of such medications, and the equipment and training to manage the child’s food allergy while the child is at the early care and education facility.

d.  Caregivers/teachers should promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the care plan.

e.  The facility should notify parents/guardians immediately of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur.

f.    The facility should recommend to the family that the child’s primary health care provider be notified if the child has required treatment by the facility for a food allergic reaction.

g.  The facility should contact the emergency medical services (EMS) system immediately if the child has any serious allergic reaction and/or whenever epinephrine (eg, EpiPen, EpiPen Jr) has been administered, even if the child appears to have recovered from the allergic reaction.

h.  Parents/guardians of all children in the child’s class should be advised to avoid any known allergens in class treats or special foods brought into the early care and education setting.

i.    Individual child’s food allergies should be posted prominently in the classroom where staff can view them and/or wherever food is served.

j.    The written child care plan, a mobile phone, and a list of the proper medications for appropriate treatment if the child develops an acute allergic reaction should be routinely carried on field trips or transport out of the early care and education setting.

For all children with a history of anaphylaxis (severe allergic reaction), or for those with peanut and/or tree nut allergy (whether or not they have had anaphylaxis), epinephrine should be readily available. This will usually be provided as a premeasured dose in an auto-injector, such as EpiPen or EpiPen Jr. Specific indications for administration of epinephrine should be provided in the detailed care plan. Within the context of state laws, appropriate personnel should be prepared to administer epinephrine when needed.

Food sharing between children must be prevented by careful supervision and repeated instruction to children about this issue. Exposure may also occur through contact between children or by contact with contaminated surfaces, such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just from being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by washing children’s hands and faces and all surfaces that were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the use of peanut butter to make a bird feeder or wheat to make modeling compound.

RATIONALE
Food allergy is common, occurring in between 2% and 8% of infants and children (1). Allergic reactions to food can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Hospitalizations from food allergy are being reported in increasing numbers, especially among children with asthma who have one or more food sensitivities (2). A major factor in death from anaphylaxis has been a delay in the administration of lifesaving emergency medication, particularly epinephrine (3). Intensive efforts to avoid exposure to the offending food(s) are, therefore, warranted. The maintenance of detailed care plans and the ability to implement such plans for the treatment of reactions are essential for all children with food allergies (4).
COMMENTS
Successful food avoidance requires a cooperative effort that must include the parents/guardians, child, child’s primary health care provider, and early care and education staff. In some cases, especially for a child with multiple food allergies, parents/guardians may need to take responsibility for providing all the child’s food. In other cases, early care and education staff may be able to provide safe foods as long as they have been fully educated about effective food avoidance.
Effective food avoidance has several facets. Foods can be listed on an ingredient list under a variety of names; for example, milk could be listed as casein, caseinate, whey, and/or lactoglobulin.

Some children with a food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have antihistamine or epinephrine available to be used in the event of a reaction.

For more information on food allergies, contact Food Allergy Research & Education (FARE) at www.foodallergy.org.
Some early care and education/school settings require that all foods brought into the classroom are store-bought and in their original packaging so that a list of ingredients is included, to prevent exposure to allergens. However, packaged foods may mistakenly include allergen-type ingredients. Alerts and ingredient recalls can be found on the FARE Web site (5).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.5.0.1 Care Plan for Children with Special Health Care Needs
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
  2. Tsuang A, Demain H, Patrick K, Pistiner M, Wang J. Epinephrine use and training in schools for food-induced anaphylaxis among non-nursing staff. J Allergy Clin Immunol Pract. 2017;5(5):1418–1420.e3
  3. Caffarelli C, Garrubba M, Greco C, Mastrorilli C, Povesi Dascola C. Asthma and food allergy in children: is there a connection or interaction? Front Pediatr. 2016;4:34
  4. Bugden EA, Martinez AK, Greene BZ, Eig K. Safe at School and Ready to Learn: A Comprehensive Policy Guide for Protecting Students with Life-threatening Food Allergies. 2nd ed. Alexandria, VA: National School Boards Association; 2012. http://www.nsba.org/sites/default/files/reports/Safe-at-School-and-Ready-to-Learn.pdf. Accessed September 20, 2017
  5. ADDITIONAL RESOURCES
    Centers for Disease Control and Prevention. Healthy schools. Food allergies in schools. https://www.cdc.gov/healthyschools/foodallergies/index.htm. Reviewed May 9, 2017. Accessed September 20, 2017

    Centers for Disease Control and Prevention. Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. Washington, DC: US Department of Health and Human Services; 2013. https://www.cdc.gov/healthyschools/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf. Accessed September 20, 2017
  6. Food Allergy Research & Education. Allergy alerts. https://www.foodallergy.org/alerts. Accessed September 20, 2017
NOTES

Content in the STANDARD was modified on 11/9/2017.

 

Standard 4.7.0.1: Nutrition Learning Experiences for Children

The facility should have a nutrition plan that integrates the introduction of food and feeding experiences with facility activities and home feeding. The plan should include opportunities for children to develop the knowledge and skills necessary to make appropriate food choices.

For centers, this plan should be a written plan and should be the shared responsibility of the entire staff, including directors and food service personnel, together with parents/guardians. The nutrition plan should be developed with guidance from, and should be approved by, the nutritionist/registered dietitian or child care health consultant.

Caregivers/teachers should teach children about the taste, smell, texture of foods, and vocabulary and language skills related to food and eating. The children should have the opportunity to feel the textures and learn the different colors, sizes, and shapes of foods and the nutritional benefits of eating healthy foods. Children should also be taught about appropriate portion sizes. The teaching should be evident at mealtimes and during curricular activities, and emphasize the pleasure of eating. Caregivers/teachers need to be aware that children between the ages of two- and five-years-old are often resistant to trying new foods and that food acceptance may take eight to fifteen times of offering a food before it is eaten (14).

RATIONALE
Nourishing and attractive food is a foundation for developmentally appropriate learning experiences and contributes to health and well-being (1-13,15). Coordinating the learning experiences with the food service staff maximizes effectiveness of the education. In addition to the nutritive value of food, infants and young children are helped, through the act of feeding, to establish warm human relationships. Eating should be an enjoyable experience for children and staff in the facility and for children and parents/guardians at home. Enjoying and learning about food in childhood promotes good nutrition habits for a lifetime (17,18).
COMMENTS
Parents/guardians and caregivers/teachers should always be encouraged to sit at the table and eat the same food offered to young children as a way to strengthen family style eating which supports child’s serving and feeding him or herself (19). Family style eating requires special training for the food service and early care and education staff since they need to monitor food served in a group setting. Portions should be age-appropriate as specified in Child and Adult Care Food Program (CACFP) guidelines. The use of serving utensils should be encouraged to minimize food handling by children. Children should not eat directly out of serving dishes or storage containers. The presence of an adult at the table with children while they are eating is a way to encourage social interaction and conversation about the food such as its name, color, texture, taste, and concepts such as number, size, and shape; as well as sharing events of the day. These are some practical examples of age-appropriate information for young children to learn about the food they eat. The parent/guardian or adult can help the slow eater, prevent behaviors that might increase risk of fighting, of eating each others’ food, and of stuffing food in the mouth in such a way that it might cause choking.

Several community-based nutrition resources can help caregivers/teachers with the nutrition and food service component of their programs (16-18). The key to identifying a qualified nutrition professional is seeking a record of training in pediatric nutrition (normal nutrition, nutrition for children with special health care needs, dietary modifications) and experience and competency in basic food service systems.

Local resources for nutrition education include:

  1. Local and state nutritionists/RDs in health departments, in maternal and child health programs, and divisions of children with special health care needs;
  2. Nutritionists/RDs at hospitals;
  3. The Women, Infants, and Children (WIC) Supplemental Food Program and cooperative extension nutritionists/RDs;
  4. School food service personnel;
  5. State administrators of the Child and Adult Care Food Program;
  6. National School Food Service Management Institute;
  7. Healthy Meals Resource System of the Food and Nutrition Information System (National Agricultural Library, U.S. Department of Agriculture);
  8. Nutrition consultants with local affiliates of the following organizations:
    1. American Dietetic Association;
    2. American Public Health Association;
    3. Society for Nutrition Education;
    4. American Association of Family and Consumer Sciences;
    5. Dairy Council;
    6. American Heart Association;
    7. American Cancer Society;
    8. American Diabetes Association;
    9. Professional home economists like teachers and those with consumer organizations;
    10. Nutrition departments of local colleges and universities.

Compliance is measured by structured observation.

Following are select resources for caregivers/teachers in providing ongoing opportunities for children and their families to learn about food and healthy eating:

  1. Brieger, K. M. 1993. Cooking up the Pyramid: An early childhood nutrition curriculum. Pine Island, NY: Clinical Nutrition Services.
  2. Cunningham, M. 1995. Cooking with children: 15 lessons for children, age 7 and up, who really want to learn to cook. New York: Alfred A. Knopf.
  3. Goodwin, M. T., G. Pollen. 1980. Creative food experiences for children. Rev. ed. Washington, DC: Center for Science in the Public Interest.
  4. King, M. 1993. Healthy choices for kids: Nutrition and activity education program based on the US Dietary Guidelines. Levels 1-3 and 4-5. Wenatchee, WA: The Growers of Washington State Apples.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.1 Written Nutrition Plan
4.5.0.4 Socialization During Meals
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.5.0.8 Experience with Familiar and New Foods
4.7.0.2 Nutrition Education for Parents/Guardians
9.2.3.11 Food and Nutrition Service Policies and Plans
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
REFERENCES
  1. Hagan, Jr., 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. Tamborlane, W. V., J. Warshaw, eds. 1997. The Yale guide to children’s nutrition. New Haven, CT: Yale University Press.
  3. Benjamin, S. E., D. F. Tate, S. I. Bangdiwala, B. H. Neelon, A. S. Ammerman, J. M. Dodds, D. S. Ward. 2008. Preparing child care health consultants to address childhood overweight: A randomized controlled trial comparing web to in-person training. Maternal Child Health J 12:662-69.
  4. Ammerman, A. S., D. S. Ward, S. E. Benjamin, et al. 2007. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care theory and design. Public Health Research, Practice, Policy 4:1-12.
  5. Story, M., K. M. Kaphingst, S. French. 2006. The role of child care settings in the prevention of obesity. The Future of Children 16:143-68
  6. Dietz, W., L. Birch. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating. Elk Grove Village, IL: American Academy of Pediatrics.
  7. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.
  8. U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start. 2009. Head Start program performance standards. Rev. ed. Washington, DC: U.S. Government Printing Office. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Requirements/45 CFR Chapter XIII/45 CFR Chap XIII_ENG.pdf.
  9. William, C. O., ed. 1998. Pediatric manual of clinical dietetics. Chicago: American Dietetic Association.
  10. Lally, J. R., A. Griffin, E. Fenichel, M. Segal, E. Szanton, B. Weissbourd. 2003. Caring for infants and toddlers in groups: Developmentally appropriate practice. Arlington, VA: Zero to Three.
  11. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  12. Sullivan, S. A., L. L. Birch. 1990. Pass the sugar, pass the salt: Experience dictates preference. Devel Psych 26:546-51.
  13. Endres, J. B., R. E. Rockwell. 2003. Food, nutrition, and the young child. 4th ed. New York: Macmillan.
  14. Wardle, F., N. Winegarner. 1992. Nutrition and Head Start. Child Today 21:57.
  15. 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.
  16. Dietz, W. H., L. Stern, eds. 1998. American Academy of Pediatrics guide to your child’s nutrition. New York: Villard.
  17. Holt K, Wooldridge N, Story M, Sofka D. Nutrition Education/ curriculum for, aspects of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 10, 55
  18. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  19. Stang, J., C. T. Bayerl, M. M. Flatt. 2006. Position of the American Dietetic Association: Child and adolescent food and nutrition programs. J American Dietetic Assoc 106:1467-75.

V. Facilities, Supplies, and Equipment

Standard 5.1.1.4: Accessibility of Facility

The facility should be accessible for children and adults with disabilities, in accordance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA). Accessibility includes access to buildings, toilets, sinks, drinking fountains, outdoor play areas, meal and snack areas, and all classroom and therapy areas.

RATIONALE
Accessibility has been detailed in full, in Section 504 of the Rehabilitation Act of 1973. It is also a key component of the ADA, barring discrimination against anyone with a disability.
COMMENTS
Any facility accepting children with motor disabilities must be accessible to all children served. Small family home caregivers/teachers may be limited in their ability to serve such children, but are not precluded from doing so if there is a reasonable degree of compliance with this standard. Accommodation of adaptive equipment for all children should be made to ensure access to all activities of the care setting. Access to public and most private facilities is a key to the implementation of the ADA. If toilet learning/training is a relevant activity, the facility may be required to provide adapted toilet equipment.

For more information on requirements regarding accessibility, consult the Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG), available at http://www.access-board.gov/adaag/html/adaag.htm, and the U.S. Access Board’s play area accessibility guidelines at http://www.access-board.gov/play/guide/intro.htm.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.4.1.7 Toilet Learning/Training Equipment
5.4.6.2 Space for Therapy Services
6.2.1.2 Play Equipment and Surfaces Meet ADA Requirements

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 5.1.2.1: Space Required per Child

In general, the designated area for children’s activities should contain a minimum of forty-two square feet of usable floor space per child. A usable floor space of fifty square feet per child is preferred.

This excludes floor area that is used for:

  1. Circulation (e.g., walkways around the activity area);
  2. Classroom support (e.g., staff work areas and activity equipment storage that may be adjacent to the activity area);
  3. Furniture (e.g., bookcases, sofas, lofts, block corners, tables and chairs);
  4. Center support (e.g., administrative office, washrooms, etc.)

Usable, indoor floor space for the children’s activity area depends on the design and layout of the child care facility, and whether there is an opportunity and space for outdoor activities.

RATIONALE
Numerous studies have explored child care space requirements that are necessary to:
  1. Provide an environment that is highly functional for program delivery and to encourage strong, positive staff-to-child relationships;
  2. Accommodate the recommended group size and staff-to-child ratio; and
  3. Efficiently use space and incorporates ease of supervision.
  4. Recommendations from research studies range between forty-two to fifty-four square feet per child (1).

Studies have shown that the quality of the physical designed environment of early child care centers is related to children’s cognitive, social, and emotional development (e.g., size, density, privacy, well-defined activity settings, modified open-plan space, a variety of technical design features and the quality of outdoor play spaces). In addition to meeting the needs of children, caregivers/teachers require space to implement programs and facilitate interactions with children.

A review of the literature indicates that in the past ten years, there has been growing research and study into how the physical design of child care settings affects child development. Historically, a standard of thirty-five square feet was used. Recommendations from research studies range between forty-two to fifty-four square feet per child. Comments from researchers indicate that other factors must also be considered when assessing the context of usable floor space for child care activities (1,5-8).

Although each child’s development is unique to that child, age groups are often used to categorize developmental needs. To meet these needs, the use of activity space for each age group will be inherently different.

Child behavior tends to be more constructive when sufficient space is organized to promote developmentally appropriate skills. Crowding has been shown to be associated with increased risk of developing upper respiratory infections (2). Also, having sufficient space will reduce the risk of injury from simultaneous activities.

Children with special health care needs may require more space than typically developing children (1).

COMMENTS
The usable floor space for children’s activities in this standard refers to indoor space that is used as the primary play space. Consideration should also be given to the presence or absence of secondary indoor play space that might be shared between programs as well as to outdoor play space.

Staff-child ratios (i.e., the number of staff required per number of children) should also be taken into account since staff consumes floor area space as well as children. Group size for various age groups should also be considered. Since groups of infants are smaller than groups of preschoolers, “infant and toddler rooms tend to be small, while preschool and school-age rooms are a bit generous at full capacity” (1). Infant and toddler rooms often dedicate a considerable amount of inflexible space to cribs and diaper changing areas. Sufficient space to accommodate these activities, space for adult seating to care for infants, and space for safe mobility of infants and toddlers requires that the per child square foot requirements are applied for their areas also.

Square footage estimates should only be intended as guidelines. Especially in child care facilities with fewer than fifty children, “plugging in” the square footage into a formula to calculate space required usually does not work (1).

It is important to keep in mind that state licensing regulations specify minimum space requirements and that they must be legally adhered to. Such requirements vary from state to state (3). For Federal child care centers, the U.S. General Services Administration’s (GSA) child care design standards require a minimum of forty-eight and one-half square feet per child in the classroom (4).

Although providing adequate space for implementing a program of activities that meets the developmental needs of children is important in providing quality child care, how that space is actually used is likely more critical (8). It has been observed that child care facilities operating in older buildings with less than ideal space can still deliver quality child care programs to meet the needs of children. Nevertheless, the amount of activity space required per child should take the known research into consideration.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
2.1.2.3 Space and Activity to Support Learning of Infants and Toddlers
2.1.4.2 Space for School-Age Activity
REFERENCES
  1. Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.
  2. The Family Child Care Accreditation Project, Wheelock College. 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: National Association for Family Child Care. http://www.nafcc.org/documents/QualStd.pdf.
  3. White, R., V. Stoecklin. 2003. The great 35 square foot myth. http://www.whitehutchinson.com/children/articles/
    35footmyth.shtml.
  4. Moore, G. T., T. Sugiyama, L. O’Donnell. 2003. Children’s physical environments rating scale. Paper presented at the Australian Early Childhood Education 2003 Conference, Hobart, Australia. http://sydney.edu.au/architecture/documents/ebs/AECA_2003_paper.pdf.
  5.  Beach J., M. Friendly. 2005. Child care centre physical environments. Working Documents, Child Care Resource and Research Unit. http://www.childcarequality.ca/wdocs/QbD
    _PhysicalEnvironments.pdf.
  6. U.S. General Services Administration (GSA). 2003. Child care center design guide. New York: GSA Public Buildings Service, Office of Child Care. http://www.gsa.gov/graphics/pbs/designguidesmall.pdf.
  7. National Child Care Information and Technical Assistance Center and the National Association for Regulatory Administration. 2009. The 2007 licensing child care study. http://www.naralicensing.org/associations/4734/files/2007 Licensing Study_full_report.pdf.
  8. Fleming, D. W., S. L. Cochi, A. W. Hightower, et al. 1987. Childhood upper respiratory tract infections: To what degree is incidence affected by daycare attendance? Pediatrics 79:55-60.

Standard 5.1.4.2: Evacuation of Children with Special Health Care Needs and Children with Disabilities

In facilities that include children who have physical disabilities or other developmental disabilities, all exits and steps necessary for evacuation should have ramps approved by the local building inspector and be clearly marked or identified. Children who have ambulatory difficulty, mobility limitations or impairments, use wheelchairs or other equipment that must be transported with the child (such as an oxygen ventilator) should be located on the ground floor of the facility or provisions should be made for efficient emergency evacuation to a safe sheltered area. Children who have special medical or dietary needs should have their medical equipment brought along during an evacuation.

RATIONALE
The facility must meet building code standards for the community and also the requirements under the Americans with Disabilities Act (ADA) and their access guidelines (1). All children must be able to exit the building quickly in case of emergency. Locating children in wheelchairs or those with special equipment on the ground floor may eliminate the need for transporting these children down the stairs during an emergency evacuation. In buildings where the ground floor cannot be used for such children, arrangements must be made to move children to a safe location, such as a fire tower stairwell, during an emergency exit. Children with diabetes, asthma, or special medical diets may need medication or special foods brought along during an evacuation.
COMMENTS
Assuring physical access to a facility also requires that a means of evacuation meeting safety standards for exit accommodates any children with special health care needs in care.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
5.1.1.4 Accessibility of Facility
5.1.1.8 Buildings of Wood Frame Construction
REFERENCES
  1. U.S. Architectural and Transportation Barriers Compliance Board (Access Board). 2002. Americans with disabilities act accessibility guidelines for buildings and facilities (ADAAG). http://www.access-board.gov/adaag/ADAAG.pdf.

Standard 5.1.4.3: Path of Egress

The minimum width of any path of egress should be thirty-six inches. An exception is that doors should provide a minimum clear width of thirty-two inches. The width of doors should accommodate wheelchairs and the needs of individuals with physical disabilities.

Where exits are not immediately accessible from an open floor area, safe and continuous passageways, aisles, or corridors leading to every exit should be maintained and should be arranged to provide access for each occupant to at least two exits by separate ways of travel. Doorways, exit access paths, passageways, corridors and exits should be kept free of materials, furniture, equipment and debris to allow unobstructed egress travel from inside the child care facility to the outside.

RATIONALE
Unobstructed access to exits is essential to prompt evacuation (1). The hallways and door openings must be wide enough to permit easy exit in an emergency. The actual exit is the enclosed stair or the actual door to the outside; doors from most rooms and the travel along a corridor are considered exit access or the path of egress. The NFPA 101: Life Safety Code from the National Fire Protection Association (NFPA) permits the usual thirty-six inches minimum to be reduced to a clear opening of thirty-two inches for doors (1). This is consistent with Americans with Disabilities Act Accessibility Guidelines for Buildings and Facilities (ADAAG) as it affords enough width for a person in a wheelchair to maneuver through the door opening (2).
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. U.S. Architectural and Transportation Barriers Compliance Board (Access Board). 2002. Americans with disabilities act accessibility guidelines for buildings and facilities (ADAAG). http://www.access-board.gov/adaag/ADAAG.pdf.

Standard 5.1.4.7: Access to Exits

Each room of a child care facility should be provided with direct access to:

  1. An exit to the outside; or
  2. A corridor or hallway providing direct access to an exit to the outside.

Where it is necessary to pass through an adjacent room for access to a corridor or exit, any doors providing passage to and through such room should not be latched or locked, or otherwise barricaded, to prevent access.

No obstructions should be placed in the corridors or passageways leading to the exits.

RATIONALE
A room that requires exit through another room to get to an exit path can entrap its occupants when there is a fire or emergency condition if passage can be impeded by a barrier or door that is latched (1).

An obstruction in the path of exit can lead to entrapment, especially in an emergency situation where groups of people may be exiting together.

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.

Standard 5.1.6.5: Areas Used by Children for Wheeled Vehicles

The area used by children for wheeled vehicles should have a flat, smooth, non-slippery surface. A physical barrier should separate this area from the following:

  1. Traffic;
  2. Streets;
  3. Parking;
  4. Delivery areas;
  5. Driveways;
  6. Stairs;
  7. Hallways used as fire exits;
  8. Balconies;
  9. Pools and other areas containing water.

RATIONALE
Uneven or slippery riding surfaces can lead to injury (1). Physical separation from environmental obstacles is necessary to prevent potential collision, injuries, falls, and drowning.
TYPE OF FACILITY
Center
RELATED STANDARDS
5.1.6.2 Construction and Maintenance of Walkways
5.1.6.3 Drainage of Paved Surfaces
5.1.6.4 Walking Surfaces
REFERENCES
  1. U.S. General Services Administration (GSA). 2003. Child care center design guide. New York: GSA Public Buildings Service, Office of Child Care. http://www.gsa.gov/graphics/pbs/designguidesmall.pdf.

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 5.3.1.4: 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 5.3.2.1: Therapeutic and Recreational Equipment

The facility should have therapeutic and recreational equipment to enhance the educational and developmental progress of children with special health care needs, to the extent that they can be safely and reasonably furnished. Some therapeutic equipment such as trampolines will need to have proper supervision for safety. Such equipment must be securely stored and inaccessible to children when not being used.

RATIONALE
Children with special health care needs may require special equipment of various types. For the individual child, the equipment should be available to meet the goals and methods outlined in the service plan. This equipment, if accessible, may pose a hazard to children in the facility.
COMMENTS
Devices and assisted technology that individual children require is unique to them, based on their own specific needs.

The Americans with Disabilities Act (ADA) does not require personal equipment (e.g., eyeglasses, wheelchairs, etc.) to be furnished by the child care program.

TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 5.3.2.2: Special Adaptive Equipment

Special adaptive equipment (such as toys, augmentative communication devices, and wheelchairs) for children with special health care needs should be available in and correctly utilized by the facility as part of their reasonable accommodations for the child.

Staff should be instructed and trained in use of communication devices and other adaptive equipment.

RATIONALE
If a facility serves one or more children with special health care needs, adaptive equipment necessary for the child’s participation in all activities is needed.
COMMENTS
Most adaptive equipment can be created by making simple adaptation of typically used items such as eating utensils, cups, plates, etc.

Caregivers/teachers are not responsible for providing personal equipment (such as hearing aids, eyeglasses, braces, and wheelchairs), but should be aware of how they should be used and if repairs are necessary.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
Appendix X: Adaptive Equipment for Children with Special Health Care Needs

Standard 5.3.2.3: Storage for Adaptive Equipment

The facility should provide storage space for all adaptive equipment (such as equipment for physical therapy, occupational therapy, or adaptive physical education) separate and apart from classroom floor space. The storage space should be easily accessible to the staff. Equipment should be stored safely and in an organized way.

RATIONALE
Frequently, storing adaptive equipment is a problem in centers. This equipment should be stored outside of classroom space to maximize floor space and minimize distracting clutter.
TYPE OF FACILITY
Center

Standard 5.3.2.4: Orthotic and Prosthetic Devices

A trained, designated staff member should check prosthetic devices (upper and lower extremity), including hearing aids, processors for cochlear implants, eyeglasses, braces, and wheelchairs, daily to ensure that these appliances are in good working order, cleaned correctly, and have been applied properly.

RATIONALE
Battery-driven devices such as hearing aids require close monitoring because the batteries have a short life and young children require adult assistance to replace them. Eyeglasses scratch and break, as do other assistive appliances. Staff members should be adequately trained to perform orthotic and prosthetic device monitoring.
COMMENTS
The facility should have parents/guardians supply extra batteries for hearing aids. Facilities should store and discard the batteries in such a manner that children cannot ingest them. With the parents’/guardians’ permission, the staff may perform minor repairs on equipment if they are trained but should not attempt major repairs.

Upper extremity and lower extremity orthotics and/or eyeglasses are not effective if they are not applied correctly to the child. Instruction from parents/guardians or professionals may be necessary to ensure proper application of devices.

TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 5.4.1.7: Toilet Learning/Training Equipment

Equipment used for toilet learning/training should be provided for children who are learning to use the toilet. Child-sized toilets or safe and cleanable step aids and modified toilet seats (where adult-sized toilets are present) should be used in facilities. Non-flushing toilets (i.e., potty chairs) should be strongly discouraged.

If child-sized toilets, step aids, or modified toilet seats cannot be used, non-flushing toilets (potty chairs) meeting the following criteria should be provided for toddlers, preschoolers, and children with disabilities who require them. Potty chairs should be:

  1. Easily cleaned and disinfected;
  2. Used only in a bathroom area;
  3. Used over a surface that is impervious to moisture;
  4. Out of reach of toilets or other potty chairs;
  5. Cleaned and disinfected after each use in a sink used only for cleaning and disinfecting potty chairs.

Equipment used for toilet learning/training should be accessible to children only under direct supervision.

The sink used to clean and disinfect the potty chair should also be cleaned and disinfected after each use.

RATIONALE
Child-sized toilets that are flushable, steps, and modified toilet seats provide for easier use and maintenance. Sanitary handling of potty chairs is difficult. Flushable toilets are superior to any type of device that exposes the staff to contact with feces or urine. Many infectious diseases can be prevented through appropriate hygiene and disinfection methods. Surveys of environmental surfaces in child care settings have demonstrated evidence of fecal contamination (1). Fecal contamination has been used to gauge the adequacy of disinfection and hygiene.
COMMENTS
If potty chairs are used, they should be constructed of plastic or similar nonporous synthetic products. Wooden potty chairs should not be used, even if the surface is coated with a finish. The finished surface of wooden potty chairs is not durable and, therefore, may become difficult to wash and disinfect effectively.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Gorski, P. A. 1999. Toilet training guidelines: Day care providers-the role of the day care provider in toilet training. Pediatrics 103:1367-68.

Standard 5.4.3.2: Safety of Bathtubs and Showers

All bathing facilities should have a conveniently located grab bar that is mounted at a height appropriate for a child to use. Nonskid surfaces should be provided in all tubs and showers. Bathtubs should be equipped with a mechanism to guarantee that drains are kept open at all times, except during supervised use. Water temperature should not exceed 120°F and anti-scald devices should be permanently installed in the faucet and shower head.

RATIONALE
Falls in tubs are a well-documented source of injury according to the National Electronic Injury Surveillance System (NEISS) data collected by the U.S. Consumer Product Safety Commission (CPSC) (2). Grab bars and nonslip surfaces reduce this risk (2). Drowning and falls in bathtubs are also a significant cause of injury for young children and children with disabilities (1,2). An open drain will prevent a pool of water from forming if a child turns on a water faucet and, therefore, will prevent a potential drowning situation. Bathtub water comprises the leading cause of scalds for young children (2). Water heated to temperatures greater than 120°F takes less than thirty seconds to burn the skin (2).
COMMENTS
Various inexpensive devices to check water temperature are available at stores and on the Internet.
TYPE OF FACILITY
Center
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.
  2. Gipson, K. 2009. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: CPSC. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.

Standard 5.4.6.2: Space for Therapy Services

In addition to accessible classrooms, in facilities where some but fewer than fifteen children need occupational or physical therapy and some but fewer than twenty children need individual speech therapy, centers should provide a quiet, private, accessible area within the child care facility for therapy. No other activities should take place in this area at the time therapy is being provided.

Family child care homes and facilities integrating children who need therapy services should receive these services in a space that is separate and private during the time the child is receiving therapy.

Additional space may be needed for equipment according to a child’s needs.

RATIONALE
Quiet, private space is necessary for physical, occupational, and speech therapies (1). Most caregivers/teachers also indicate that the other children in the facility are disrupted less if the therapies are provided in a separate area. For speech therapy, working with the child in a quiet location is especially important. Caregivers/teachers should attempt to incorporate therapeutic principles into the child’s general child care activities. Doing so will achieve maximum benefit for the child receiving therapy and promote understanding on the part of the child’s peers and caregivers/teachers about how to address the child’s disability when the therapist is not present.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Olds, A. R. 2001. Zoning a group room. In Child care design guide, 137-165. New York: McGraw-Hill.

Standard 5.6.0.1: First Aid and Emergency Supplies

The facility should maintain first aid and emergency supplies in each location where children are cared for. The first aid kit or supplies should be kept in a closed container, cabinet, or drawer that is labeled and stored in a location known to all staff, accessible to staff at all times, but locked or otherwise inaccessible to children. When children leave the facility for a walk or to be transported, a designated staff member should bring a transportable first aid kit. In addition, a transportable first aid kit should be in each vehicle that is used to transport children to and from a child care facility.

First aid kits or supplies should be restocked after use. An inventory of first aid supplies should be conducted at least monthly. A log should be kept that lists the date that each inventory was conducted, verification that expiration dates of supplies were checked, location of supplies (i.e., in the facility supply, transportable first aid kit(s), etc.), and the legal name/signature of the staff member who completed the inventory.

The first aid kit should contain at least the following items:

  1. Disposable nonporous, latex-free or non-powdered latex gloves (latex-free recommended);
  2. Scissors;
  3. Tweezers;
  4. Non-glass, non-mercury thermometer to measure a child’s temperature;
  5. Bandage tape;
  6. Sterile gauze pads;
  7. Flexible roller gauze;
  8. Triangular bandages;
  9. Safety pins;
  10. Eye patch or dressing;
  11. Pen/pencil and note pad;
  12. Cold pack;
  13. Current American Academy of Pediatrics (AAP) standard first aid chart or equivalent first aid guide such as the AAP Pediatric First Aid For Caregivers and Teachers (PedFACTS) Manual;
  14. Coins for use in a pay phone and cell phone;
  15. Water (two liters of sterile water for cleaning wounds or eyes);
  16. Liquid soap to wash injury and hand sanitizer, used with supervision, if hands are not visibly soiled or if no water is present;
  17. Tissues;
  18. Wipes;
  19. Individually wrapped sanitary pads to contain bleeding of injuries;
  20. Adhesive strip bandages, plastic bags for cloths, gauze, and other materials used in handling blood;
  21. Flashlight;
  22. Whistle;
  23. Battery-powered radio (1).

When children walk or are transported to another location, the transportable first aid kit should include ALL items listed above AND the following emergency information/items:

  1. List of children in attendance (organized by caregiver/teacher they are assigned to) and their emergency contact information (i.e., parents/guardian/emergency contact home, work, and cell phone numbers);
  2. Special care plans for children who have them;
  3. Emergency medications or supplies as specified in the special care plans;
  4. List of emergency contacts (i.e., location information and phone numbers for the Poison Center, nearby hospitals or other emergency care clinics, and other community resource agencies);
  5. Maps;
  6. Written transportation policy and contingency plans.

RATIONALE
Facilities must place emphasis on safeguarding each child and ensuring that the staff members are able to handle emergencies (2).
COMMENTS
Many centers simply leave a first aid kit in all vehicles used to transport children, regardless of whether the vehicle is used to take a child to or from a center, or for outings. Maps are required in case transporting staff need to find an alternate way back to the facility or another route to emergency services when roads are closed and/or communication and power systems are inaccessible. Programs may want to have access to hand-held or stationary electronic/cellular, or satellite devices (e.g., GIS systems or phones that include relevant features) when transporting to help locate alternative routes during an emergency.

Syrup of Ipecac should not be used to induce vomiting and should not be included in first aid kits or available at a child care program (1). Contact the local poison center at 1-800-222-1222 for instructions if needed.

Hand sanitizers may be used under supervision as an alternative to washing hands with soap and water if wipes are used to remove visible soil before the hand sanitizer is applied.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.2.5 Hand Sanitizers
3.6.1.3 Thermometers for Taking Human Temperatures
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. 2007. Pediatric first aid for caregivers and teachers. Rev ed. Elk Grove Village, IL: AAP. http://www.pedfactsonline.com/.

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/.

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
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.1.3.1 Active Opportunities for Physical Activity
5.1.1.5 Environmental Audit of Site Location
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 6.2.1.2: Play Equipment and Surfaces Meet ADA Requirements

Play equipment and play surfaces should conform to recommendations from the Americans with Disabilities Act (ADA) (1).

RATIONALE
Play equipment and play surfaces that are safe and accessible to children with disabilities will encourage all children to play together (2).
COMMENTS
For additional information regarding playground equipment and play surfaces accessible to children with disabilities, review the Americans with Disabilities Act Accessibility Guidelines (ADAAG) and the U.S. Access Board’s Summary of Accessibility Guidelines for Play Areas at http://www.access-board.gov/play/guide/guide.pdf.
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. 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.

Standard 6.5.1.1: Competence and Training of Transportation Staff

At least one adult who accompanies or drives children for field trips and out-of-facility activities should receive training by a professional knowledgeable about child development and procedures, to ensure the safety of all children. The caregiver should hold a valid pediatric first aid certificate, including rescue breathing and management of blocked airways, as specified in First Aid and CPR Standards 1.4.3.1-1.4.3.3. Any emergency medications that a child might require, such as self-injecting epinephrine for life-threatening allergy, should also be available at all times as well as a mobile phone to call for medical assistance. Child:staff ratios should be maintained on field trips and during transport, as specified in Standards 1.1.1.1-1.1.1.5; the driver should not be included in these ratios. No child should ever be left alone in the vehicle.

All drivers, passenger monitors, chaperones, and assistants should receive instructions in safety precautions. Transportation procedures should include:

  1. Use of developmentally appropriate safety restraints;
  2. Proper placement of the child in the motor vehicle in accordance with state and federal child restraint laws and regulations and recognized best practice;
  3. Training in handling of emergency medical situations. If a child has a chronic medical condition or special health care needs that could result in an emergency (such as asthma, diabetes, or seizures), the driver or chaperone should have written instructions including parent/guardian emergency contacts, child summary health information, special needs and treatment plans, and should:
    1. Recognize the signs of a medical emergency;
    2. Know emergency procedures to follow (3);
    3. Have on hand any emergency supplies or medications necessary, properly stored out of reach of children;
    4. Know specific medication administration (ex. a child who requires EpiPen or diazepam);
    5. Know about water safety when field trip is to a location with a body of water.
  4. Knowledge of appropriate routes to emergency facility;
  5. Defensive driving;
  6. Child supervision during transport, including never leaving a child unattended in or around a vehicle;
  7. Issues that may arise in transporting children with behavioral issues (e.g., temper tantrums or oppositional behavior).

The receipt of such instructions should be documented in a personnel record for any paid staff or volunteer who participates in field trips or transportation activities.

Vehicles should be equipped with a first aid kit, fire extinguisher, seat belt cutter, and maps. At least one adult should have a functioning cell phone at hand. Information, names of the children and parent/guardian contact information should be carried in the vehicle along with identifying information (name, address, and telephone number) about the child care center.

RATIONALE
Injuries are more likely to occur when a child’s surroundings or routine changes. Activities outside the facility may pose increased risk for injury. When children are excited or busy playing in unfamiliar areas, they are more likely to forget safety measures unless they are closely supervised at all times.

Children have died from heat stress from being left unattended in closed vehicles. Temperatures in hot motor vehicles can reach dangerous levels within fifteen minutes. Due to this danger, vehicles should be locked when not in use and checked after use to make sure no child is left unintentionally in a vehicle. Children left unattended also can be victims of backovers (when an unseen child is run over by being behind a vehicle that is backing up), power window strangulations, and other preventable injuries (1,2).

All adults cannot be assumed to be knowledgeable about the various developmental levels or special needs of children. Training by someone with appropriate knowledge and experience is needed to appropriately address these issues. This is particularly important with high incidence disabilities such as autistic spectrum disorders and ADHD.

COMMENTS
When field trips are planned, all field trip sites should be visited by a member of the child care staff and all potential hazards identified. The child care staff should be knowledgeable about location and any emergency plans of the location. For example, if the children are taken to the zoo, the zoo will have its own emergency procedures that the child care would be expected to follow. This standard also applies when caregivers/teachers are walking with children to and from a destination.

A designated staff person should check to ensure all children safely exit the vehicle when it arrives at the designated location. This may include use of an attendance list of all children being transported so it can be checked against those who get out of the vehicle. Also, have another staff member do a thorough and complete inspection of the
vehicle to see that the vehicle is empty before locking.

The National Highway Traffic Safety Administration has materials on child passenger safety at: https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/documents/child_passenger_safety_slr.pdf as well as materials from the American Academy of Pediatrics at https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/documents/child_passenger_safety_slr.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.4.3.3 CPR Training for Swimming and Water Play
5.3.1.12 Availability and Use of a Telephone or Wireless Communication Device
2.2.0.4 Supervision Near Bodies of Water
2.2.0.5 Behavior Around a Pool
6.5.2.1 Drop-Off and Pick-Up
6.5.2.4 Interior Temperature of Vehicles
REFERENCES
  1. Guard, A., S. S. Gallagher. 2005. Heat related deaths to young children in parked cars: An analysis of 171 fatalities in the United States, 1995-2002. Injury Prevention 11:33-37.
  2. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention, and Council on School Health. 2007. Policy statement: School transportation safety. Pediatrics 120:213-20.
  3. Babcock-Dunning, L., A. Guard, S. S. Gallagher, E. Streit-Kaplan. 2008. Guidelines for developing educational materials to address children unattended in vehicles. Newton, MA: Health and Human Development Programs, Education Development Center. http://www.hhd.org/sites/hhd.org/files/Children Unattended in Vehicles.pdf.

Standard 6.5.2.2: Child Passenger Safety

When children are driven in a motor vehicle other than a bus, school bus, or a bus operated by a common carrier, the following should apply:

  1. A child should be transported only if the child is restrained in developmentally appropriate car safety seat, booster seat, seat belt, or harness that is suited to the child’s weight, age, and/or psychological development in accordance with state and federal laws and regulations and the child is securely fastened, according to the manufacturer’s instructions, in a developmentally appropriate child restraint system.
  2. Age and size-appropriate vehicle child restraint systems should be used for children under eighty pounds and under four-feet-nine-inches tall and for all children considered too small, in accordance with state and federal laws and regulations, to fit properly in a vehicle safety belt. The child passenger restraint system must meet the federal motor vehicle safety standards contained in the Code of Federal Regulations, Title 49, Section 571.213 (especially Federal Motor Vehicle Safety Standard 213), and carry notice of such compliance.
  3. For children who are obese or overweight, it is important to find a car safety seat that fits the child properly. Caregivers/teachers should not use a car safety seat if the child weighs more than the seat’s weight limit or is taller than the height limit. Caregivers/teachers should check the labels on the seat or manufacturer’s instructions if they are unsure of the limits. Manufacturer’s instructions that include these specifications can also be found on the manufacturer’s Website.
  4. Child passenger restraint systems should be installed and used in accordance with the manufacturer’s instructions and should be secured in back seats only.
  5. All children under the age of thirteen should be transported in the back seat of a car and each child not riding in an appropriate child restraint system (i.e., a child seat, vest, or booster seat), should have an individual lap-and-shoulder seat belt (2).
  6. For maximum safety, infants and toddlers should ride in a rear-facing orientation (i.e., facing the back of the car) until they are two years of age or until they have reached the upper limits for weight or height for the rear-facing seat, according to the manufacturer’s instructions (1). Once their seat is adjusted to face forward, the child passenger must ride in a forward-facing child safety seat (either a convertible seat or a combination seat) until reaching the upper height or weight limit of the seat, in accordance with the manufacturer’s instructions (10). Plans should include limiting transportation times for young infants to minimize the time that infants are sedentary in one place.
  7. A booster seat should be used when, according to the manufacturer’s instructions, the child has outgrown a forward-facing child safety seat, but is still too small to safely use the vehicle seat belts (for most children this will be between four feet nine inches tall and between eight and twelve years of age) (1).
  8. Car safety seats, whether provided by the child’s parents/guardians or the child care program, should be labeled with the child passenger’s name and emergency contact information.
  9. Car safety seats should be replaced if they have been recalled, are past the manufacturer’s “date of use” expiration date, or have been involved in a crash that meets the U.S. Department of Transportation crash severity criteria or the manufacturer’s criteria for replacement of seats after a crash (3,11).
  10. The temperature of all metal parts of vehicle child restraint systems should be checked before use to prevent burns to child passengers.

If the child care program uses a vehicle that meets the definition of a school bus and the school bus has safety restraints, the following should apply:

  1. The school bus should accommodate the placement of wheelchairs with four tie-downs affixed according to the manufactures’ instructions in a forward-facing direction;
  2. The wheelchair occupant should be secured by a three-point tie restraint during transport;
  3. At all times, school buses should be ready to transport children who must ride in wheelchairs;
  4. Manufacturers’ specifications should be followed to assure that safety requirements are met.

RATIONALE
According to the National Center for Health Statistics, motor vehicle crashes are the leading cause of death among children ages three to fourteen in the United States (4). Safety restraints are effective in reducing death and injury when they are used properly. The best car safety seat is one that fits in the vehicle being used, fits the child being transported, has never been in a crash, and is used correctly every time. The use of restraint devices while riding in a vehicle reduces the likelihood of any passenger suffering serious injury or death if the vehicle is involved in a crash. The use of child safety seats reduces risk of death by 71% for children less than one year of age and by 54% for children ages one to four (4). In addition, booster seats reduce the risk of injury in a crash by 45%, compared to the use of an adult seat belt alone (5).

The safest place for all infants and children under thirteen years of age is to ride in the back seat. Head-on crashes cause the greatest number of serious injuries. A child sitting in the back seat is farthest away from the impact and less likely to be injured or killed. Additionally, new cars, trucks and vans have had air bags in the front seats for many years. Air bags inflate at speeds up to 200 mph and can injure small children who may be sitting too close to the air bag or who are positioned incorrectly in the seat. If the infant is riding in the front seat, a rapidly inflating air bag can hit the back of a rear-facing infant seat behind a baby’s head and cause severe injury or death. For this reason, a rear-facing infant must NEVER be placed in the front seat of a vehicle with active passenger air bags.

Infants under one year of age have less rigid bones in the neck. If an infant is placed in a child safety seat facing forward, a collision could snap the infant’s head forward, causing neck and spinal cord injuries. If an infant is placed in a child safety seat facing the rear of the car, the force of a collision is absorbed by the child restraint and spread across the infant’s entire body. The rigidity of the bones in the neck, in combination with the strength of connecting ligaments, determines whether the spinal cord will remain intact in the vertebral column. Based on physiologic measures, immature and incompletely ossified bones will separate more easily than more mature vertebrae, leaving the spinal cord as the last link between the head and the torso (6). After twelve months of age, more moderate consequences seem to occur than before twelve months of age (7). However, rear-facing positioning that spreads deceleration forces over the largest possible area is an advantage at any age. Newborns seated in seat restraints or in car beds have been observed to have lower oxygen levels than when placed in cribs, as observed over a period of 120 minutes in each position (8).

As of March 1, 2010, all but three states required booster seat use for children up to as high as nine years of age. Child passenger restraints are recommended increasingly for older children. State child restraint requirements are listed by state at: http://www.iihs.org/laws/ChildRestraint.aspx. Booster seats are recommended for use only with both lap and shoulder belts; NEVER install a booster seat with the lap belt only. When the vehicle safety belts fit properly, the lap belt lies low and tightly across the child’s upper thighs (not the abdomen) and the shoulder belt lies flat across the chest and shoulder, away from the neck and face.

COMMENTS
A Child Passenger Safety Technician may be able to help find a car safety seat that fits a larger child. Car safety seat manufacturers increasingly are making car safety seats that fit larger children. To locate a Child Passenger Safety Technician see https://ssl13.cyzap.net/dzapps/dbzap.bin/apps/assess/webmembers/tool?pToolCode=TAB9&pCategory1=TAB9_CERTSEARCH&Webid=SAFEKIDSCERTSQL. See http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats
-Product-Listing-2010.aspx for a list of available car safety seats. For toddlers or young children whose behavior will not yet allow safe use of a booster seat but who are too large for a forward-facing seat with a harness, caregivers/teachers can consider using a travel vest (9).

When school buses meet current standards for the transport of school-age children, containment design features help protect children from injury, although the use of seat belts would provide additional protection. The U.S. Department of Transportation and U.S. Federal Motor Vehicle Safety standards for school buses apply only to vehicles equipped with factory-installed seat belts after 1967. To obtain the Federal Regulations, contact the Superintendent of Documents at the Government Printing Office.

Written transportation policy that is communicated to parents/guardians, staff, and all who transport children can help assure understanding of requirements/recommendations for child passenger safety as well as decisions about the value/necessity of the trip.

Car seat manufacturer’s the National Highway Traffic Safety Administration (NHTSA) guidance on car seat replacement after a crash is available at http://www.nhtsa.gov/people/injury/childps/ChildRestraints/ReUse/index.htm.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.5.1 Transportation Policy for Centers and Large Family Homes
9.2.5.2 Transportation Policy for Small Family Child Care Homes
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
6.5.3.1 Passenger Vans
REFERENCES
  1. Durbin, D. R., American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2011. Policy statement: Child passenger safety. Pediatrics 127:788-93.
  2. Child Restraint Safety. Manufacture and expiration. http://www.childrestraintsafety.com/manufacture-expiration.html.
  3. American Academy of Pediatrics. 2015. Car safety seats: Information for families for 2015. http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx
  4. American Academy of Pediatrics. Obese children and car safety seats: Suggestions for parents. http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-and-Obese-Children-Suggestions-for-Parents.aspx
  5. Cerar, L. K., C. V. Scirica, I. S. Gantar, D. Osredkar, D. Neubauer, T. B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in car safety seats and beds. Pediatrics 124: e396-e402.
  6. Weber, K., D. Dalmotas, B. Hendrick. 1993. Investigation of dummy response and restraint configuration factors associated with upper spinal cord injury in a forward-facing child restraint. Warrendale, PA: Society of Automotive Engineers.
  7. Huelke, D. F., G. M. Mackay, A. Morris, M. Bradford. 1993. Car crashes and non-head impact cervical spine injuries in infants and children. Warrendale, PA: Society of Automotive Engineers.
  8. Arbogast, K. B., J. S. Jermakian, M. J. Kallan, D. R. Durbin. 2009. Effectiveness of belt positioning booster seats: An updated assessment. Pediatrics 124:1281-86
  9. National Highway Traffic Safety Administration’s National Center for Statistics and Analysis 2008. Traffic safety facts, 2008, Childrenhttp://www-nrd.nhtsa.dot.gov/Pubs/811157.PDF.
  10. National Highway Traffic Safety Administration. Child restraint re-use after minor crashes.http://www.nhtsa.dot.gov/people/injury/childps/ChildRestraints/ReUse/index.htm.
  11. National Highway Trafic Safety Administration. Questions and answers about air bag safety. Safe and Sober Campaign. http://www.nhtsa.gov/people/injury/alcohol/Archive/Archive/safesobr/12qp/airbag.html.

VII. Infectious Diseases

Standard 7.2.0.1: Immunization Documentation

Child care facilities should require that all parents/guardians of children enrolled in child care provide written documentation of receipt of immunizations appropriate for each child’s age. Infants, children, and adolescents should be immunized as specified in the “Recommended Immunization Schedules for Persons Aged 0 Through 18 Years – United States” developed by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Children whose immunizations are not up-to-date or have not been administered according to the recommended schedule should receive the required immunizations, unless contraindicated or for legal exemptions (1,2).

An updated immunization schedule is published annually in the AAP’s Pediatrics and in the CDC’s MMWR and should be consulted for current information. In addition to print versions of the recommended immunization schedules, the current child, adolescent, and catch-up schedules are posted on the Websites of the CDC at http://www.cdc.gov/vaccines/ and the AAP at http://www.aap.org/
immunization/.

RATIONALE
Routine immunizations at the appropriate age are the best means of protecting children against vaccine-preventable diseases. Legal requirements for age-appropriate immunizations of children attending licensed facilities exist in almost all states (see http://www.immunize.org/laws/). Parents/guardians of children who attend unregulated child care facilities should be encouraged to comply with the most recent “Recommended Immunization Schedules” (2).

Immunization is particularly important for children in child care because preschool-aged children have the highest age-specific incidence or are at high risk of complications from many vaccine-preventable diseases (specifically, measles, pertussis, rubella, influenza, varicella [chickenpox], rotavirus, and diseases due to Haemophilus influenzae type b (Hib) and pneumococcus) (3).

COMMENTS
Early education and child care settings present unique challenges for infection control due to the highly vulnerable population, close interpersonal contact, shared toys and other objects, and limited ability of young children to understand or practice good respiratory etiquette and hand hygiene. Parents/guardians, early childhood caregivers/teachers, and public health officials should be aware that, even under the best of circumstances, transmission of infectious diseases cannot be completely prevented in early childhood or other settings. No policy can keep everyone who is potentially infectious out of these settings (4).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
9.2.3.5 Documentation of Exemptions and Exclusion of Children Who Lack Immunizations
REFERENCES
  1. Centers for Disease Control and Prevention. 2015. Recommended immunization schedules for persons aged 0-18 years – United States, 2015. http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
  2. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  3. Centers for Disease Control and Prevention (CDC). 2009. CDC guidance on helping child care and early childhood programs respond to influenza during the 2009–2010 influenza season. Atlanta: CDC. http://www.cdc.gov/h1n1flu/childcare/pdf/guidance.pdf.
  4. American Academy of Pediatrics, Committee on Infectious Diseases. 2011. Policy statement: Recommended childhood and adolescent immunization schedules – United States, 2011. Pediatrics 127:387-88.

Standard 7.2.0.2: Unimmunized Children

If immunizations have not been or are not to be administered because of a medical condition (contraindication), a statement from the child’s primary care provider documenting the reason why the child is temporarily or permanently medically exempt from the immunization requirements should be on file. If immunizations are not to be administered because of the parents/guardians’ religious or philosophical beliefs, a legal exemption with notarization, waiver or other state-specific required documentation signed by the parent/guardian should be on file (1,2).

The parent/guardian of a child who has not received the age-appropriate immunizations prior to enrollment and who does not have documented medical, religious, or philosophical exemptions from routine childhood immunizations should provide documentation of a scheduled appointment or arrangement to receive immunizations. This could be a scheduled appointment with the primary care provider or an upcoming immunization clinic sponsored by a local health department or health care organization. An immunization plan and catch-up immunizations should be initiated upon enrollment and completed as soon as possible according to the current “Recommended Immunization Schedules for Persons Aged 0 Through 18 Years – United States” from the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Parents/guardians of children who attend an unlicensed child care facility should be encouraged to comply with the “Recommended Immunization Schedules” (6).

If a vaccine-preventable disease to which children are susceptible occurs in the facility and potentially exposes the unimmunized children who are susceptible to that disease, the health department should be consulted to determine whether these children should be excluded for the duration of possible exposure or until the appropriate immunizations have been completed. The local or state health department will be able to provide guidelines for exclusion requirements.

RATIONALE
Routine immunization at the appropriate age is the best means of protecting children against vaccine-preventable diseases. Mandates requiring age-appropriate immunization of children attending licensed facilities exist in all states (1).

Exclusion of an unimmunized (susceptible) or underimmunized child from the child care facility in the event of a risk of exposure to an outbreak of a vaccine-preventable disease protects the health of the unimmunized or underimmunized child and minimizes potential for further spread of that disease to other children, staff, family, and community members (2).

COMMENTS
A sample statement excluding a child from immunizations is: “This is to inform you that [NAME] should not be immunized with [VACCINE] because of [CONDITION, such as immunosuppression]. I expect this condition to persist for _______. [SIGNED], [PRIMARY CARE PROVIDER] [DATE]”

Vaccine Safety and Parental Choice – Some parents/guardians question the safety of routinely recommended vaccines. Sometimes they choose not to have their children fully vaccinated or to delay particular vaccinations. Unfortunately, this leaves the unimmunized child at risk for serious diseases and puts other children and caregivers/teachers who spend time with the unimmunized child at risk (2). Illness and death from vaccine-preventable diseases, including whooping cough and measles, have occurred in communities where there are unimmunized children who spread these diseases (3,4).

Vaccines are tested to establish safety and effectiveness before they are licensed by the U.S. Food and Drug Administration (FDA). The ACIP, a non-Federal advisory committee makes evidence-based recommendations to the Centers for Disease Control and Prevention (CDC) following review of all data before a new vaccine is recommended. ACIP is one of many reputable sources of information. The Committee on Infectious Diseases makes evidence-based vaccine recommendations to the board of directors of the AAP. There are biased, inaccurate sources of vaccine information which are not based on evidence and often can confuse parents.

Autism allegedly has been associated with specific vaccines or ingredients in vaccines or combinations of vaccines. There is no evidence-based literature to support this association (5). Hesitant parents/guardians should be referred to reputable sources where evidence-based information is provided to assist them in making informed decisions about the benefits of immunization. Sites where reputable information can be found are shown below.

Since 1999, the mission of the AAP’s Childhood Immunization Support Program (CISP) has been to improve the immunization delivery system for children across the nation by developing an infrastructure within the Academy to support its members and provide education and resources for parents and pediatricians on immunization and immunization-related issues (6).

Three sources of accurate information about immunizations are shown below. Each of the sites provides additional sources of information.

  1. https://www2.aap.org/immunization/about/programfacts.html -- CISP provides education and resources for parents/guardians and pediatricians on immunizations; CISP Goals are:
    1. Promote quality improvement and best immunization practices in community- and office-based primary care settings and other identified medical homes;
    2. Enable pediatricians and pediatric primary care providers to communicate effectively with parents/guardians;
    3. Promote system-wide improvements in the national immunization delivery system;
    4. Provide accurate and up-to-date resources to parents/guardians that address their most frequent immunization concerns (6).
  2. http://www.cdc.gov/vaccines/ -- This CDC site provides information for health care professionals and parents/guardians about all aspects of immunization including vaccine recommendations, understanding vaccines and their purpose, vaccine misconceptions, and answers to commonly asked questions about vaccines (7).
  3. http://www.immunizationinfo.org -- The mission of the National Network for Immunization Information (NNii) is to provide the public, health care professionals, policy makers, and the media with up-to-date, scientifically valid information related to immunization to assist with understanding the issues so that informed decisions can be made (8).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.3.5 Documentation of Exemptions and Exclusion of Children Who Lack Immunizations
REFERENCES
  1. Institute of Medicine Immunization Safety Review Committee. Immunization safety review. http://iom.edu/Activities/PublicHealth/ImmunizationSafety.aspx.
  2. Centers for Disease Control and Prevention. 2008. Update: Measles – United States, January-July 2008. MMWR 57 (33): 893-96. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5733a1.htm.
  3. Centers for Disease Control and Prevention. 2009. Invasive Haemophilus influenzae type B disease in five young children – Minnesota, 2008. MMWR 58 (03): 58-60. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5803a4.htm.
  4. Omer, S. B., D. A. Salmon, W. A. Orenstein, M. P. deHart, N. Halsey. 2009. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New Eng J Med 360:1981-88.
  5. Immunization Action Commission. State mandates on immunization and vaccine-preventable diseases. http://www
    .immunize.org/laws/.
  6. National Network for Immunization Information. NNii. http://www.immunizationinfo.org.
  7. Centers for Disease Control and Prevention. Vaccines and immunizations. http://www.cdc.gov/vaccines/.
  8. American Academy of Pediatrics. Immunization. Childhood Immunization Support Program (CISP).http://www2.aap.org/immunization/about/programfacts.html

Standard 7.2.0.3: Immunization of Caregivers/Teachers

Caregivers/teachers should be current with all immunizations routinely recommended for adults by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) as shown in the “Recommended Adult Immunization Schedule” at http://www.cdc.gov/vaccines/schedules/index.html. This schedule is updated annually at the beginning of the calendar year and can be found in Appendix H.

Caregivers/teachers should have received the recommended vaccines in the following categories: (1,2)

  1. Vaccines recommended for all adults who meet the age requirements and who lack evidence of immunity (i.e., lack documentation of vaccination or have no evidence of prior infection):
    1. Tdap/Td;
    2. Varicella-zoster;
    3. MMR (measles, mumps, and rubella);
    4. Seasonal influenza;
    5. Human papillomaviruses (HPV) (eleven through twenty-six years of age);
    6. Others as determined by the ACIP and state and local public health authorities.
  2. Recommended if a specific risk factor is present:
    1. Pneumococcal;
    2. Hepatitis A;
    3. Hepatitis B;
    4. Meningococcal;
    5. Others as determined by the ACIP and state and local public health authorities.
  3. If a staff member is not appropriately immunized for medical, religious or philosophical reasons, the child care facility should require written documentation of the reason.
  4. If a vaccine-preventable disease to which adults are susceptible occurs in the facility and potentially exposes the unimmunized adults who are susceptible to that disease, the health department should be consulted to determine whether these adults should be excluded for the duration of possible exposure or until the appropriate immunizations have been completed. The local or state health department will be able to provide guidelines for exclusion requirements.

RATIONALE
Routine immunization of adults is the best means of preventing vaccine-preventable diseases. Vaccine-preventable diseases of adults represent a continuing cause of morbidity and mortality and a source of transmission of infectious organisms. Vaccines, which are safe and effective in preventing these diseases, need to be used in adults to minimize disease and to eliminate potential sources of transmission (1-3).
COMMENTS
Several of the vaccines recommended routinely for adults will prevent diseases that can be transmitted to children in the child care setting, including pertussis, varicella, measles, mumps, rubella and influenza. One dose of Tdap is a new recommendation for all adults and is especially important for those in close contact with infants. Adults often spread pertussis (whooping cough) to vulnerable infants and young children. Yearly influenza vaccination of adults in contact with children is also an especially important way to protect young infants. Hepatitis A vaccine is not recommended for routine administration to caregivers/teachers; however, hepatitis A vaccine can be administered to any person seeking protection from hepatitis A virus (HAV). Hepatitis A is an illness that often spreads to caregivers/teachers in early education and child care settings. Caregivers/teachers should be aware of the availability of hepatitis A vaccine. As of the printing of this edition, hepatitis A and B, pneumococcal and meningococcal vaccines are only recommended for adults with high risk conditions or in high risk settings unless requested.

Caregivers/teachers who do not complete the recommended immunization series put themselves, and children for whom they care, at risk. For additional information on adult immunization, visit the CDC Website on immunizations and vaccines at http://www.cdc.gov/vaccines/.

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. Centers for Disease Control and Prevention. 2015. Recommended adult immunization schedule – United States, 2015. http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html.
  2. Centers for Disease Control and Prevention. 2011. General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices. MMWR 60 (RR02). http://www.cdc.gov/mmwr/pdf/rr/rr6002.pdf.
  3. Advisory Committee on Immunization Practices. 2011. Recommended adult immunization schedule – United States, 2011. Ann Intern Med 154:168-73.

VIII. Children with Special Health Care Needs and Disabilities

Standard 8.2.0.1: Inclusion in All Activities

All children should be included in all activities possible unless a specific medical contraindication exists.

RATIONALE
The goal is to provide fully integrated care to the extent feasible given each child’s limitations. Federal and state laws do not permit discrimination on the basis of the disability (i.e., Americans with Disabilities Act [ADA] and Section 504 of the Rehabilitation Act) (4,5).

Studies have found the following benefits of inclusive child care: Children with special needs develop increased social skills and self-esteem; families of children with special needs gain social support and develop more positive attitudes about their child; children and families without special needs become more understanding and accepting of differences and disabilities; caregivers/teachers learn from working with children, families, and service providers and develop skills in individualizing care for all children (6).

COMMENTS
Caregivers/teachers may need to seek professional guidance and obtain appropriate training in order to include children with special needs, such as children with severe disabilities and children with special health care needs such as chronic illnesses, into child care settings. These may include technology-dependent children and children with serious and severe chronic medical problems. The child care health consultant should be involved in the transition and enrollment process in order to support individual accommodations and the care of children with special health care needs. Every attempt should be made, however, to achieve inclusion if the parent/guardian so wishes.

The facility should pursue mechanisms available to supplement funding for services in the facility. These resources usually require the parents/guardians’ consent and may require that the parents be actively involved in the pursuit for funding. Even so, caregivers/teachers can and should discuss options with the parents/guardian as potential sources of financial assistance for needed services. These sources might include:

  1. Medicaid, including waiver funding (Title XIX);
  2. Private health insurance;
  3. State or federal funds for child care, education, or for Children with Special Health Care Needs (Title V);
  4. IDEA (particularly Part C funding);
  5. Community resources (e.g., volunteers, lending libraries, and free equipment available from community-based organizations);
  6. Tax incentives (credits and deductions are available under federal law to most for-profit child care programs).

Section 504 is a civil rights law, and protects children from discrimination. It provides for supports and accommodations so a child can access the curriculum. In order to qualify for supports, a child must have a physical or mental impairment that substantially limits at least one major life activity such as walking, hearing, seeing, breathing, learning, reading, writing, etc. Section 504 requires an evaluation from multiple sources. There is no federally mandated plan, nor do parents/guardians have to be involved in the creation of the plan. We know from best practice, however, that parents/guardians should be active participants in plans to care for their children. Section 504 provides for accommodations during testing and for accessibility. It does not provide for the individual plans and protections that are provided under IDEA. For more information, go to http://www.wrightslaw
.com.

Another resource for parents/guardians and caregivers/teachers are the Protection and Advocacy Centers funded by the federal government to protect rights of persons with disabilities.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
8.2.0.2 Planning for Inclusion

Standard 8.2.0.2: Planning for Inclusion

Inclusion and participation of children with special health care needs requires proactive planning. The facility must plan for the resources, support, and education necessary to increase the understanding and knowledge of staff, but also of parents/guardians, and the children without disabilities within the facility. Planning to include children with disabilities and with special health care needs requires time, resources, support and education. Every effort should be made to plan fully to include children with disabilities and children with special health care needs to maximize success. In planning for the inclusion of children with disabilities and children with special health care needs, safety considerations should be an additional factor considered.

RATIONALE
Inclusion without adequate preparation, understanding, training, mobilization of resources, and development of skills among all those involved, may lead to failure.
COMMENTS
Available resources include, but are not limited to: brochures, books, guest speakers, advice from parents/guardians of children with special health care needs, expert consultation from child care health consultants, and utilization of child care health consultants. Methods may vary according to need and availability and, specific to educating children without disabilities in the facility, using age-appropriate resources is particularly important. Communication between child care, parents/guardians, and primary care providers (with written parental/guardian permission) helps facilitate a smooth inclusion process. The facility should provide opportunities to discuss the similarities as well as the differences among all the children enrolled. Professionals or knowledgeable parents/guardians who facilitate such discussions should assure that caregivers and typically developing children in the facility receive presentations and participate in discussions about the special equipment that the children with special needs may require, and that they understand other differences, such as a prescribed diet or limitations of activity. Children without disabilities or special health care needs should be given the opportunity to explore and learn about these differences. Caregivers/teachers should take special care to demonstrate cultural competency, confidentiality, respect for privacy, and be generally sensitive in all communications with parents/guardians and when discussing the child and the family, particularly in discussion of an inherited condition.
TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 8.3.0.1: Initial Assessment of the Child to Determine His or Her Special Needs

Children with disabilities and children with special health care needs and their families and caregivers/teachers should have access to and be encouraged to receive a multidisciplinary, interdisciplinary, or transdisciplinary assessment by qualified health providers before the child starts in the facility. This information needs to be shared, with the parents/guardians’ consent and agreement to disclose information if it is relevant to the health and safety concerns in the child care setting. If the parents/guardians consent to disclose the information and if the information is relevant to health and safety concerns in the child care setting, this evaluation should consist of the following:

  1. A medical care plan developed by the child’s primary care provider/medical home;
  2. Results of medical and developmental examinations;
  3. Assessments of the child’s behavior, cognitive functioning, or current overall adaptive functioning;
  4. Evaluations of the family’s needs, cultural and linguistic differences, concerns, and priorities;
  5. Other evaluations as needed.

The multidisciplinary, interdisciplinary, or transdisciplinary assessment should also consider a family’s needs, cultural and linguistic differences, priorities, and resources as the team develops recommendations for interventions. Such recommendations should be focused on optimizing the child’s development, health, and safety.

RATIONALE
The definitive characteristic of services for children and their families is the necessity of individualizing their care to meet their needs. Therefore, individual assessments must precede services.

The family’s needs, values, and childrearing practices are highly relevant and respected in the provision of care to the child; however, the child’s special needs continue to be the central focus of intervention.

COMMENTS
This comprehensive assessment would be done largely by an outside center, clinic, school district, or professionals who conduct evaluations of this nature. The multi-disciplinary, interdisciplinary or transdisciplinary assessment must be administered by qualified individuals using reliable and valid age and culturally and linguistically appropriate instruments and methodologies. For young children with disabilities, the designated lead agency for Part C would be responsible for conducting the initial evaluation. Under Part B (three- through five-year-olds), the school district is responsible for conducting the initial evaluation. This evaluation forms the basis of planning for the child’s needs in the child care setting and for the pertinent information available to the staff. The comprehensive assessment should be used to develop a written plan for the child’s caregivers/teachers that they believe they can implement. Relevant medical information will form the basis of the health care plan for the child in the program. This may need to be created with help of parents/guardians, child care health consultants, and medical providers.

The facility should pursue the many funding mechanisms available to supplement funding for services in the facility. Even so, caregivers/teachers can and should discuss these options with the parents/guardians as potential sources of financial assistance for the needed services. These sources might include:

  1. Medicaid, including waiver funding (Title XIX);
  2. Private health insurance and state-subsidized private health insurance under programs such as SCHIP;
  3. State or federal funds for child care, education, or for Children with Special Health Care Needs (Title V);
  4. Individuals with Disabilities Education Improvement Act (IDEA) (particularly Part C funding);
  5. Tax incentives (credits and deductions are available under federal law to most for-profit child care programs).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.5.0.1 Care Plan for Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs
Appendix O: Care Plan for Children with Special Health Care Needs

Standard 8.4.0.1: Determining the Type and Frequency of Services

The parents/guardians of a child with a disability or a child with special health care needs, the child’s primary care provider, any authorized service coordinator, any provider of intervention services, and the caregiver/teacher should discuss and determine the type and frequency of the services to be provided within the child care facility.

RATIONALE
To serve children with varying forms and severities of disabilities or special health care needs, caregivers/teachers should take a flexible approach to combine and deliver services. Parents/guardians must be involved to assure that the plan is compatible with their care and expectations for the child.
COMMENTS
In facilities that are not designed primarily to serve a population with disabilities or special health care needs, the additional therapeutic services may be obtained through consultants or arrangements with outside programs serving children with disabilities or children with special health care needs. These services may be available, as arranged, through the Individualized Family Service Plan (IFSP) or the Individualized Education Program (IEP) or through special health personnel such as RNs or LPNs under RN supervision. Most States have a case manager for Developmental Disabilities Services under a Medicaid Waiver for DD/MR children. The caregiver/teacher may become a member of the IFSP or IEP team if the parents/guardians of a child with disabilities so request.

When there is an IFSP, IDEA requires the appointment of an authorized service coordinator.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.5.0.1 Care Plan for Children with Special Health Care Needs
8.4.0.4 Designation and Role of Staff Person Responsible for Coordinating Care in the Child Care Facility

Standard 8.4.0.2: Formulation of an Action Plan

The formulation of a plan on how to best meet the child’s needs should be based on the assessment process specified in Standards 8.3.0.1 and 8.4.0.1 and by the child’s medical care plan which is created by the child’s primary care provider in collaboration with the child care health consultant and family. Such a plan should be written, reviewed with the parents/guardians and should be maintained as part of each child’s confidential record.

RATIONALE
The plan may be developed and implemented after the parents/guardians have discussed and approved it. The facility should keep the plan as a permanent part of the child’s confidential record.
COMMENTS
All issues and questions should be dealt with during the discussion with families; consensus should be obtained and the plan written accordingly. Parents/guardians should provide written consent for the agreement to any plan before implementation for the child. Parents/guardians may revoke their consent at any time by written notice. This is standard procedure in the implementation of the Individuals with Disabilities Education Act (IDEA) for those child care programs involved with the Individualized Education Program (IEP) and the Individualized Family Service Plan (IFSP). All release of information must be in accordance with IDEA, as well as state regulations.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.5.0.1 Care Plan for Children with Special Health Care Needs
8.4.0.4 Designation and Role of Staff Person Responsible for Coordinating Care in the Child Care Facility
Appendix O: Care Plan for Children with Special Health Care Needs

Standard 8.4.0.3: Determination of Eligibility for Special Services

The Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP) and any other plans for special services should be developed for children identified as eligible in collaboration with the family, representatives from disciplines and organizations involved with the child and family, the child’s primary care provider, and the staff of the facility, depending on the family’s wishes, the agency’s resources, and state laws and regulations.

RATIONALE
For the IFSP, IEP, or any other needed or required special service plan to provide systematic guidance of the child’s developmental achievement and to promote efficient service delivery, service providers from all of the involved disciplines/settings must be familiar with the overall multidisciplinary or interdisciplinary plans and work toward the same goals for the child. To be optimally effective, one comprehensive IFSP or IEP is developed and one service or care coordinator is designated to oversee implementation of the plan. If the parents/guardians choose to involve them, the caregivers/teachers should be partners in developing and implementing the IFSP or IEP to obtain the best possible evaluation and plan for the child with a disability within the child care facility.
COMMENTS
Development and implementation of the IFSP or IEP is a team effort. The various aspects of planning include the input of the child care program in which the child is enrolled in the evaluation for eligibility for Part B or C, the development of IFSP/IEP, and the child care program’s role in implementation. Components of the IFSP or IEP may include elements developed to meet service needs developed elsewhere, when applicable in the child care setting.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs
8.5.0.1 Coordinating and Documenting Services

Standard 8.4.0.4: Designation and Role of Staff Person Responsible for Coordinating Care in the Child Care Facility

If a child has an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP), or any plan for medical services, the child care facility should designate one person in the child care setting to be responsible for coordinating care within the facility and with any caregiver/teacher or coordinator in other service settings, in accordance with the written plan. The role of the designated person should include:

  1. Documentation of coordination;
  2. Written or electronic communication with other care or service providers for the child, including their medical home, to ensure a coordinated, coherent service plan;
  3. Sharing information about the plan, staff conferences, written reports, consultations, and other services provided to the child and family (informed, written parental/guardian consent must be sought before sharing this confidential information);
  4. Ensuring implementation of the components of the plan that is relevant to the facility.

When the evaluators who are to determine if the child has special health care needs or is eligible for services under the Individuals with Disabilities Education Improvement Act (IDEA 2004) are not part of the child care staff, the lead agency should develop a formal mechanism for coordinating reevaluations and program revisions. The designated staff member from the facility should routinely be included in the evaluation process and team conferences. Any care plan should be updated whenever the child is hospitalized or has a significant change in therapy.

RATIONALE
One person being responsible for coordinating all elements of services avoids confusion and allows easier and more consistent communication with the family. When carrying out coordination duties, this person is called a child care coordinator or service coordinator. Each child should have a care coordinator/service coordinator assigned in the child care facility at the time the service plan is developed.

With more than half of all mothers in the workforce, caregivers other than the parents/guardians (such as teachers, grandparents, foster parents, or neighbors) frequently spend considerable time with the children. These caregivers/teachers need to know and understand the aims and goals of the service plan; otherwise, program approaches will not carry over into the home environment.

This requirement does not preclude outside agencies or caregivers/teachers from having their own care coordinator, service coordinator, or case manager. The intent is to ensure communication and coordination among all the child’s sources of care, both in the facility and elsewhere in the community. The child’s care coordinator or service coordinator does not have responsibility for directly implementing all program components but, rather, is accountable for checking to make sure the plans in the facility are being carried out, encouraging implementation of the service plan, and helping obtain or gain access to services.

A facility assuming responsibility for serving children with disabilities or children with special health care needs must develop mechanisms for identifying the needs of the children and families and obtaining appropriate services, whether or not those children have an IEP/IFSP. The child care coordinator will be responsible for coordination of health services with the program child care health consultant, as needed.

COMMENTS
Usually, the person who coordinates care or services within the child care facility will not be the person assigned to coordinate overall care or provide overall case management for the child and family. Nevertheless, the facility may assume both roles if the parents/guardians so request and state law permits. The components and the role may vary, and each facility will determine these components and roles, which may depend on the roles and responsibilities of the staff in the facility and the responsibilities assumed by the family and care providers in the community. The person who coordinates care or services within the child care facility may be the Health Advocate or someone else who is working closely with the child’s family and the teaching staff in the facility.
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
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs

Standard 8.4.0.5: Development of Measurable Objectives

The individualized service or treatment plan for a child with disabilities or a child with special health care needs should include services aimed at enhancing and improving the child’s health and developmental functioning, based on measurable, functional outcomes agreed to by the parents/guardians. Each functional outcome objective should delineate the services, along with the designated responsibility for provision and financing. The development of the plan and its goals and objectives should not only include the child care agency staff, but all of the professionals, including various therapists and/or consultants, who will have the responsibility to assure its implementation.

With the assistance of the child’s service coordinator, the caregiver/teacher should contribute to the assessment of measurable outcome objectives (service plan) within the child care setting at least every three months, or more often if the child’s or family’s circumstances change, and should contribute to a full, documented case review each year. Reevaluations should consider a self-assessment by the caregiver/teacher of the caregiver’s competence to provide services that the child requires.

Service reviews should involve the child care staff or persons providing the intervention and supervision, the parents/guardians, and any independent observers. The results of such evaluations should be documented in a written plan given to each of the child’s caregivers/teachers and the child’s family. Such conferences and lists of participants should be documented in the child’s health record at the facility.

Each objective should include persons responsible for its monitoring.

RATIONALE
When measurable-outcome objectives form the basis for the service plan, the family and service providers jointly formulate the expected and desired outcomes for the child and family. By using measurable-outcome objectives rather than service units, all interested parties can concentrate on how well the child is achieving the outcome objectives. Thus, for example, progress toward speech and language development assumes more importance than the number of hours of speech and language therapy provided.

Further, measurable outcome objectives constitute an individualized approach to meeting the needs of the child and family and, as such, can be integrated into, but are not solely dependent upon, the array of services available in a specific geographic area. The measurable-outcome objectives will provide the facility with a meaningful framework for enhancing the child’s health and developmental status on an ongoing basis.

Regularly scheduled reassessments of the outcome objectives provide the family and service providers with a framework for anticipating changes in the kind of services that may be needed, the financial requirements for providing the services, and identification of the appropriate service provider. The changing needs of children with disabilities and/or special health care needs do not always follow a predictable course. Ad hoc reevaluations may be necessitated by changes in circumstances.

COMMENTS
The defining of measurable objectives provides a useful structure for the caregiver/teacher and aids in assessing the child’s progress and the appropriateness of components of the service plan. Though this principle should apply to all children in all settings, implementation, especially in small and large family child care homes, will require ongoing assistance from and participation of specialists, including those connected with programs outside of the child care setting, to provide the needed services.

Many facilities that provide intervention services review the child’s progress at least every three months. This is not a comprehensive review, but an interim analysis of the progress toward meeting objectives and to decide if any modifications are needed in the service plan and its implementation. Generally, the entire plan and the child’s progress receive a comprehensive review annually. It is likely that caregivers/teachers will need training on development of goals and the means of assessing progress.

It is assumed that staff members who interact with the child will have the training described in Pre-service Qualifications and Special Training, Standards 1.3.1.1-1.3.3.1, and Training, Standards 1.4.2.1-1.4.6.2, which includes child growth and development. These topics are intended to extend caregivers’/teachers’ basic knowledge and skills to help them work more effectively with children who have disabilities or children who have special health care needs and their families. Caregivers/teachers should have a basic knowledge of what constitutes a disability or special health care need, supplemented by specialized training for children with disabilities and children with special health care needs. The number of hours offered in any in-service training program should be determined by the experience and professional background of the staff.

Training and other technical assistance can be obtained from the following sources:

  1. American Academy of Pediatrics (AAP);
  2. American Nurses Association (ANA);
  3. National Association for the Education of Young Children (NAEYC) and its local chapters;
  4. National Association of Pediatric Nurse Practitioners (NAPNAP) Child Care Special Interest Group;
  5. National Association of School Nurses (NASN);
  6. State and community nursing associations;
  7. National therapy associations (e.g., National Rehabilitation Association, Association for Behavioral and Cognitive Therapies);
  8. National Association of Child Care Resource and Referral Agencies (NACCRRA) and its local resource and referral agencies;
  9. Federally funded University Centers for Excellence in Developmental Disabilities Education, Research, and Service (UCEDD);
  10. Local children’s hospitals;
  11. Other colleges and universities with expertise in training people to work with children who have special needs;
  12. Community-based organizations serving people with disabilities and/or special health care needs (e.g., Autism Society of America, United Cerebral Palsy Associations, The ARC, Easter Seals, American Diabetes Association, American Lung Association, Epilepsy Foundation, etc.);
  13. Zero to Three Policy Network.

The state-designated lead agency responsible for implementing IDEA may provide additional help. If the child has an IFSP, the lead agency will be responsible for coordinating the review process. If the child has an IEP, the local education agency will be responsible for seeing that the review occurs. If not, a less formal evaluation process may need to be conducted.

Assessments may be the financial responsibility of the IDEA Part C State-designated lead agency or other organizations (see Standard 8.4.0.6). Funding available through implementation of IDEA Part C should provide resources to assist in implementing the IFSP.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
8.4.0.2 Formulation of an Action Plan
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs
9.4.2.1 Contents of Child’s Records

Standard 8.4.0.6: Contracts and Reimbursement

If a child with a disability and/or special health care needs has an Individualized Family Service Plan (IFSP), the lead agency may arrange and contract for specialized services to be conducted in the child care facility in addition to the child’s home and other natural environments. If a child with disabilities or special health care needs has an Individualized Education Program (IEP), the local education agency may arrange and contract for specialized services to be conducted in the child care facility.

If the child or the specialized service or intervention is not covered by IEP/IFSP:

  1. The caregiver/teacher should cover the cost when the service is reasonable and necessary for the child to participate in the program;
  2. The parents/guardians or source arranged by the parents/guardians should cover the cost when the service is not a reasonable expectation of the caregiver/teacher or if it is provided while the child is in child care only for convenience and is separately billable (such as speech and language therapy).

RATIONALE
Child care facilities may have to collaborate with other service providers to meet the needs of a child and family, particularly if the number of children who require these services is too few to maintain the service onsite. To achieve maximum benefit from services, those services should be provided in the setting that is the most natural and convenient for the child and family. Whenever possible, treatment specialists (therapists) should provide these services in the facility where the child receives daytime care.

“Reasonableness” is a legal standard that looks at the impact of cost and other factors.

COMMENTS
The agency that has evaluated the child and/or is planning the entire service plan, or the facility, should make the arrangements. The specific methods by which these services will be coordinated with the child care facility is determined locally.

The facility should pursue the many funding mechanisms available to supplement funding for services in the facility. Even so, caregivers/teachers can and should discuss these options with the parents/guardians as potential sources of financial assistance for the needed accommodations. These sources might include:

  1. Medicaid, including waiver funding (Title XIX);
  2. Private health insurance, publicly subsidized private health insurance such as under the state child health insurance program (SCHIP);
  3. State or federal funds for child care, education, or for children with special health care needs (Title V);
  4. Individuals with Disabilities Education Improvement Act (IDEA) (particularly Part C funding);
  5. Community resources (such as volunteers, lending libraries, and free equipment available from community-based organizations);
  6. Tax incentives (credit and deductions are available under federal law to most for profit child care programs);
  7. Local Community Development Block Grants (CDBG) and other community development funding.
TYPE OF FACILITY
Center
RELATED STANDARDS
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs

Standard 8.5.0.1: Coordinating and Documenting Services

Services for all children should be coordinated in a systematic manner so the facility can document all of the services the child is receiving inside of the facility and is aware of the services the child is receiving outside of the facility. If the parents/guardians of a child with disabilities or a child with special health care needs so choose, the facility should be an integral component of the child’s overall service plan.

RATIONALE
Coordination of individualized services is a fundamental component in implementing a plan for care of a child with special health care needs. This is particularly true of the need to coordinate the overall child care with specialized developmental services, therapies, and child care procedures in the facility.
COMMENTS
Children with Individualized Family Service Plans (IFSP) have a service coordinator; children with Individualized Education Programs (IEP) have a primary provider or other identified service coordinator. These are the contact persons within the local education agency or lead agency. This method of service coordination is consistent throughout all of the states under the Individuals with Disabilities Education Improvement Act (IDEA). Caregivers/teachers need to become informed of how this system works and what their responsibilities are.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
8.4.0.4 Designation and Role of Staff Person Responsible for Coordinating Care in the Child Care Facility

Standard 8.5.0.2: Written Reports on IFSPs/IEPs to Caregivers/Teachers

With the prior written, informed consent of the parents/guardians in the parents/guardians’ native language, child care facilities may obtain written reports on Individualized Family Service Plans (IFSPs) or Individualized Education Programs (IEPs), conferences, and treatments provided.

RATIONALE
This information is confidential and parental/guardian consent for release is required if the child care facility is to gain access to it. Written documentation ensures better accountability.
TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 8.6.0.1: Reevaluation Process

The facility care coordinator should ensure that formal reevaluations of the child’s functioning and health care needs in the child care setting and the family’s needs are conducted at least yearly, or as often as is necessary to deal with changes in the child’s or family’s circumstances. Medical care plans should be reviewed and revised if needed whenever there is a significant health event such as a hospitalization, or at least annually. This reevaluation should include the parents/guardians and caregiver/teacher. Such conferences and lists of participants should be documented in the child’s health record at the facility.

RATIONALE
The changing needs of children with disabilities and children with special health care needs do not follow a predictable course. A periodic, thorough process of reevaluation is essential to identify appropriate goals and services for the child. The child’s primary care provider or medical home and the program’s child care health consultant should be involved in the development and reevaluation of the plan. A child’s health is such an integral part of his or her availability to learn and to retain learned information that health- and development-related information is critical for a complete review/reevaluation process to occur.
COMMENTS
Though regular intervention services are recommended for review at three-month intervals, ad hoc reevaluations may be necessitated by changes in circumstances.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
8.4.0.5 Development of Measurable Objectives

Standard 8.6.0.2: Statement of Program Needs and Plans

Each reevaluation conference should result in a new statement of program needs and plans which parents/guardians have agreed to and support.

RATIONALE
Continued collaboration, participation, and coordination among all involved parties are essential.
TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 8.7.0.1: Facility Self-Assessment

Facilities that serve children with special health care needs and children with disabilities eligible for services under IDEA 2004 should have a written self-assessment developed in consultation with an expert multi-disciplinary team of professionals experienced in the care and education of children with disabilities and children with special health care needs. These self-assessments should be used to create a plan for the facility to determine how it may become more accessible and ready to care for children with disabilities and children with special health care needs. The facility should review and update the plan at least every two years, unless a caregiver requests a revision at an earlier date.

RATIONALE
A self-assessment stimulates thought about the caregiver’s/teacher’s present capabilities and attitudes and the medical and educational particulars of a range of special health care needs and disabilities. Also, parents/guardians will have the opportunity to review the records of the written self-assessment and decide whether a facility is well-prepared to handle children with, for example, developmental delays, cognitive disabilities, or hearing impairment but is not able to offer proper care to a child with more complex medical needs.
COMMENTS
Under both the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, a program must make reasonable accommodations in order to serve a child with disabilities and/or special health care needs. Often, if architectural or other major changes are made to accommodate a particular child with physical or other disability, many other children and adults are helped by the changes. An important source of information for self-assessment is interviewing the parents/guardians of children with disabilities and/or special health care needs to see how well the program is working for their family and what could be improved. “Reasonableness” is a legal standard that looks at cost and other ADA criteria. Section 504 applies to recipients of federal funds. The ADA extends coverage to private entities that do not receive federal funds.

Parents/guardians have the right to choose which child care program will care for their child. Self-assessment should be done to evaluate what the program needs to do to be more inclusive by developing staff capability and program activities to accommodate the child’s needs.

SpeciaLink: The National Centre for Child Care Inclusion, at the University of Winnipeg (http://www.specialinkcanada.org) has developed an inclusion scale much like ECERS to determine how well a program is providing inclusive care.

TYPE OF FACILITY
Center, Large Family Child Care Home

Standard 8.7.0.2: Technical Assistance in Developing Plan

The caregiver/teacher should seek technical assistance in developing and formulating the plan for future services for children with special health care needs.

RATIONALE
Assistance is needed where caregivers/teachers lack specific capabilities.
COMMENTS
Documentation of the caregiver’s/teacher’s request and of the regulating agencies’ responses in offering or providing assistance furnishes evidence of compliance. State regulatory agencies should be in a position to provide such assistance to facilities.

Training and other technical assistance sources can be obtained from or arranged by the following:

  1. Child’s primary care provider;
  2. Program’s child care health consultant;
  3. Local children’s hospital;
  4. American Academy of Pediatrics (AAP);
  5. National Association of Pediatric Nurse Practitioners (NAPNAP);
  6. American Nurses Association (ANA);
  7. National Association of School Nurses (NASN);
  8. State and community nursing associations;
  9. National therapy associations (e.g., National Rehabilitation Association, Association for Behavioral and Cognitive Therapies);
  10. Local resource and referral agencies;
  11. Federally funded University Centers for Excellence in Developmental Disabilities Education, Research, and Service (UCEDD);
  12. Other colleges and universities with expertise in training others to work with children who have special health care needs;
  13. Community-based organizations serving people with disabilities and/or special health care needs (e.g., Autism Society of America, United Cerebral Palsy Associations, ARC, Easter Seals, American Diabetes Association, American Lung Association, Epilepsy Foundation, etc.);
  14. ADA regional technical assistance offices.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs

Standard 8.7.0.3: Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs

The facility’s plan for serving children with or children with special health care needs should be reviewed at least annually to see if it is in compliance with the legal requirements of the Individuals with Disabilities Education Improvement Act (IDEA 2004) and Americans with Disabilities Act (ADA), as well as Section 504 of the Rehabilitation Act of 1973 (if it receives federal funding and is achieving the overall objectives for the agency or facility).

RATIONALE
An annual review by caregivers/teachers is a cornerstone of any quality assurance procedure.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.5.0.1 Care Plan for Children with Special Health Care Needs
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs

IX. 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 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/Teachers

At enrollment, and before assumption of supervision of children by caregivers/teachers at the facility, the facility should provide parents/guardians and caregivers/teachers with a statement of services, policies, and procedures, including, but not limited, to the following:

  1. The licensed capacity, child:staff ratios, ages and number of children in care. If names of children and parents/guardians are made available, parental/guardian permission for any release to others should be obtained;
  2. Services offered to children including a written daily activity plan, sleep positioning policies and arrangements, napping routines, guidance and discipline policies, diaper changing and toilet learning/training methods, child handwashing, medication administration policies, oral health, physical activity, health education, and willingness for special health or therapy services delivered at the program (special requirements for a child should be clearly defined in writing before enrollment);
  3. Hours and days of operation;
  4. 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;
  5. Payment of fees, deposits, and refunds;
  6. Methods and schedules for conferences or other methods of communication between parents/guardians and staff.

Policies on:

  1. Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
  2. Inclusion of children with special health care needs;
  3. Nondiscrimination;
  4. Termination and parent/guardian notification of termination;
  5. Supervision;
  6. Discipline;
  7. Care of children and caregivers/teachers who are ill;
  8. Temporary exclusion and alternative care for children who are ill;
  9. Health assessments and immunizations;
  10. Handling urgent medical care or threatening incidents;
  11. Medication administration;
  12. Use of child care health consultants, education and mental health consultants;
  13. Plan for health promotion and prevention (tracking routine child health care, health consultation, health education for children/staff/families, oral health, sun safety, safety surveillance, etc.);
  14. Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
  15. Security;
  16. Confidentiality of records;
  17. Transportation and field trips;
  18. Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
  19. Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
  20. Sanitation and hygiene;
  21. Presence and care of any animals on the premises;
  22. Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
  23. Evening and night care plan;
  24. Smoking, tobacco use, alcohol, prohibited substances, and firearms;
  25. Preventing and reporting child abuse and neglect;
  26. Use of pesticides and other potentially toxic substances in or around the facility.

Parents/guardians and caregivers/teachers should sign that they have reviewed and accepted this statement of services, policies, and procedures. Policies, plans and procedures should generally be reviewed annually or when any changes are made.

RATIONALE
Model Child Care Health Policies, available at http://www.ecels-healthychildcarepa.org/content/MHP4thEd Total.pdf, has text to comply with many of the topics covered in this standard. Each policy has a place for the facility to fill in blanks to customize the policies for a specific site. The text of the policies can be edited to match individual program operations. Starting with a template such as the one in Model Child Care Health Policies can be helpful.
COMMENTS
For large and small family child care homes, a written statement of services, policies, and procedures is strongly recommended and should be added to the “Parent Handbook.” Conflict over policies can lead to termination of services and inconsistency in the child’s care arrangements. If the statement is provided orally, parents/guardians should sign a statement attesting to their acceptance of the statement of services, policies and procedures presented to them. Model Child Care Health Policies can be adapted to these smaller settings.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.6.0.1 Child Care Health Consultants
2.1.1.1 Written Daily Activity Program and Statement of Principles
2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.1.1.5 Helping Families Cope with Separation
2.1.1.9 Verbal Interaction
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.2.5 Toilet Learning/Training
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.2.0.3 Screen Time/Digital Media Use
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
2.2.0.10 Using Physical Restraint
2.4.2.1 Health and Safety Education Topics for Staff
2.4.3.2 Parent/Guardian Education Plan
3.1.3.2 Playing Outdoors
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.3 Care for Animals
3.4.3.1 Emergency Procedures
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.2.9 Information Required for Children Who Are Ill
3.6.3.1 Medication Administration
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
6.5.1.1 Competence and Training of Transportation Staff
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
9.2.1.1 Content of Policies
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
3.1.1.1 Conduct of Daily Health Check
3.1.1.2 Documentation of the Daily Health Check
3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.3.1 Active Opportunities for Physical Activity
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
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
3.2.1.4 Diaper Changing Procedure
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
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib Surfaces
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.2.2 Prohibited Animals
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
3.6.2.1 Exclusion and Alternative Care for Children Who Are Ill
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
3.6.3.2 Labeling, Storage, and Disposal of Medications
4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.6.0.1 Selection and Preparation of Food Brought From Home
4.6.0.2 Nutritional Quality of Food Brought From Home
9.2.3.2 Content and Development of the Plan for Care of Children and Staff Who Are Ill
9.2.3.9 Written Policy on Use of Medications
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
9.2.3.13 Plans for Evening and Nighttime Child Care
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
9.2.3.16 Policy Prohibiting Firearms
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
9.2.4.3 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
9.2.4.6 Use of Daily Roster During Evacuation Drills
9.2.4.7 Sign-In/Sign-Out System
9.2.4.8 Authorized Persons to Pick Up Child
9.2.4.9 Policy on Actions to Be Followed When No Authorized Person Arrives to Pick Up a Child
9.2.4.10 Documentation of Drop-Off, Pick-Up, Daily Attendance of Child, and Parent/Provider Communication
9.4.1.3 Written Policy on Confidentiality of Records
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.1.1.7 Communication in Native Language Other Than English
2.1.1.8 Diversity in Enrollment and Curriculum
2.1.2.2 Interactions with Infants and Toddlers
2.1.2.3 Space and Activity to Support Learning of Infants and Toddlers
2.1.2.4 Separation of Infants and Toddlers from Older Children
2.1.3.2 Opportunities for Learning for Three- to Five-Year-Olds
2.1.3.3 Selection of Equipment for Three- to Five-Year-Olds
2.1.3.4 Expressive Activities for Three- to Five-Year-Olds
2.1.3.5 Fostering Cooperation of Three- to Five-Year-Olds
2.1.3.6 Fostering Language Development of Three- to Five-Year-Olds
2.1.3.7 Body Mastery for Three- to Five-Year-Olds
2.1.4.1 Supervised School-Age Activities
2.1.4.2 Space for School-Age Activity
2.1.4.3 Developing Relationships for School-Age Children
2.1.4.4 Planning Activities for School-Age Children
2.1.4.5 Community Outreach for School-Age Children
2.1.4.6 Communication Between Child Care and School
2.2.0.1 Methods of Supervision of Children
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
2.2.0.4 Supervision Near Bodies of Water
2.2.0.5 Behavior Around a Pool
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
2.4.1.3 Gender and Body Awareness
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians
6.4.2.2 Helmets
6.4.2.3 Bike Routes

Standard 9.2.1.5: Nondiscriminatory Policy

The facility’s written admission policy should be nondiscriminatory in regard to race, culture, sex, religion, national origin, ancestry, sexual preference, or disability. A copy of the policy and definitions of eligibility should be available for review on demand.

RATIONALE
Nondiscriminatory policies advocate for quality child care services for all children regardless of the child’s citizenship, residency status, financial resources, and language differences (1).
COMMENTS
Facilities should be able to accommodate all children except those whose needs require extreme modifications beyond the capability of the facility’s resources. Facilities should not have blanket policies against admitting children with disabilities. Instead, a facility should make an individual assessment of a child’s needs and the facility’s ability to meet those needs. Federal laws (e.g., Americans with Disabilities Act) do not permit discrimination based on disability. Inclusion of children with special health care needs and disabilities in all child care and early childhood educational programs is strongly encouraged.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Department of Justice, Civil Rights Division, Disability Rights Section. 1997. Commonly asked questions about child care centers and the Americans with Disabilities Act. http://www.ada.gov/childq%26a.htm.

Standard 9.2.1.6: Written Discipline Policies

Each facility should have a written discipline policy reflective of the positive methods of guidance appropriate to the ages of the children enrolled outlined in Standard 2.2.0.6 and prohibited caregiver behaviors as outlined in Standard 2.2.0.9.

The facility should have policies for dealing with biting, hitting, and other undesired behavior by children and written protocol reflective guidance outlined in Standard 2.2.0.7.

Policies should explicitly prohibit corporal punishment, psychological abuse, humiliation, abusive language, binding or tying to restrict movement, restriction of access to large motor physical activities, and the withdrawal or forcing of food and other basic needs.

All caregivers/teachers should sign an agreement to implement the facility’s discipline policies. A policy explicitly stating the consequence for staff who do not follow the discipline policies should be reviewed and signed by each staff member prior to hiring.

RATIONALE
Caregivers/teachers are more likely to avoid abusive practices if they are well-informed about effective, non-abusive methods for managing children’s behaviors. Positive methods of discipline create a constructive and supportive social group and reduce incidents of aggression.

Corporal punishment may be physical abuse or may become abusive very easily. Research links corporal punishment with negative effects such as later criminal behavior and impairment of learning (1-3). Primary factors supporting the prohibition of certain methods of punishment include current child development theory and practice, legal aspects (namely that a caregiver/teacher is not acting in place of parents/guardians with regard to the child), and increasing liability suits. According to the NARA 2008 Child Care Licensing Study, forty-eight states prohibit corporal punishment in centers; forty-three of forty-four states that license small family child care homes prohibit corporal punishment and only one state does not prohibit corporal punishment in large family child care homes (4).

COMMENTS
Parents/guardians should be encouraged to utilize similar positive discipline methods at home in order to encourage these practices and to provide a more consistent discipline approach for the child.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
REFERENCES
  1. American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in the schools. Pediatrics 106:343.
  2. Education Commission of the States. 1999. Collection of clearinghouse notes, 1998-1999. Denver, CO: ECS.
  3. Paintal, S. 1999. Banning corporal punishment of children: A position paper. Child Educ 76:36-39.

Standard 9.2.2.1: Planning for Child’s Transition to New Services

If a parent/guardian requests assistance with the transition process from the facility to a public school or another program, the designated care or service coordinator at the facility should review the child’s records, including needs, learning style, supports, progress, and recommendations. The designated care or service coordinator should obtain written informed consent from the parent/guardian prior to sharing information at a transition meeting, in a written summary, or in some other verbal or written format.

The process for the child’s departure should also involve sharing and the exchange of progress reports with other care providers for the child and the parents/guardians of the child within the realm of confidentiality guidelines.

Any special health care need of the child and successful strategies that have been employed while at child care should be shared. For children who are receiving services under Part C of IDEA 2004, a transition plan is required, usually at least ninety days prior to the time that the child will leave the facility or program.

In the case of a child who may be eligible for preschool services, with approval of the family of the child, a conference should be convened among the lead agency, the family, and the local educational agency not less than ninety days (and at the discretion of all such parties, not more than nine months) before the child is eligible for the preschool services, to discuss any such services that the child may receive. In the case of a child who may not be eligible for such preschool services, with the approval of the family, reasonable efforts should be made to convene a conference among the lead agency, the family, and providers of other appropriate services, to discuss the appropriate services that the child may receive; to review the child’s program options; for the period from the child’s third birthday through the remainder of the school year; and to establish a transition plan, including as appropriate, steps to exit from the program. A plan also requires description of efforts to promote collaboration among Early Head Start programs under section 645A of the Head Start Act, early education and child care programs.

The facility should determine in what form and for how long archival records of transitioned children should be maintained by the facility.

RATIONALE
All children and their families will experience one or more program transitions during early childhood. One of the most common transitions is from preschool to kindergarten. Families in transition benefit when support and advocacy are available from a facility representative who is aware of their needs and of the community’s resources (1). This process is essential in planning the child’s departure or transition to another program. Information regarding successful behavior strategies, motivational strategies, and similar information may be helpful to staff in the setting to which the child is transitioning.
COMMENTS
Some families are capable of advocating effectively for themselves and their children; others require help negotiating the system outside of the facility. An interdisciplinary process is encouraged. Though coordinating and evaluating health and therapeutic services for children with special health care needs is primarily the responsibility of the school district or regional center, staff from the child care facility (one of many service providers) should participate, as staff members have had a unique opportunity to observe the child. In small and large family child care homes where an interdisciplinary team is not present, the caregivers/teachers should participate in the planning and preparation along with other care or treatment providers, with parent/guardian written consent.

It is important for all providers of care to coordinate their activities and referrals; otherwise the family may not be well informed. If records are shared electronically, providers should ensure that the records are encrypted for security and confidentiality.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.2.2 Format for the Transition Plan
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians
REFERENCES
  1. Harbin, G., B. Rous, N. Peeler, J. Schuster, K. McCormick. 2007. Research brief: Desired family outcomes of the early childhood transition process. http://community.fpg.unc.edu/connect/

Standard 9.2.2.2: Format for the Transition Plan

Each service agency or primary care provider should have a format and timeline for the process of developing a transition plan for children with special health care needs to be followed when each child leaves the facility. The plan should include the following components:

  1. Review and final preparation of the child’s records;
  2. A child and family needs assessment;
  3. Identification of potential child care, educational, or programmatic arrangements;
  4. Summary of any special health care needs and successful strategies that were employed in child care.

RATIONALE
Many factors contribute to the success or failure of a transition. These concerns can be monitored effectively when a written plan is developed and followed to ensure that all steps in a transition are included and are undertaken in a timely, responsive manner (1).
COMMENTS
Though the child care provider can and should offer support in this process, child care is a free-market system where the parent/guardian is the consumer and decision-maker.

It is best if the process of planning begins at least nine months prior to the child turning three and an anticipated transition, since finding the proper facility for a child can be a complex and time consuming process in some communities. Each state is required to develop transition guidelines that implement the federal guidelines in respect to timelines, procedural due process expectations, and the required representation at the various meetings. Each agency can adapt the format to its own needs. However, consistent formats for planning and information exchange, requiring written parental/guardian consent, would be useful to both caregivers/teachers and families in both localities when children with special health care needs are involved. The use of outside consultants for small and large family child care homes is especially important in meeting this type of standard.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.2.1 Planning for Child’s Transition to New Services
REFERENCES
  1. Harbin, G., B. Rous, N. Peeler, J. Schuster, K. McCormick. 2007. Research brief: Desired family outcomes of the early childhood transition process. http://community.fpg.unc.edu/connect/Desired-Family-Outcomes-of-the-Early-Childhood-Transition-Process-1.pdf.

Standard 9.2.3.2: Content and Development of the Plan for Care of Children and Staff Who Are Ill

All child care facilities should have written policies for the management and care of children and staff who are ill. The facility’s plan for the care of children and staff who are ill should be developed in consultation with the facility’s child care health consultant and other health care professionals to address current understanding of the technical issues of contagion and other health risks. This plan should include:

  1. Policies and procedures for urgent and emergency care;
  2. Admission, inclusion/exclusion, and re-entry policies;
  3. A description of illnesses common to children in child care, their management, and precautions to address the needs and behavior of the child who is ill, as well as to protect the health of other children and staff;
  4. A procedure to obtain and maintain updated individual care plans for children and staff with special health care needs;
  5. A procedure for documenting the name of person affected, date and time of illness, a description of symptoms, the response of the caregiver/teacher or other staff to these symptoms, who was notified (such as a parent/guardian, primary care provider, nurse, physician, or health department), and the response;
  6. Medication policy;
  7. Seasonal and pandemic influenza policy; and
  8. Staff illness-guidelines for exclusion and re-entry.

In group care, the facility should address the well-being of all those affected by illness: the child, the staff, parents/guardians of the child, other children in the facility and their parents/guardians, and the community. The priority of the policy should be to meet the needs of the child who is ill and the other children in the facility. The policy should address the circumstances under which separation of the affected individual (child or staff person) from the group is required; the circumstances under which the staff, parents/guardians, or other designated persons need to be informed; and the procedures to be followed in these cases.

The policy should take into consideration:

  1. The physical facility;
  2. The number and the qualifications of the facility’s personnel;
  3. The fact that children do become ill frequently and at unpredictable times;
  4. The fact that adults may be on staff with known health problems or may develop health problems while at work;
  5. The fact that working parents/guardians often are not given leave for their children’s illnesses; and
  6. The amount of care the child who is ill requires if the child remains in the program, whether staff can devote the time for caring for a child who is ill in the classroom without leaving other children unattended, and whether the child is able to participate in any of the classroom activities (1).

RATIONALE
Infectious diseases are a major concern of parents/guardians and staff. Since children, especially those in group settings, can be a reservoir for many infectious agents, and since caregivers/teachers and other staff come into close and frequent contact with children, they are at risk for developing a wide variety of infectious diseases (1). Following the infection control standards will help protect both children and staff from infectious disease. Recording the occurrence of illness in a facility and the response to the illness characterizes and defines the frequency of the illness, suggests whether an outbreak has occurred, may suggest an effective intervention, and provides documentation for administrative purposes.
COMMENTS
Facilities may comply by adopting a model policy and using reference materials as authoritative resources. The current edition of Managing Infectious Diseases in Child Care and Schools, a publication of the American Academy of Pediatrics (AAP), is a reference for policies and their implementation. This publication includes detailed handouts that can be used to inform parents/guardians and outline guidelines and rationale for exclusion, return to care, and notification of public health authorities.

Other helpful references include the current edition of Model Child Care Health Policies (2), or the current edition of the Red Book (3). Caregivers/teachers can check for other materials provided by the licensing agency, resource and referral agency, or health department. Curriculum for Managing Infectious Diseases, an online training module for caregivers/teachers is available from the AAP at http://www.healthychildcare.org/ParticipantsManualID.html.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
3.4.3.1 Emergency Procedures
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.3.1 Medication Administration
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
9.2.3.9 Written Policy on Use of Medications
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.4.2.1 Contents of Child’s Records
Appendix A: Signs and Symptoms Chart
Appendix F: Enrollment/Attendance/Symptom Record
Appendix AA: Medication Administration Packet
REFERENCES
  1. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 138-146


  2. Pennsylvania chapter of the American Academy of Pediatrics. Model Child Care Health Polices. Aronson SS, ed. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
  3. 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.

Standard 9.2.3.4: Written Policy for Obtaining Preventive Health Service Information

Each facility should develop and follow a written policy for obtaining necessary medical information including immunizations (see Appendix G: Recommended Childhood Immunization Schedule) and periodic preventive health assessments (see Appendix I: Recommendations for Preventive Pediatric Health Care) as recommended by the American Academy of Pediatrics (AAP) in Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (1-3). Facility staff should encourage parents/guardians to schedule these preventive health services in a timely fashion.

Documentation of an age-appropriate health assessment that includes current immunizations and health screenings should be filed in the child’s record at the facility. Immunization records should be provided at the time of enrollment. The health assessment should be provided within two weeks of admission or indication that an appointment has been made with the health care provider. Updates of the health record should be maintained according to the American Academy of Pediatrics’ (AAP’s) periodicity schedule, Appendix I: Recommendations for Preventive Pediatric Health Care. Health record information should be reviewed by the staff of the facility and information sharing between the staff, the parents/guardians, and the child’s health care professional should be encouraged and facilitated in order to provide better care for the child in the child care setting.

Centers should have written procedures for the verification of compliance with recommended immunizations and periodic health assessments of children. Centers should maintain confidential records of immunizations, periodic health assessments, including Body Mass Index (BMI) for children age two and older, and any special health considerations.

RATIONALE
Health assessments are important to ensure prevention, early detection of remediable problems, and planning for adaptations needed so that all children can reach their potential. When age-appropriate health assessments and use of health insurance benefits are promoted by caregivers/teachers, children enrolled in child care will have increased access to immunizations and other preventive services (4). With the expansion of eligibility for medical assistance and the federal subsidy of state child health insurance plans (SCHIP), the numbers of children who lack insurance for routine preventive health care should lessen.

Requiring facilities to maintain a current health record encourages and supports discussion of a child’s health needs between parents/guardians, caregivers/teachers, and the child’s primary care provider. It also encourages parents/guardians to seek preventive and primary care services in a timely fashion for their child.

The facility should have accurate, current information regarding the medical status and treatment of each child so it will be able to determine and adjust its capability to provide needed services. This documentation should consist of more than a statement from the child’s primary care provider that the child is up-to-date. Because of the administrative burden posed by requests to fill out forms, unless the specifics of services rendered are requested, the information may not reflect the child’s actual receipt of services according to the nationally recommended schedule. Instead, it may only represent that the child has a current health record in the primary care provider’s office. Until tracking systems become more widespread and effective in health care settings, a joint effort by the education system, family and primary care provider is required to ensure that children receive the preventive health services that ensure they are healthy and ready to learn.

COMMENTS
Assistance for caregivers/teachers and low income parents/guardians can be obtained through the Medicaid Early Periodic Screening and Diagnostic Treatment (EPSDT) program (Title XIX) and the state’s version of the federal Child Health Insurance Program (SCHIP) (5).

Most states require that caregivers/teachers document that the child’s health records are up-to-date to protect the child and other children whom the unimmunized child would expose to increased risk of vaccine-preventable disease. State regulations regarding immunization requirements for children may differ, but the child care facility should strive to comply with the national, annually published, “Recommended Childhood Immunization Schedule,” available at http://www.cispimmunize.org from the AAP, Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP).

A child’s entrance into the facility need not be delayed if an appointment for health supervision is scheduled. Often appointments for well-child care must be scheduled several weeks in advance. In such cases, the child care facility should obtain a health history report from the parents/guardians and documentation of an appointment for routine health supervision, as a minimum requirement for the child to attend the facility on a routine basis. The child should receive immunizations on admission or provide evidence of an immunization plan to prevent an increased exposure to vaccine-preventable diseases.

Local public health staff (such as the staff of immunization units, EPSDT programs) should provide assistance to caregivers/teachers in the form of record-keeping materials, educational materials, and on-site visits for education and help with surveillance activities. A copy of a form to use for documentation of routine health supervision services is available from Model Child Care Health Policies at http://www.ecelshealthychildcarepa.org/content/MHP4thEd Total.pdf.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
9.4.1.3 Written Policy on Confidentiality of Records
Appendix I: Recommendations for Preventive Pediatric Health Care
Appendix FF: Child Health Assessment
REFERENCES
  1. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid. Children’s health insurance program. http://www.cms.hhs.gov/home/chip.asp.
  2. Haskins, R., J. Kotch. 1986. Day care and illness: Evidence, costs, and public policy. Pediatrics 77:951-82.
  3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. American Academy of Pediatrics. 2008. Recommendations for preventive pediatric health care. http://practice.aap.org/content
    .aspx?aid=1599&nodeID=4000.
  5. American Academy of Pediatrics. Recomended childhood immunization schedules. http://www2.aap.org/immunization/izschedule.html.
     

Standard 9.2.3.5: Documentation of Exemptions and Exclusion of Children Who Lack Immunizations

For children who have been exempted from required, up-to-date immunizations, these exemptions should be documented in the child’s health record as a cross reference, (acceptable documentation includes a statement from the child’s primary provider, a legal exemption with notarization, waiver, or other state-specific required documentation signed by the parent/guardian). See Standard 7.2.0.2 for more information.

Within two weeks of enrollment the parent/guardian should provide documentation to the child care program regarding progress in obtaining immunizations. The parent/guardian should receive written notice of exclusion if noncompliance or lack of progress is evident. If more than one immunization is needed in a series, time should be allowed for the immunizations to be obtained at the appropriate intervals. Exemptions from the requirement related to compliance with the federal McKinney-Vento Homeless Assistance Act for children experiencing homelessness are documented and include a plan for obtaining available documents within a reasonable period of time.

RATIONALE
National surveys document that child care has a positive influence on protection from vaccine-preventable illness (1). Immunizations should be required for all children in child care and early education settings. Facilities must consider the consequences if they accept responsibility for exposing a child who cannot be fully immunized (because of immaturity) to an unimmunized child who may bring disease to the facility. Although up to two weeks after the child starts to participate in child care may be allowed for the acquisition of immunizations for which the child is eligible, parents/guardians should maintain their child’s immunization status according to the nationally recommended schedule to avoid potential exposure of other children in the facility to vaccine-preventable disease.
COMMENTS
An updated immunization schedule is published annually near the beginning of the calendar year in the AAP’s Pediatrics journal and in the CDC’s MMWR and should be consulted for current information. In addition to print versions of the recommended childhood immunization schedule, the “Recommended Immunization Schedules for Persons Aged 0 through 18 Years – United States” is posted on the Websites of the CDC at http://www.cdc.gov/vaccines/schedules/index.html and the AAP at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunization/Pages/Immunization-Schedule.aspx.

When a child who has a medical exemption from immunization is included in child care, reasonable accommodation of that child requires planning to exclude such a child in the event of an outbreak. Caregivers/teachers should check the Website http://www.immunize.org/laws/ for specific state-mandated immunization requirements and exemptions.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
7.2.0.2 Unimmunized Children
REFERENCES
  1. Aronson, S. S. 1986. Maintaining health in child care settings. In Group care for young children, ed. N. Gunzenhauser, B. M. Caldwell. New Brunswick, NJ: Johnson and Johnson Baby Products Company.

Standard 9.2.3.6: Identification of Child’s Medical Home and Parental Consent for Information Exchange

As part of the enrollment of a child, the caregiver/teacher should ask the family to identify the child’s primary care provider, his or her medical home, and other specialty health care professionals. The parent/guardian should provide written consent to enable the caregiver/teacher to establish communication with those providers. The family should always be informed prior to the use of the permission unless it is an emergency. The providers with whom the facility should exchange information (with parental consent) should include:

  1. Sources of regular medical and dental care (such as the child’s primary care provider, dentist, and medical facility);
  2. Special clinics the child may attend, including sessions with medical specialists and registered dietitians;
  3. Special therapists for the child (e.g., occupational, physical, speech, and nutritional), along with written documentation of the services rendered provided by the special therapist;
  4. Counselors, therapists, or mental health service providers for parents/guardians (e.g., social workers, psychologists, or psychiatrists);
  5. Pharmacists for children who take prescription medication on a regular basis or have emergency medications for specific conditions.

RATIONALE
Primary care providers are involved not only in the medical care of the child but also involved in supporting the child’s emotional and developmental needs (1-3). A major barrier to productive working relationships between child care and health care professionals is inadequate communication (1,2).

Knowing who is treating the child and coordinating services with these sources of service is vital to the ability of the caregivers/teachers to offer appropriate care to the child. Every child should have a medical home and those with special health care needs may have additional specialists and therapists (4-7). The primary care provider and needed specialists will create the Care Plan which will be the blueprint for healthy and safe inclusion into child care for the child with special health care needs.

COMMENTS
A source of health care may be a community or specialty clinic, a public health department, specialist, or a private primary care provider. Families should also know the location of the hospital emergency room departments nearest to their home and child care facility.

The California Childcare Health Program has developed a form to help facilitate the exchange of information between the health professionals and the parents/guardians and caregivers/teachers at http://ucsfchildcarehealth.org/pdfs/forms/CForm_ExchangeofInfo.pdf. They also release an information form at http://ucsfchildcarehealth.org/pdfs/forms/CF_ReferralRel.pdf. For more information on the medical home concept, see the American Academy of Pediatrics’ (AAP) Medical Home Website at http://www.medicalhome
info.org.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior
3.5.0.1 Care Plan for Children with Special Health Care Needs
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix AA: Medication Administration Packet
Appendix FF: Child Health Assessment
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.
  2. 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.
  3. Nowak, A. J., P. S. Casamassimo. 2002. The dental home: A primary care concept. JADA 133:93-98.
  4. Inkelas, M., M. Regolado, N. Halfon. 2005. Stategies for integrating developmental services and promoting medical homes. Los Angeles: National Center for Infant and Early Childhood Health Policy.
  5. Homer, C. J., K. Klatka, D. Romm, K. Kuhlthau, S. Bloom, P. Newacheck, J. Van Cleave, J. M. Perrin. 2008. A review of the evidence for the medical home for children with special health care needs. Pediatrics 122:e922–37.
  6. Starfield, B., L. Shi. 2004. The medical home, access to care, and insurance: A review of evidence. Pediatrics 113:1493-98.
  7. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

Standard 9.2.3.7: Information Sharing on Therapies and Treatments Needed

The person at the child care facility who is responsible for planning care for the child with special therapies or treatments should obtain an individualized care plan, developed by the child’s primary care provider or specialist on allergies, medications, therapies, and treatments being provided to the child that are directly relevant to the health and safety of the child in the child care facility. The written consent of the child’s parents/guardians and, where appropriate, the child’s primary care provider should be obtained before this confidential information is sought from outside sources. Therapies and treatments need to meet the criteria for evidenced based practices.

RATIONALE
The facility must have accurate, current information regarding the health status and treatment of the child so it will be able to determine the facility’s capability to provide needed services or to obtain them elsewhere.

Medicines can be crucial to the health and wellness of children. They can also be very dangerous if the wrong type or wrong amount is given to the wrong person or at the wrong time.

Parents/guardians should always be notified in every instance when medication is used. Telephone instructions from a primary care provider are acceptable if the caregiver/teacher fully documents them and if the parent/guardian initiates the request for primary care provider or child care health consultant instruction. In the event medication for a child becomes necessary during the day or in the event of an emergency, administration instructions from a parent/guardian and the child’s primary care provider are required before a caregiver/teacher may administer medication.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.6.3.1 Medication Administration
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix AA: Medication Administration Packet

Standard 9.2.3.9: Written Policy on Use of Medications

The facility should have a written policy for the administration of any prescription or non-prescription (over-the-counter [OTC]) medication. The policy should address at least the following:

  1. The use of written parental/guardian consent forms for each prescription and OTC medication to be administered at the child care facility. The consent form should include:
    1. The child’s name;
    2. The name of the medication;
    3. The date(s) and times the medication is to be given;
    4. The dose or amount of medication to be given;
    5. How the medication is to be administered;
    6. The period of time the consent form is valid, which may not exceed the length of time the medication is prescribed for, the expiration date of the medication or one year, whichever is less.
  2. The use of the prescribing health professional’s authorization forms for each prescription and OTC medication to be administered at the child care facility.
  3. The circumstances under which the facility will agree to administer medication. This may include the administration of:
    1. Topical medications such as non-medicated diaper creams, insect repellants, and sun screens;
    2. OTC medicines for fever including acetaminophen and ibuprofen;
    3. Long-term medications that are administered daily for children with chronic health conditions that are managed with medications;
    4. Controlled substances, such as psychotropic medications;
    5. Emergency medications for children with health conditions that may become life-threatening such as asthma, diabetes, and severe allergies;
    6. One-time medications to prevent conditions such as febrile seizures.
  4. The circumstances under which the facility will not administer medication. This should include:
    1. No authorization from parent/guardian and/or prescribing health professional;
    2. Prohibition of administering OTC cough and cold medication;
    3. Not administering a new medication for the first time to a child while he or she is in child care;
    4. If the instructions are unclear or the supplies needed to measure doses or administer the medication are not available or not in good working condition;
    5. The medication has expired;
    6. If a staff person or his/her backup who has been trained to give that particular medication is not present (in the case of training for medications that require specific skills to administer properly, such as inhalers, injections, or feeding tubes/ports).
  5. The process of accepting medication from parents/guardians. This should include:
    1. Verifying the consent form;
    2. Verifying the medication matches what is on the consent form;
    3. Accepting authorization for prescription medications from the child’s prescribing health professional only if the medications are in their original container and have the child’s name, the name of the medication, the dose and directions for giving the medication, the expiration date of the medication, and a list of warnings and possible side effects;
    4. Accepting authorization for OTC medications from the child’s prescribing health professional only if the authorization indicates the purpose of the medication and time intervals of administration, and if the medications are in their original container and include the child’s name, the name of the medication, dose and directions for use, an expiration date for the medication, and a list of warnings and possible side effects;
    5. Verifying that a valid Care Plan accompanies all long-term medications (i.e., medications that are to be given routinely or available routinely for chronic conditions such as asthma, allergies, and seizures);
    6. Verifying any special storage requirements and any precautions to take while the child is on the prescription or OTC medication.
  6. The proper handling and storage of medications, including:
    1. Emergency medications – totally inaccessible to children but readily available to supervising caregivers/teachers trained to give them;
    2. Medications that require refrigeration;
    3. Controlled substances;
    4. Expired medications;
    5. A policy to insure confidentiality;
    6. Storing and preparing distribution in a quiet area completely out of access to children;
    7. Keeping all medication at all times totally inaccessible to children (e.g., locked storage);
    8. Whether to require even short-term medications be kept at the facility overnight.
  7. The procedures to follow when administering medications. These should include:
    1. Assigning administration only to an adequately trained, designated staff;
    2. Checking the written consent form;
    3. Adhering to the “six rights” of safe medication administration (child, medication, time/date, dose, route, and documentation) (1);
    4. Documenting and reporting any medication errors;
    5. Documenting and reporting and adverse effects of the medication;
    6. Documenting and reporting whether the child vomited or spit up the medication.
  8. The procedures to follow when returning medication to the family, including:
    1. An accurate account of controlled substances being administered and the amount being returned to the family;
    2. When disposing of unused medication, the remainder of a medication, including controlled substances.
  9. The disposal of medications that cannot be returned to the parent/guardian.

A medication administration record should be maintained on an ongoing basis by designated staff and should include the following:

  1. Specific, signed parental/guardian consent for the caregiver/teacher to administer medication including documentation of receiving controlled substances and verification of the amount received;
  2. Specific, signed authorization from the child’s prescribing health professional, prescribing the medication, including medical need, medication, dosage, and length of time to give medication.
  3. Information about the medication including warnings and possible side effects;
  4. Written documentation of administration of medication and any side effects;
  5. Medication errors log.

The facility should consult with the State Board of Nursing, other interested organizations and their child care health consultant about required training and documentation for medication administration. Based on the information, the facility should develop and implement a plan regarding medication administration training (9).

RATIONALE
Administering medication requires skill, knowledge and careful attention to detail. Parents/guardians and prescribing health professionals must give a caregiver/teacher written authorization to administer medication to the child (12). Caregivers/teachers must be diligent in their adherence to the medication administration policy and procedures to prevent any inadvertent medication errors, which may be harmful to the child (11). There is always a risk that a child may have a negative reaction to a medication, and children should be monitored for serious side effects that may require an emergency response. Because children twenty-four months of age and younger are in a period of rapid development and are more vulnerable to the possible side effects of medications, extra care should be given to the circumstances under which medications will be administered to this population. A child may have a negative reaction to a medication that was given at home or to one administered while attending child care. For these reasons caregivers/teachers need to be aware of each of the medications a child received at child care as well as at home. They should know the names of the medication(s), when each was given, who prescribed them, and what the known reactions or side effects may be in the event that a child has a negative reaction to the medicine (2,10).

OTC medicines are often assumed to be safe and not afforded the proper diligence. Even common drugs such as acetaminophen and ibuprofen can result in significant toxicity for infants and small children. Inaccurate dosing from the use of inaccurate measuring tools can result in illness or even death (2,3).

Cough and cold medications (CCM) are readily available OTC in the United States and are widely used to treat upper respiratory infection. These products are not safe for infants and young children and were withdrawn by the Consumer Healthcare Products Association for children less than two years of age in 2007 (4-6,8). The Food and Drug Administration (FDA) issued a public health advisory in 2008 stating these medications should not be used in children less than two years of age. The American Academy of Pediatrics (AAP) states that CCMs are not effective for children less than six years of age and their use can result in serious, adverse effects (7).

The medication record protects the person administering medication by documenting the process. The medication errors log can be reviewed and will point out what kind of intervention, if any, will be helpful in reducing the number of medication errors. Accounting for medications administered and thrown away is important for several reasons. It may assist a health professional in determining whether the child is actually getting the medicine, especially when the child is not getting better from treatment. Some medications are “controlled substances,” meaning that the medication is regulated by the federal government due to potential for abuse. Controlled substances include narcotic pain medicine, some behavior medications for ADHD, and some seizure medications. A prescribing health professional may need proper accounting for these types of medications to assure that requests for refills are because the medication was given to the patient and not used/abused by adults. Some medications, (i.e., antibiotics), can have a harmful affect on the environment if not disposed of properly.

For children with chronic health conditions or special health care needs, administering medications while the child is attending child care may be part of the child’s individualized family service plan (IFSP) or individualized education plan (IEP). Child care facilities must comply with the Americans with Disabilities Act.

COMMENTS
When a child care facility cannot return unused medication to the parent/guardian, the facility needs to dispose of the medication. An example of when medication cannot be returned is when a parent/guardian has removed the child from care and the facility cannot reach the parent/guardian to return the medication. Herbal and folk medicines and home remedies are not regulated and should not be given at child cares without a prescribing health professional’s order and complete pharmaceutical labeling. If they are given at home, the caregiver/teacher should be aware of their use and possible side effects.

A curriculum for child care providers on safe administration of medications in child care is available from the AAP at http://www.healthychildcare.org/HealthyFutures.html. A sample medication administration policy is located in Appendix AA: Medication Administration Packet.

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
3.6.3.2 Labeling, Storage, and Disposal of Medications
9.4.2.6 Contents of Medication Record
Appendix AA: Medication Administration Packet
REFERENCES
  1. Sinkovits, H. S., M. W. Kelly, M. E. Ernst. 2003. Medication administration in day care centers for children. J Am Pharm Assoc 43:379-82.
  2. Friedman, J. F., G. M. Lee, K. P. Kleinman, J. A. Finkelstein. 2004. Child care center policies and practices for management of ill children. Ambulatory Pediatrics 4:455-60.
  3. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and medication administration in child care setttings: A case study. Policy, Politics, and Nurs Prac 6:86-98.
  4. Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/pressroom/10_11_07_OralInfantMedicines.aspx.
  5. U.S. Food and Drug Administration. 2007. Nonperscription cough and cold medicine use in children. http://www.fda.gov/Safety/
    MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm152691.htm.
  6. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medicines in children. Pediatrics 121:783-87.
  7. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Sloan Survey. Pediatrics 122:e323-29.
  8. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
  9. American Academy of Pediatrics. 2009. Healthy futures: Medication administration in early education and child care settings. http://www.healthychildcare.org/HealthyFutures.html.
  10. North Carolina Child Care Health & Safety Resource Center. 2007. Steps to administering medication. http://www.healthychild
    carenc.org/PDFs/steps_admin_medication.pdf.
  11. American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.
  12. Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.

Standard 9.2.4.1: Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents

The facility should have a written plan for reporting and managing what they assess to be an incident or unusual occurrence that is threatening to the health, safety, or welfare of the children, staff, or volunteers. The facility should also include procedures of staff training on this plan.

The management, documentation, and reporting of the following types of incidents, at a minimum, that occur at the child care facility should be addressed in the plan:

  1. Lost or missing child;
  2. Suspected maltreatment of a child (also see state’s mandates for reporting);
  3. Suspected sexual, physical, or emotional abuse of staff, volunteers, or family members occurring while they are on the premises of the child care facility;
  4. Injuries to children requiring medical or dental care;
  5. Illness or injuries requiring hospitalization or emergency treatment;
  6. Mental health emergencies;
  7. Health and safety emergencies involving parents/guardians and visitors to the program;
  8. Death of a child or staff member, including a death that was the result of serious illness or injury that occurred on the premises of the child care facility, even if the death occurred outside of child care hours;
  9. The presence of a threatening individual who attempts or succeeds in gaining entrance to the facility.

The following procedures, at a minimum, should be addressed in the plan for urgent care:

  1. Provision for a caregiver/teacher to accompany a child to a source of urgent care and remain with the child until the parent/guardian assumes responsibility for the child;
  2. Provision for the caregiver/teacher to provide the medical care personnel with an authorization form signed by the parent/guardian for emergency medical care and a written informed consent form signed by the parent/guardian allowing the facility to share the child’s health records with other service providers;
  3. Provision for a backup caregiver/teacher or substitute for large and small family child care homes to make the arrangement for urgent care feasible (child:staff ratios must be maintained at the facility during the emergency);
  4. Notification of parent/guardian(s);
  5. Pre-planning for the source of urgent medical and dental care (such as a hospital emergency room, medical or dental clinic, or other constantly staffed facility known to caregivers/teachers and acceptable to parents/guardians);
  6. Completion of a written incident/injury report and the program’s response;
  7. Assurance that the first aid kits are resupplied following each first aid incident, and that required contents are maintained in a serviceable condition, by a monthly review of the contents;
  8. Policy for scheduled reviews of staff members’ ability to perform first aid for averting the need for emergency medical services;
  9. Policy for staff supervision following an incident when a child is lost, missing, or seriously injured.

RATIONALE
Emergency situations are not conducive to calm and composed thinking. A written plan provides the opportunity to prepare and to prevent poor judgments made under the stress of an emergency.

Unannounced mock situations used as drills can help ease tension and build confidence in the staff’s ability to respond calmly in the event of a real incident. Discussion regarding performance and opportunities for improvement should follow the drill.

An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided to children in child care. Such an approach requires written plans, policies, 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.

Routine restocking of first aid kits is necessary to ensure supplies are available at the time of an emergency. Staff should be trained in the use of standard precautions during the response to any situation in which exposure to bodily fluids could occur. Management within the first hour or so following a dental injury may save a tooth.

Intrusions by threatening individuals to child care facilities have occurred, some involved violence resulting in injury and death. These threats have come from strangers who gained access to the playground or an unsecured building, or impaired family members who had easy access to a secured building. Facilities must have a plan for what to do in such situations (1-3).

COMMENTS
The American Academy of Pediatrics’ policy statement, “Medical Emergencies Occurring at School” contains information including a comprehensive list of resources that is relevant to child care facilities. The Emergency Medical Services for Children National Resource Center (http://www.childrensnational.org/emsc/) has downloadable print information for emergency medical training, particularly the brochure entitled “Emergency Guidelines for School” at http://ems.ohio.gov/EMSC web site_11_04/pdf_doc files/EMSCGuide.pdf. This site also lists internet links to emergency plans for specific health needs such as diabetes, asthma, seizures, and allergic reactions. Resources for emergency response to non-medical incidents can be found at http://www.chtc.org/dl/handouts/20061114/20061114-2.pdf and http://dcf.vermont.gov/sites/dcf/files/pdf/cdd/care/EmergencyResponse.pdf.

It is recommended that parents/guardians inform caregivers/teachers their preferred sources for medical and dental care in case of emergency. Parents/guardians should be notified, if at all possible, before dental services are rendered, but emergency care should not be delayed because the child’s own dentist is not immediately available.

Facilities should develop and institute measures to control access of a threatening individual to the facility and the means of alerting others in the facility as well as summoning the police if such an event occurs.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.5.0.2 Orientation of Substitutes
3.6.4.5 Death
1.5.0.1 Employment of Substitutes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
9.2.4.2 Review of Written Plan for Urgent Care
9.2.4.3 Disaster Planning, Training, and Communication
9.4.1.9 Records of Injury
9.4.1.10 Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program
9.4.1.11 Review and Accessibility of Injury and Illness Reports
9.4.2.1 Contents of Child’s Records
REFERENCES
  1. Guerra, C. 2010. Child care providers get lessons in Lee County on being prepared. News-Press, Apr 19. http://beta.news
    -press.com.
  2. Haggerty, R. 2010. Man kills self after firing shots at day care. Journal Sentinel, Feb 17. http://www.jsonline.com/news/crime/.
  3. AFP. 2009. Belgian charged over daycare killings. Nine News, Jan 24. http://news.ninemsn.com.au/world/.

Standard 9.2.4.2: Review of Written Plan for Urgent Care

The facility’s written plan for urgent medical care and threatening incidents should be reviewed and updated annually or as needed. It should be reviewed with each employee upon employment and yearly thereafter in the facility to ensure that policies and procedures are understood and followed in the event of such an occurrence. The plan and associated procedures should be reviewed with a child care health consultant once a year, signed and dated.

In the event that there is an urgent medical care or threatening incident, the facility should plan to review the process within one to two months after the incident to determine opportunities for improvement and any changes that need to be made to the plan for future incidents.

The care plan for a child with special health care needs should cover emergency care needs and be shared with and discussed between parents/guardians and caregivers/teachers prior to an emergency situation (1).

RATIONALE
Emergency situations are not conducive to calm and composed thinking. Developing a written plan and reviewing it in pre-service meetings with new employees and annually thereafter, provides the opportunity to prepare and to prevent poor judgments made under the stress of an emergency.

An organized, comprehensive approach to injury prevention and control based on current practice and evidence is necessary to ensure that a safe environment is provided to children in child care. Such an approach requires written plans, policies, 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.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.3.1 Emergency Procedures
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
9.2.4.3 Disaster Planning, Training, and Communication
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix CC: Incident Report Form
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. 2008. Policy statement: Emergency preparedness for children with special health care needs. Pediatrics 122:450.

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 9.4.1.3: Written Policy on Confidentiality of Records

The facility should establish and follow a written policy on confidentiality of the records of staff and children that ensures that the facility will not disclose material in the records (including conference reports, service plans, immunization records, and follow-up reports) without the written consent of parents/guardians for children, or of staff for themselves. Consent forms should be in the native language of the parents/guardians, whenever possible, and communicated to them in their normal mode of communication. Foreign language interpreters should be used whenever possible to inform parents/guardians about their confidentiality rights. At the time when facilities obtain prior, informed consent from parents/guardians for release of records, caregivers/teachers should inform parents/guardians who may be looking at the records (e.g., child care health consultants, mental health consultants, and specialized agencies providing services).

Written releases should be obtained from the child’s parent/guardian prior to forwarding or sharing information and/or the child’s records to other service providers. The content of the written procedures for protecting the confidentiality of medical and social information should be consistent with federal, state, and local guidelines and regulations and should be taught to caregivers/teachers. Confidential medical information pertinent to safe care of the child should be provided to facilities within the guidelines of state or local public health regulations. However, under all circumstances, confidentiality about the child’s medical condition and the family’s status should be preserved unless such information is released at the written request of the family, except in cases where child maltreatment is a concern or to determine compliance with licensing regulations. In such cases, state laws and regulations apply.

The director of the facility should decide who among the staff may have confidential information shared with them. Clearly, this decision must be made selectively, and all caregivers/teachers should be taught the basic principles of all individuals’ rights to confidentiality. Caregivers/teachers should not disclose or discuss personal information regarding children and their families with any unauthorized person. Confidential information should be seen by and discussed only with staff members who need the information in order to provide services. Caregivers/teachers should not discuss confidential information about families in the presence of others in the facility.

Procedures should be developed and a method established to ensure accountability and to ensure that the exchange is being carried out. The child’s record should be available to the parents/guardians for inspection at all times.

If other children are mentioned in a child’s record that is authorized for release, the confidentiality of those children should be maintained. The record should be edited to remove any information that could identify another child.

Caregivers/teachers should not disclose or discuss personal information regarding children and their families with any unauthorized person. Confidential information should be seen by and discussed only with staff members who need the information in order to provide services. Caregivers/teachers should not discuss confidential information about families in the presence of others in the facility.

RATIONALE
Confidentiality must be maintained to protect the child and family and is defined by law (1). Serving children and families involves significant facility responsibilities in obtaining, maintaining, and sharing confidential information. Each caregiver/teacher must respect the confidentiality of information pertaining to all families, staff, and volunteers served (2).

Someone in each facility must be authorized to make decisions about the sharing of confidential information, and the director is the logical choice. The decision about sharing information must also involve the parent/guardian(s). Sharing of confidential information should be selective and should be based on a need-to-know and on the parent’s/guardian’s authorization for disclosure of such information (3).

Requiring written releases ensures confidentiality. Continuity of care and information is invaluable during childhood when growth and development are rapidly changing. Providing consent forms in the native language of the parents/guardians and providing an interpreter to explain the confidentiality policy and procedures helps to insure that the signed consent is informed consent.

The California Childcare Health Program developed with the Child Care Law Center, “Consent for Exchange of Information Form” that can be viewed at: http://ucsfchildcarehealth.org/pdfs/forms/CForm_ExchangeofInfo.pdf.

COMMENTS
Parental trust in the caregiver is the key to the caregiver’s ability to work toward health promotion and to obtain needed information to use in decision making and planning for the child’s best interest. Assurance of confidentiality fosters this trust. When custody has been awarded to only one parent, access to records must be limited to the custodial parent. In cases of disputed access, the facility may need to request that the parents/guardians supply a copy of the court document that defines parental rights. Operational control to accommodate the health and safety of individual children requires basic information regarding each child in care.

Release formats may vary from state to state and within facilities. User friendly forms furnished for all caregivers/teachers may facilitate the exchange of information.

TYPE OF FACILITY
Center
RELATED STANDARDS
9.4.2.8 Release of Child’s Records
REFERENCES
  1. U.S. Department of Education. FERPA regulations. http://www2.ed.gov/policy/gen/reg/ferpa/.
  2. U.S. Department of Health and Human Services (DHHS), Office for Civil Rights. HIPAA administrative simplification statute and rules. Washington, DC: DHHS. http://www.hhs.gov/ocr/privacy/hipaa/administrative/index.html.
  3. U.S. Congress. 1974. Family Educational Rights and Privacy Act (FERPA). 20 USC Sec 1232.

Standard 9.4.1.17: Documentation of Child Care Health Consultation/Training Visits

Documentation of child care health/early childhood mental health consultation visits should be maintained in the facility’s files. Documentation should include at least the following:

  1. Name of child care health/early childhood mental health consultant;
  2. Date and time of visit;
  3. Recipient(s) of service;
  4. Reason for the visit/phone/internet consultation;
  5. Type of service provided;
  6. Recommendations;
  7. Follow-up, if any.

All training or education provided by child care health consultants for early care and education professionals should be documented in a manner that can be used to meet professional development requirements or documentation. Recommendations and improvement plans should be provided to the staff.

RATIONALE
Child care health consultants, including mental health consultants, licensing agents, health departments, and fellow caregivers/teachers should reinforce the importance of appropriate health behavior. Documentation of health consultation by a child care health consultant or other health professional provides a record of the assessed need in a facility, the strategies to make improvements, and the barriers that result from implementing strategies. The documentation can also be useful in evaluating the effectiveness of the services provided (1).

The documentation from the child care health consultant should take the form of a quality improvement plan that includes goals, objectives, timeline, and financial considerations. All encounters should be documented by the child care health consultant. The child care health consultant should use the same standards as would be used to document “patient care” the patient or client in this case is the child care business.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
1.6.0.3 Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants
REFERENCES
  1. Norwood, S. L. 2003. Nursing consultation: A Framework for working with communities. 2nd ed. Upper Saddle River, NJ: Prentice Hall.

Standard 9.4.1.19: Community Resource Information

The facility should obtain or have access to a community resource file that is updated at least annually. This resource file should be made available to parents/guardians as needed. For families who do not speak English, community resource information should be provided in the parents’/guardians’ native language or through the use of interpreters (1).

RATIONALE
Posting resources in a public place is a service to the community.
COMMENTS
In many communities, community agencies (such as resource and referral agencies) offer community resource files and may be able to supply updated information or service directories to local caregivers/teachers. Even small family child care home caregivers/teachers will be able to maintain a list of telephone numbers of human services, such as that published in the telephone directory. If a resource file is maintained, it must be updated regularly and should be used by a caregiver/teacher knowledgeable about health and the community (i.e., Health Advocate).

Local resource and referral agencies, mental health services, WIC (Women, Infants, and Children), Child Find, Legal Aid, specialty clinics serving the developmentally disabled, poison centers, social services, community health centers, hospitals, private physicians, state child health insurance programs (SCHIP), medical homes, food banks and pantries, energy/housing assistance, churches, child care payment assistance, public health nurses, Head Start, the American Red Cross, public schools, early intervention programs, and county extension services, faith-based organizations, local government agencies are examples of potential resources.

For locating community resources, see the Maternal and Child Health Library Community Services Locator at http://www.mchlibrary.info/KnowledgePaths/kp_community.html. American Academy of Pediatrics’ State Chapter Child Care Contacts are available at http://www.healthychildcare.org.

TYPE OF FACILITY
Center
RELATED STANDARDS
2.3.2.3 Support Services for Parents/Guardians
10.3.4.5 Resources for Parents/Guardians of Children with Special Health Care Needs
REFERENCES
  1. Gonzalez-Mena, J. 2007. 50 early childhood strategies for working and communicating with diverse families. Upper Saddle River, NJ: Pearson Merrill Prentice Hall.

Standard 9.4.2.1: Contents of Child’s Records

The facility should maintain a file for each child in one central location within the facility. This file should be kept in a confidential manner but should be immediately available to the child’s caregivers/teachers (who should have parental/guardian consent for access to records), the child’s parents/guardians, and the licensing authority upon request.

The file for each child should include the following:

  1. Pre-admission enrollment information;
  2. Admission agreement signed by the parent/guardian at enrollment;
  3. Initial health care professional assessment, completed and signed by the child’s primary care provider and based on the child’s most recent well care visit and containing a complete immunization record as recommended at http://www.aap.org/immunization/ and a statement of any special needs with a care plan for how the program should accommodate these special needs (this should be on file preferably at enrollment or a two week written plan should be provided upon admission);
  4. Updated health care professional assessments should be completed from the initial assessment filed except that such assessments should be at the recommended intervals by the American Academy of Pediatrics (AAP) until the age of two years and annually thereafter;
  5. Health history to be completed by the parent/guardian at admission, preferably with staff involvement;
  6. Medication record, maintained on an ongoing basis by designated staff;
  7. Authorization form for emergency medical care (see Appendix KK: Authorization for Emergency Medical/Dental Care for an example; this form should not be used for routine problems or when the parent can be reached);
  8. Any written informed consent forms signed by the parent/guardian allowing the facility to share the child’s health records with other service providers.

RATIONALE
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. Prior informed, written consent of the parent/guardian is required for the release of records/information (verbal and written) to other service providers, including process for secondary release of records. Consent forms should be in the native language of the parents/guardians, whenever possible, and communicated to them in their normal mode of communication. Foreign language interpreters should be used whenever possible to inform parents/guardians about their confidentiality rights (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.4.1.3 Written Policy on Confidentiality of Records
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
Appendix I: Recommendations for Preventive Pediatric Health Care
Appendix KK: Authorization for Emergency Medical/Dental Care
REFERENCES
  1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. 2007. Policy statement: Consent for emergency medical services for children and adolescents. Pediatrics 120:683-84.

Standard 9.4.2.2: Pre-Admission Enrollment Information for Each Child

The file for each child should include the following pre-admission enrollment information (pre-admission requirements may be waived to comply with the federal McKinney-Vento Homeless Assistance Act regarding health and health records):

  1. The child’s name, address, sex, and date of birth;
  2. The full names of the child’s parents/guardians, and their home and work addresses and telephone numbers, which should be updated quarterly (telephone contact numbers should be confirmed by a call placed to the contact number during the facility’s hours of operation);
  3. The names, addresses, and telephone numbers of at least two additional persons to be notified in the event that the parents/guardians cannot be located (telephone information should be confirmed and updated as specified in item b) above);
  4. The names and telephone numbers of the child’s medical home provider and main sources of specialty medical care (if any), emergency medical care, and dental care;
  5. The child’s health payment resource or health insurance;
  6. Written instructions (in the form of a care plan) of the parent/guardian and the child’s primary care provider for any special dietary needs or special needs due to a health condition or allergy; or any other special instructions from the parent/guardian;
  7. Scheduled days and hours of attendance;
  8. In the event that a custody or guardianship order has been issued regarding the child, legal documentation evidencing the child’s custodian or guardian;
  9. Enrollment date, reason for entry in child care, and fee arrangements;
  10. Signed permission to act on parent/guardian’s behalf for emergency treatment;
  11. Authorization to release child to designated individuals other than the custodial parent/guardian.

The emergency information in items a) through e) above should be obtained in duplicate with original parent/guardian signatures on both copies. One copy should be in the child’s confidential record and one copy should be easily accessible at all times. This information should be updated quarterly and as necessary. A copy of the emergency information must accompany the child to all offsite excursions.

RATIONALE
These records and reports are necessary to protect the health and safety of children in care. An organized, comprehensive approach to illness and injury prevention and control is necessary to ensure that a healthy and safe environment is provided for children in child care. Such an approach requires written plans, policies, 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.

Emergency information is the key to obtaining needed care in emergency situations (1). Caregivers/teachers must have written parental permission to allow them access to information they and emergency medical services personnel may need to care for the child in an emergency (1). Contact information must be verified for accuracy. Health payment resource information is usually required before any non-life-threatening emergency care is provided.

COMMENTS
Duplicate records are easily made by scanning copies or making photocopies.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.4.8 Authorized Persons to Pick Up Child
9.2.4.9 Policy on Actions to Be Followed When No Authorized Person Arrives to Pick Up a Child
9.2.4.10 Documentation of Drop-Off, Pick-Up, Daily Attendance of Child, and Parent/Provider Communication
Appendix BB: Emergency Information Form for Children with Special Health Care Needs
Appendix KK: Authorization for Emergency Medical/Dental Care
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.

Standard 9.4.2.3: Contents of Admission Agreement Between Child Care Program and Parent/Guardian

The file for each child should include an admission agreement signed by the parent/guardian at enrollment. The admission agreement should contain the following topics and documentation of consent:

  1. General topics:
    1. Operating days and hours;
    2. Holiday closure dates;
    3. Payment for services;
    4. Drop-off and pick-up procedures;
    5. Family access (visiting site at any time when their child is there and admitted immediately under normal circumstances) and involvement in child care activities;
    6. Name and contact information of any primary staff person designation, especially primary caregivers/teachers designated for infants and toddlers, to make parent/guardian contact of a caregiver/teacher more comfortable.
  2. Health topics:
    1. Immunization record;
    2. Breast feeding policy;
    3. For infants, statement that parent/guardian(s) has received and discussed a copy of the program’s infant safe sleep policy;
    4. Documentation of written consent signed and dated by the parent/guardian for:
    5. Any health service obtained for the child by the facility on behalf of the parent/guardian. Such consent should be specific for the type of care provided to meet the tests for “informed consent” to cover on-site screenings or other services provided;
    6. Administration of medication for prescriptions and non-prescription medications (over-the-counter [OTC]) including records and special care plans (if needed).
  3. Safety topics:
    1. Prohibition of corporal punishment in the child care facility;
    2. Statement that parent/guardian has received and discussed a copy of the state child abuse and neglect reporting requirements;
    3. Documentation of written consent signed and dated by the parent/guardian for:
    4. Emergency transportation;
    5. All other transportation provided by the facility;
    6. Planned or unplanned activities off-premises (such consent should give specific information about where, when, and how such activities should take place, including specific information about walking to and from activities away from the facility);
    7. Swimming, if the child will be participating;
    8. Release of any information to agencies, schools, or providers of services;
    9. Written authorization to release the child to designated individuals other than the parent/guardian.

RATIONALE
These records and reports are necessary to protect the health and safety of children in care.

These consents are needed by the person delivering the medical care. Advance consent for emergency medical or surgical service is not legally valid, since the nature and extent of injury, proposed medical treatment, risks, and benefits cannot be known until after the injury occurs, but it does allow the parent/guardian to guide the caregiver/teacher in emergency situations when the parent/guardian cannot be reached (1). See Appendix KK: Authorization for Emergency Medical/Dental Care for an example.

The parent/guardian/child care partnership is vital.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
Appendix KK: Authorization for Emergency Medical/Dental Care
REFERENCES
  1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. 2007. Policy statement: Consent for emergency medical services for children and adolescents. Pediatrics 120:683-84.

Standard 9.4.2.4: Contents of Child’s Primary Care Provider’s Assessment

The file for each child should include an initial health assessment completed and signed by the child’s primary care provider. This should be on file preferably at enrollment and no later than within six weeks of admission. (Requirements may be waived to comply with the federal McKinney-Vento Homeless Assistance Act regarding health and health records.) It should include:

  1. Immunization Records;
  2. Growth Assessment – may include percentiles of weight, height, and head circumference (under age of two); recording body mass index (BMI) and percentile for age is especially helpful in those children age two years and older who are over or underweight;
  3. Health Assessment – includes descriptions of any current acute and/or chronic health issues and should also include any findings from an exam or screening that may need follow-up, e.g., vision, hearing, dental, obesity, or nutritional screens or tests for lead, anemia, or tuberculosis (these health concerns may require a care plan and possibly a medication plan [see h) below]);
  4. Developmental Issues – includes descriptions of concerns and the child’s special needs in a child care setting, (for example, a vision or hearing deficit, a developmental variation, prematurity, or an emotional or behavioral disturbance);
  5. Significant physical findings so that caregivers/teachers can note if there are changes from baseline and report those findings;
  6. Dates of Significant Illnesses and/or Injuries;
  7. Allergies;
  8. Medication(s) List – includes dosage, time and frequency of administration of any ongoing prescription or non-prescription (over-the-counter [OTC]) medication that the person with prescriptive authority recommends for the child. This list would also include information on recognizing side-effects and responding to them appropriately and it may also contain the same information for intermittent use of a fever reducer medication;
  9. Dietary modifications;
  10. Emergency plans;
  11. Other special instructions for the caregiver/teacher;
  12. Care Plan – (if the child has a special health need as indicated by c) or d) above) includes routine and emergency management plans that might be required by the child while in child care. This plan also includes specific instructions for caregiver/teacher observations, activities or services that differ from those required by typically developing children and should include specific instructions to caregivers/teachers on how to provide medications, procedures, or implement modifications required by children with asthma, severe allergic reactions, diabetes, medically-indicated special feedings, seizures, hearing impairments, vision problems, or any other condition that requires accommodation in child care;
  13. Parent’s/Guardian’s assessment and concerns (4).

For children up the age of three years, health care professional assessments should be at the recommended intervals indicated by the American Academy of Pediatrics (AAP) (3). For all other children, the Health Care Professional Assessment updates should be obtained annually. It should include any significant health status changes, any new medications, any hospitalizations, and any new immunizations given since the previous health assessment. This health report will be supplemented by the health history obtained from the parents/guardians by the child care provider at enrollment.

RATIONALE
The requirement of a health report for each child reflecting completion of health assessments and immunizations is a valid way to ensure timely preventive care for children who might not otherwise receive it and can be used in decision-making at the time of admission and during ongoing care (2). This requirement encourages families to have a primary care provider (medical home) for each child where timely and periodic well-child evaluations are done. The objective of timely and periodic evaluations is to permit detection and treatment for improved oral, physical, mental, and emotional/social health (1,3). The reports of such evaluations provide a conduit for communication of information that helps the primary care provider and the caregiver/teacher determine appropriate services for the child. When the parent/guardian carries the request for the report to the primary care provider, concerns of the caregiver/teacher can be delivered by the parent/guardian to the child’s primary care provider and consent for communication is thereby given. The parent/guardian can give written consent for direct communication between the primary care provider and the caregiver/teacher so that the forms can be faxed or mailed.

Quality child care requires information about the child’s health status and need for accommodations in child care (2).

COMMENTS
The purpose of a health care professional assessment is to:
  1. Give information about a child’s health history, special health care needs, and current health status to allow the caregiver/teacher to provide a safe setting and healthy experience for each child;
  2. Promote individual and collective health by fostering compliance with approved standards for health care assessments and immunizations;
  3. Document compliance with licensing standards;
  4. Serve as a means to ensure early detection of health problems and a guide to steps for remediation;
  5. Serve as a means to facilitate and encourage communication and learning about the child’s needs among caregivers/teachers, primary care providers, and parents/guardians.

This approach is usually the most efficient, effective and least costly since the primary care provider has the child, the family member, and the record in hand, to provide the information that the child care facility should have. When the data are requested separate from the visit to the primary care provider for the health assessment, the record must be pulled from the file and the information retrieved from the notes in the file. Some health care facilities charge families for the cost of the additional work to complete forms either at the time of a health care visit or later. Collaborating in reducing the burden of form completion by writing in as much information as is known before giving the forms to the primary care provider helps foster effective communication. Many primary care providers appreciate having identifying information filled in on the form about the child care facility, the child, the family and a note about any concerns to be addressed.

Caregivers/teachers may offer a four-week grace period during which the parent/guardian can arrange to get this assessment. The health history can serve as an interim health assessment during this grace period.

Health data should be presented in a form usable for caregivers/teachers to help identify any special needs for care. Local Early Periodic Screening and Diagnostic Treatment (EPSDT) program contractor, if available, should be called upon to help with liaison and education activities. In some situations, screenings may be performed at the facilities, but it is always preferable that the child have a medical home and primary care provider who screens the child and provides the information. When clinicians do not fill out forms completely enough to assist the caregiver/teacher in understanding the significance of health assessment findings or the unique characteristics of a child, the caregiver/teacher should obtain parental consent to contact the child’s primary care provider to explain why the information is needed and to request clarification.

Health assessments should be in a format easily usable by caregivers/teachers to identify any special needs for care.

A child’s primary care provider is a key resource to families when racial, ethnic, socioeconomic, or educational disparities create barriers to the child receiving regular dental care. He or she can perform an oral examination and conduct an oral health risk assessment and triage for infants and young children. Children with suspected oral problems should see a dentist immediately, regardless of age or interval.

The American Academy of Pediatrics (AAP) and Bright Futures recommend vision/hearing and dental screenings are:

  1. Vision/hearing at every well care visit (with objective measures of visual acuity by four years and audiometry measures of hearing by five years of age); and
  2. Dental exam at one year (or sooner if there are suspected oral problems) (3).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.4.2.1 Contents of Child’s Records
9.4.2.5 Health History
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix FF: Child Health Assessment
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.
  2. 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.
  3. Crowley A. A., G. C. Whitney. 2005. Connecticut’s new comprehensive and universal early childhood health assessment form. J School Health 75:281-85.
  4. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Bright Futures Steering Committee. 2007. Policy statement: Recommendations for preventive pediatric health care. Pediatrics 120:1376.

Standard 9.4.2.5: Health History

The file for each child should include a health history completed by the parent/guardian at admission, preferably with staff involvement. This history should include the following:

  1. Identification of the child’s medical home/primary care provider and dental home;
  2. Permission to contact these professionals in case of emergency;
  3. Chronic diseases/health issues currently under treatment;
  4. Developmental variations, sensory impairment, serious behavior problems or disabilities that may need consideration in the child care setting;
  5. Description of current physical, social, and language developmental levels;
  6. Current medications, medical treatments and other therapeutic interventions;
  7. Special concerns (such as allergies, chronic illness, pediatric first aid information needs);
  8. Specific diet restrictions, if the child is on a special diet;
  9. Individual characteristics or personality factors relevant to child care;
  10. Special family considerations;
  11. Dates of infectious diseases;
  12. Plans for medical emergencies;
  13. Any special equipment that might be needed;
  14. Special transportation adaptations.

RATIONALE
A health history is the basis for meeting the child’s medical and psychosocial needs in the child care setting. This information must be obtained and reviewed at admission by the significant caregiver/teacher. This information may be the only health information on file for up to the first four weeks following enrollment.
COMMENTS
This history will complement the child’s health history which is completed by the primary care provider.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.4.2.1 Contents of Child’s Records

Standard 9.4.2.6: Contents of Medication Record

The file for each child should include a medication record maintained on an ongoing basis by designated staff for all prescription and non-prescription (over-the-counter [OTC]) medications. State requirements should be checked and followed. The medication record for prescription and non-prescription medications should include the following:

  1. A separate consent signed by the parent/guardian for each medication the caregiver/teacher has permission to administer to the child; each consent should include the child’s name, medication, time, dose, how to give the medication, and start and end dates when it should be given;
  2. Authorization from the prescribing health professional for each prescription and non-prescription medication; this authorization should also include potential side effects and other warnings about the medication (exception: non-prescription sunscreen and insect repellent always require parental/guardian consent but do not require instructions from each child’s individual medical provider);
  3. Administration log which includes the child’s name, the medication that was given, the dose, the route of administration, the time and date, and the signature or initials of the person administering the medication. For medications given “as needed,” record the reason the medication was given. Space should be available for notations of any side-effects noted after the medication was given or if the dose was not retained because of the child vomiting or spitting out the medication. Documentation should also be made of attempts to give medications that were refused by the child;
  4. Information about prescription medication brought to the facility by the parents/guardians in the original, labeled container with a label that includes the child’s name, date filled, prescribing clinician’s name, pharmacy name and phone number, dosage/instructions, and relevant warnings. Potential side effects and other warnings about the medication should be listed on the authorization form;
  5. Non prescription medications should be brought to the facility in the original container, labeled with the child’s complete name and administered according to the authorization completed by the person with prescriptive authority;
  6. For medications that are to be given or available to be given for the entire year, a Care Plan should also be in place (for instance, inhalers for asthma or epinephrine for possible allergy);
  7. Side effects.

RATIONALE
Before assuming responsibility for administration of prescription or non-prescription medicine, facilities must have written confirmation of orders from the prescribing health professional that includes clear, accurate instructions and medical confirmation of the child’s need for medication while in the facility. Caregivers/teachers should not administer medication based solely on a parent’s/guardian’s request. Proper labeling of medications is crucial for safety (1). Both the child’s name and the name and dose of the medication should be clear. Medications should never be removed from their original container. All containers should have child resistant packaging. Potential side-effects are usually included on prescription and OTC medications if the packaging is left intact (2).

Medications may have side-effects, and parents/guardians might not be aware that their child is experiencing those symptoms unless they are recorded and reported. Serious medication side-effects might require emergency care. Adjustments or additional medications might help those symptoms if the prescribing health professional is made aware of them. Children who do not tolerate medications may vomit or spit up the medication. Notation should be made if any of the medication was retained in those cases. Children may also vigorously refuse medications, and plans to deal with this should be made (1,2).

The Medication Log is a legal document and should be kept in the child’s file for as long as required by state licensing requires.

COMMENTS
A curriculum for child care providers on safe administration of medications in child care is available from the American Academy of Pediatrics at: http://www.healthychildcare.org/HealthyFutures.html.
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
9.2.3.9 Written Policy on Use of Medications
9.4.2.1 Contents of Child’s Records
3.6.3.2 Labeling, Storage, and Disposal of Medications
Appendix AA: Medication Administration Packet
REFERENCES
  1. Healthy Child Care America. 2010. Healthy futures: Medication administration in early education and child care settings. American Academy of Pediatrics. http://www.healthychildcare.org/HealthyFutures.html.
  2. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.

Standard 9.4.2.7: Contents of Facility Health Log for Each Child

The file for each child should include a facility health log maintained on an ongoing basis by designated staff. The facility health log should include:

  1. Staff and parent/guardian observations of the child’s health status, behavior, and physical condition;
  2. Response to any treatment provided while the child is in child care, and any observable side effects;
  3. Notations of health-related referrals and follow-up action;
  4. Notations of health-related communications with parents/guardians or the child’s primary care provider;
  5. Staff observations of changes in and assessments of the child’s learning and social activity;
  6. Documentation of planned communication with parents/guardians and a list of participants involved;
  7. Documentation of parent/guardian participation in health education.

RATIONALE
A facility health log maintained by caregivers/teachers can document staff’s observations and concerns that may lead to intervention decisions.
COMMENTS
The facility health log is a confidential, chronologically-oriented location for the recording of staff observations, patterns of illness, and parent/guardian concerns. It can be followed and can become guidelines for intervention, if needed.

Facility observation logs provide useful information over time on each child’s unique characteristics. Parents/guardians and caregivers/teachers can use these logs in planning for the child’s needs. On occasion, the child’s primary care provider can use them as an aid in diagnosing health conditions.

“Hands-on” opportunities for parents/guardians to work with their own child or others in the company of caregivers/teachers should be encouraged and documented.

Staff notations on communication with parents/guardians can be in a parent/guardian log separate from the child’s health record.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.3.2.1 Parent/Guardian Conferences
2.3.2.3 Support Services for Parents/Guardians
2.4.3.2 Parent/Guardian Education Plan
9.4.1.6 Availability of Documents to Parents/Guardians
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians
Appendix F: Enrollment/Attendance/Symptom Record
Appendix AA: Medication Administration Packet

Standard 9.4.2.8: Release of Child’s Records

The parents’/guardians’ written requests to release their child’s records must be specific about to whom the record is being released, for what purpose, and what parts of the record are being copied and sent. Upon parent/guardian request, designated portions or all of the child’s records should be copied and released to specific individuals named and authorized in writing by the parents/guardians to receive this information. The original records and the written requests should be retained by the facility.

RATIONALE
The facility must retain the original records in case legal defense is required, but parents/guardians have the right to know and have the full contents of the records. Sending the record to another source of service for the child may enhance the ability of other service providers to provide appropriate care for the child and family.
COMMENTS
Parents/guardians may want a copy of the record themselves or may want the record sent to another source of care for the child. An effective way to educate parents/guardians on the value of maintaining the child’s developmental and health information is to have them focus on their own child’s records. Such records should be used as a mutual education tool by parents/guardians and caregivers/teachers. Facilities may charge a reasonable fee for making a copy.
TYPE OF FACILITY
Center
RELATED STANDARDS
9.4.1.3 Written Policy on Confidentiality of Records

X. Licensing and Community Action

Standard 10.3.2.1: Child Care Licensing Advisory Board

States should have an official child care licensing advisory body for regulatory and related policy issues. A child care advisory board should:

  1. Review proposed rules and regulations prior to adoption;
  2. Recommend administrative policy;
  3. Recommend changes in legislation; and
  4. Guide enforcement, if granted this authority via the legislative process.

The advisory group should include representatives from the following agencies and groups:

  1. State agencies with regulatory responsibility or an interest in child care (human services, public health, fire marshal, emergency medical services, education, human resources, attorney general, safety council);
  2. Organizations with a child care emphasis;
  3. Operators, directors, owners, and caregivers/teachers reflecting various types of child care programs including for-profit and non-profit;
  4. Professionals with expertise related to the rules; may include pediatrics, physical activity, nutrition, mental health, oral health, injury prevention, resource and referral, early childhood education, and early childhood professional development;
  5. Parents/guardians who reflect the diversity of the families that are consumers of licensed child care programs.

This advisory board should be linked to the State Early Childhood Advisory Council (see Standard 10.3.2.2) as required by the Head Start Act of 2007 (1). 

RATIONALE
The advisory group should actively seek citizen participation in the development of child care policy, including parents/guardians, child care administrators, and caregivers/teachers. The licensing advisory board should report directly to the agency having administrative authority over licensing.
RELATED STANDARDS
10.3.2.2 State Early Childhood Advisory Council
REFERENCES
  1. U.S. Congress. 2007. Head Start Act. 42 USC 9801. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Act/.

Standard 10.3.3.5: Licensing Agency Role in Communicating the Importance of Compliance with Americans with Disabilities Act

Licensing agencies should consistently make known the requirements under the Americans with Disabilities Act that child care programs must follow.

RATIONALE
Child care programs must comply with the requirements of the Americans with Disabilities Act.
COMMENTS
Procedures for evaluating allegations of physical and emotional abuse may or may not be the purview of the licensing agency. This responsibility may fall to another agency to which the licensing agency refers child abuse allegations.

Standard 10.3.4.1: Sources of Technical Assistance to Support Quality of Child Care

Public authorities (such as licensing agencies) and private agencies (such as resource and referral agencies), should develop systems for technical assistance to states, localities, child care agencies, and caregivers/teachers that address the following:

  1. Meeting licensing requirements;
  2. Establishing programs that meet the developmental needs of children;
  3. Educating parents/guardians on specific health and safety issues through the production and distribution of related material.
 

RATIONALE
The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:
  1. Licensing agencies (on ways to meet the regulations);
  2. Health departments (on health related matters);
  3. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
  4. Child care health, education, mental health consultant networks; American Academy of Pediatrics (AAP) state chapters and child care contacts; and state Early Childhood Comprehensive Systems (ECCS) grants are examples of partners providing technical assistance on health and related child care matters.

The state agency has a continuing responsibility to assist an applicant in qualifying for a license and to help licensees improve and maintain the quality of their facility. Regulations should be available to parents/guardians and interested citizens upon request and should be translated if needed. Licensing inspectors throughout the state should be required to offer assistance and consultation as a regular part of their duties and to coordinate consultation with other technical assistance providers as this is an integral part of the licensing process.

The Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) and the Office of Child Care (OCC) of the Administration for Children and Families (ACF) continue to develop initiatives that provide funding to support technical assistance to early care and education. States should check with their State Child Care Administrators, Maternal and Child Health Directors, and Head Start State Collaboration Directors, for more information.

Providing centers and networks of small or large family child care homes with guidelines and information on establishing a program of care is intended to promote appropriate programs of activities. Child care staff is rarely trained health professionals. Since staff and time are often limited, caregivers/teachers should have access to consultation on available resources in a variety of fields (such as physical and mental health care; nutrition; safety, including fire safety; oral health care; developmental disabilities; and cultural sensitivity) (1,2).

The public agencies can facilitate access to children and their families by providing useful materials to child care providers.

RELATED STANDARDS
2.4.3.2 Parent/Guardian Education Plan
10.3.3.1 Credentialing of Individual Child Care Providers
10.4.1.3 Licensing Agency Procedures Prior to Issuing a License
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians
REFERENCES
  1. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.
  2. American Academy of Pediatrics. 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

Standard 10.3.4.3: Support for Consultants to Provide Technical Assistance to Facilities

State agencies should encourage the arrangement and coordination of and the fiscal support for consultants from the local community to provide technical assistance for program development and maintenance. Consultants should have training and experience in early childhood education, early childhood growth and development, issues of health and safety in child care settings, business practices, ability to establish collegial relationships with child care providers, adult learning techniques, and ability to help establish links between facilities and community resources. There should be collaboration among all parts of the early care and education community to provide technical assistance and consultation to improve the quality of care. The licensing agency should be an integral part of the quality rating and improvement system (QRIS) in the state; all parts of the system must collaborate to assure the most effective and efficient use of resources to encourage quality improvement. See Glossary for definition of QRIS.

The state regulatory agency with the Title V or State Child Care Resource and Referral Agency should provide or arrange for other public agencies, private organizations or technical assistance agencies (such as a resource and referral agency) to make the following consultants available to the community of child care providers of all types:

  1. Program consultant, to provide technical assistance for program development and maintenance and business practices. Consultants should be chosen on the basis of training and experience in early childhood education and ability to help establish links between the facility and community resources;
  2. Child care health consultant (CCHC), who has knowledge and expertise in child health and child development, is knowledgeable about the special needs of children in out-of-home care settings, and knows the child care licensing requirements and available health resources. A regional plan to make consultants accessible to facilities for ongoing relationships should be developed;
  3. Nutritionist/registered dietitian, who also has the knowledge of infant and child development, food service, nutrition and nutrition education methods, to be responsible for the development of policies and procedures and for the implementation of nutrition standards to provide high quality meals, nutrition education programs and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors;
  4. Early childhood education consultant, to assist centers, large family child care homes, and networks of small family child care homes in partnering with families in meeting the individual development and learning needs of children, including any special developmental and educational needs that a child may have. Early Childhood Education Consultants can assist providers n early detection and referral for identifying and addressing special learning needs, especially infants and toddlers;
  5. Early childhood mental health consultant (ECMHC), to assist centers, large family child care homes, and networks of small family child care homes in meeting the emotional needs of children and families. The state mental health agency should promote funding through community mental health agencies and child guidance clinics for these services. At the least, such consultants should be available when caregivers/teachers identify children whose behaviors are more difficult to manage than typically developing children;
  6. Dental health consultant, to assist centers, large family child care homes and networks small family child care homes in meeting the oral health needs of children. The dental health consultant should have knowledge of pediatric oral health and be able to help with policy and procedure development in this area;
  7. Physical activity consultant, who has knowledge in infant and child motor development (developmental biomechanics), locomotion, ballistic, and manipulative skills, sensory-perceptual development, social, psychosocial, and cultural constraints in motor development, and development of cardio-respiratory endurance, strength and flexibility, and body composition, to be responsible for the development of policies and procedures for the implementation of age and developmentally appropriate physical activity standards to provide children with the movement experiences needed for optimal growth and development, physical education/movement programs, and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors.

A plan should be in place that supports the interdisciplinary collaboration of consultant support to programs to ensure coordinated support, avoid duplication and stress on programs and families, and promote efficient use of consultant resources.

Additionally, a plan should be in place that outlines how the state identifies, trains, and supports consultants who, in turn, support programs. Minimum qualifications required of consultants may be specified in state regulations. There are resources for training consultants that can be integrated into state plans for supporting health and other early childhood consultants. States will ideally take advantage of opportunities to partner with Head Start, child welfare, Part C and Part B, and others to maintain an ongoing system of supporting consultants and fostering partnerships that support children, families and programs and help improve the overall quality of services provided in the community.

RATIONALE
Securing expertise is acceptable by whatever method is most workable at the state or local level (for example, consultation could be provided from a resource and referral agency). Providers, not the regulatory agency, are responsible for securing the type of consultation that is required by their individual facilities. Ongoing relationships with CCHCs, nutritionists/registered dietitians, and ECMHCs are effective in promoting healthy and safe environments (3-5).
COMMENTS
Several states now have mental health consultants specifically serving the child care community. There are different models of mental health consultation. Some models are programmatic and only include the staff, others work with individual children with behavioral and emotional problems and the third model integrates both approaches. MHCs are usually social workers or professionals with a child development or psychology background who are trained to work in child care settings (2). There is no formal or standardized training for ECMHCs nationally. Developmental and behavioral pediatricians, child and adolescent psychiatrists, and child psychologists are resources for the behavioral and mental health needs of young children (1). Some, but not all, adolescent and child psychiatrists and psychologists, social workers and child counselors have the necessary skills to work with behavior problems of this youngest age group. To find such specialists, contact the Department of Pediatrics at academic centers or the State Department of Mental Health. The faculty at such centers can usually refer child care facilities to individuals with the necessary skills in their area.

The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:

  1. AAP Chapter Child Care Contact (contact information can be found at http://www.healthychildcare.org);
  2. Licensing agencies (on ways to meet the regulations and make quality improvements);
  3. Health departments (on health related matters);
  4. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
  5. Community action programs or non-profit organizations (on health related matters including physical education, for health education and/or quality improvement issues);
  6. Local university kinesiology departments (on early childhood motor development and physical activity issues);
  7. Small business administration (on financial issues related to program operations);
  8. Subsidy agencies may fund a variety of consultants to programs through the Child Care and Development Fund (CCDF) quality dollars;
  9. Education departments often administer the food program dollars and may have technical assistance related to the Individuals with Disabilities Education Act (IDEA).
REFERENCES
  1. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.
  2. 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.
  3. Crowley, A. A., J. M. Kulikowich. Impact of training on child care health consultant knowledge and practice. Ped Nurs 35:93-100.
  4. Healthy Child Care America. 2006. The influence of child care health consultants in promoting children’s health and well-being: A status report. Rockville, MD: Maternal and Child Health Bureau.
  5. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

Standard 10.3.4.5: Resources for Parents/Guardians of Children with Special Health Care Needs

The state agency or council of agencies responsible for child care services for children with special health care needs should aid parents/guardians in their assessment of facilities for care of children with special health care needs. Agencies should provide printed and audiovisual information about assessment of specialized health care to the parents/guardians.

In addition, the regulatory agency should refer parents/guardians of children with special health care needs to a medical home for assistance in development and formulation of a written care plan to be used within a child care program.

RATIONALE

 Parents/guardians of children with special health care needs require support to enable their identification and evaluation of facilities where their children can receive quality child care.

Parents/guardians should participate in the facility evaluation, both formally and informally. Unless the Interagency Coordinating Council (ICC) or some similar body provides information to parents/guardians, they are unlikely to be able to find and evaluate options for child care for children with special health care needs. While the professionals involved with the family may do this on behalf of the family, the parents/guardians should have every opportunity to play a significant role in the process.

The state licensing agency as well as the state agencies responsible for implementation of the Individuals with Disabilities Education Act (IDEA) should assist child care caregivers/teachers to recognize the opportunity they have to participate in the child’s overall care planning and to obtain training on effective inclusion in order to provide care to the children (1).

REFERENCES
  1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. State Title V contacts. https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp.

Standard 10.3.4.6: Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs

The agency (or a council of such agencies) within the state responsible for overseeing child care for children with special health care or educational needs should assure that the Individualized Family Service Plan (IFSP) or the Individualized Education Program (IEP) includes compensation for the hours of time spent by members of the multidisciplinary team and the staff from the child care program in developing the assessment defined in Standards 8.7.0.1-8.7.0.3.

RATIONALE

Unless there is a source of compensation for the time spent in planning and completing assessments, these requirements cannot be implemented.

Funding under Individuals with Disabilities Education Act (IDEA) makes it possible for the resources and funding for service to follow the child. Traditionally, these funds have paid for individual therapists only, and not for others who participate in formulating the IFSP or IEP. This tradition of restrained spending inhibits effective service delivery for children and families (1).

COMMENTS
For more information and resources, contact the State Children with Special Health Care Needs Program Director. Contact information for each state can be found at: https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp.
RELATED STANDARDS
8.7.0.1 Facility Self-Assessment
8.7.0.2 Technical Assistance in Developing Plan
8.7.0.3 Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs
REFERENCES
  1. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. State Title V contacts. https://perfdata.hrsa.gov/mchb/mchreports/link/state_links.asp.

Standard 10.3.4.7: Technical Assistance to Facilities to Address Diversity in the Community

Technical assistance and incentives should be provided by state, municipal, public, and private agencies to encourage facilities to address within their programs, the cultural and socioeconomic diversity in the broader community, not just in the neighborhood where the child care facility is located.

RATIONALE
 Children who are exposed to cultural and socioeconomic diversity in early childhood are more likely to value and accept differences between their own backgrounds and those of others as they move through life (1,2). This attitude results in improved self-esteem and mental health in children from all backgrounds. Facilities may be able to attract participants from different income and cultural groups by paying attention to the location of the facility and available subsidies for low income families.
REFERENCES
  1. Biles, B. Activities that promote racial and cultural awareness. http://www.pbs.org/kcts/preciouschildren/diversity/read_activities.html.
  2. National Childcare Accreditation Council. 2005. Diversity in programming: Family day care quality assurance - Factsheet #4. http://www.ncac.gov.au/factsheets/factsheet4.pdf.

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 10.6.1.2: 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
1.4.5.2 Child Abuse and Neglect Education
1.4.5.1 Training of Staff Who Handle Food
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
10.5.0.1 State and Local Health Department Role