Special Collection

Stepping Stones to Caring for Our Children, 3rd Edition (SS3)

Stepping Stones, Third Edition (SS3) is the collection of selected CFOC3 standards which, when put into practice, are most likely to prevent serious adverse outcomes in child care and early education settings.

Adverse outcomes are defined as harm resulting from failure to practice the recommendations in the CFOC3 standards. These harmful results may include frequent or severe disease or injury, disability, or death (morbidity and mortality).

This valuable resource was developed with our collaborative partners, the American Academy of Pediatrics (AAP) and the American Public Health Association (APHA). 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.


Stepping Stones to Caring for Our Children, 3rd Edition Compliance/Comparison Checklist - PDF

Suggestions for Use of the Compliance/Comparison Checklist:

  • By licensing staff who want to compare Stepping Stones standards to the subject areas covered in their state regulations and determine where there are gaps and where regulations should be added.
  • By caregivers/teachers/directors who want to be sure they are complying with those standards that have the most potential to prevent harm to children in their settings.
  • By families who want to be sure their child’s early care and education program is complying with these important standards.
  • By child care health consultants and trainers to assess what topics need to be covered when providing training.
  • Be sure to save the checklist to your device in order to use the interactive checklist feature.

Table of Contents

Chapter 1 - Staffing

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.2.0.2 Background Screening
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
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
1.4.2.2 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
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.5.0.1 Employment of Substitutes
1.5.0.2 Orientation of Substitutes
1.6.0.1 Child Care Health Consultants

Chapter 2 - Program Activities for Healthy Development

2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.2.0.1 Methods of Supervision of Children
2.2.0.4 Supervision Near Bodies of Water
2.2.0.6 Discipline Measures
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
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior

Chapter 3 - Health Promotion and Protection

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
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.1 Routine Oral Hygiene Activities
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
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.3.1 Emergency Procedures
3.4.3.3 Response to Fire and Burns
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.5.1 Sun Safety Including Sunscreen
3.4.6.1 Strangulation Hazards
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
3.6.1.4 Infectious Disease Outbreak Control
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
3.6.3.3 Training of Caregivers/Teachers to Administer Medication

Chapter 4 - Nutrition and Food Service

4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.6 Availability of Drinking Water
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.10 Care for Children with Food Allergies
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.5.0.9 Hot Liquids and Foods
4.5.0.10 Foods that Are Choking Hazards
4.8.0.1 Food Preparation Area
4.8.0.3 Maintenance of Food Service Surfaces and Equipment
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply

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

5.1.1.2 Inspection of Buildings
5.1.1.3 Compliance with Fire Prevention Code
5.1.1.5 Environmental Audit of Site Location
5.1.3.2 Possibility of Exit from Windows
5.1.4.1 Alternate Exits and Emergency Shelter
5.1.5.4 Guards at Stairway Access Openings
5.1.6.6 Guardrails and Protective Barriers
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.1.10 Gas, Oil, or Kerosene Heaters, Generators, Portable Gas Stoves, and Charcoal and Gas Grills
5.2.1.11 Portable Electric Space Heaters
5.2.4.2 Safety Covers and Shock Protection Devices for Electrical Outlets
5.2.4.4 Location of Electrical Devices Near Water
5.2.5.1 Smoke Detection Systems and Smoke Alarms
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.7.6 Storage and Disposal of Infectious and Toxic Wastes
5.2.8.1 Integrated Pest Management
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.2 Use of a Poison Center
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.13 Testing for Lead
5.3.1.1 Safety of Equipment, Materials, and Furnishings
5.3.1.12 Availability and Use of a Telephone or Wireless Communication Device
5.4.5.2 Cribs
5.5.0.6 Inaccessibility to Matches, Candles, and Lighters
5.5.0.7 Storage of Plastic Bags
5.5.0.8 Firearms
5.6.0.1 First Aid and Emergency Supplies
5.7.0.4 Inaccessibility of Hazardous Equipment

Chapter 6 - Play Areas/Playgrounds and Transportation

6.1.0.6 Location of Play Areas Near Bodies of Water
6.1.0.8 Enclosures for Outdoor Play Areas
6.2.1.9 Entrapment Hazards of Play Equipment
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
6.2.4.4 Trampolines
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
6.3.1.1 Enclosure of Bodies of Water
6.3.1.4 Safety Covers for Swimming Pools
6.3.1.6 Pool Drain Covers
6.3.2.1 Lifesaving Equipment
6.3.5.1 Hot Tubs, Spas, and Saunas
6.3.5.2 Water in Containers
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
6.4.1.5 Balloons
6.4.2.2 Helmets
6.5.1.1 Competence and Training of Transportation Staff
6.5.1.2 Qualifications for Drivers
6.5.2.2 Child Passenger Safety
6.5.2.4 Interior Temperature of Vehicles
6.5.3.1 Passenger Vans

Chapter 7 - Infectious Disease

7.2.0.2 Unimmunized Children
7.2.0.3 Immunization of Caregivers/Teachers
7.3.3.1 Influenza Immunizations for Children and Caregivers/Teachers
7.3.3.2 Influenza Control
7.3.5.1 Recommended Control Measures for Invasive Meningococcal Infection in Child Care
7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.5.10.1 Staphylococcus Aureus Skin Infections Including MRSA

Chapter 9 - Policies

9.2.3.2 Content and Development of the Plan for Care of Children and Staff Who Are Ill
9.2.3.12 Infant Feeding Policy
9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.5 Emergency and Evacuation Drills/Exercises Policy
9.2.4.7 Sign-In/Sign-Out System
9.2.4.8 Authorized Persons to Pick Up Child
9.4.1.10 Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program
9.4.1.12 Record of Valid License, Certificate, or Registration of Facility
9.4.2.6 Contents of Medication Record

Chapter 10 - Licensing and Community Action

10.4.2.1 Frequency of Inspections for Child Care Centers, Large Family Child Care Homes, and Small Family Child Care Homes

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 J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix L: Cleaning Up Body Fluids
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 P: Situations that Require Medical Attention Right Away
Appendix S: Physical Activity: How Much Is Needed?
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment
Appendix AA: Medication Administration Packet
Appendix CC: Incident Report Form
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America’s Playgrounds Safety Report Card
Appendix JJ: Our Child Care Center Supports Breastfeeding
Appendix G: Recommended Childhood Immunization Schedule

Chapter 1 - Staffing

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 1.1.1.4: Ratios and Supervision During Transportation

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

RATIONALE

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

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

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

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

Developmental Levels

Child:Staff Ratio

Infants

1:1

Toddlers

1:1

Preschoolers

4:1

School-age Children

6:1

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

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

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

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

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

Standard 1.2.0.2: Background Screening

Directors of centers and caregivers/teachers in large and small family child care homes should conduct a complete background screening before employing any staff member (including substitutes, cooks, clerical staff, transportation staff, bus drivers, or custodians who will be on the premises or in vehicles when children are present). The background screening should include:

  1. Name and address verification;
  2. Social Security number verification;
  3. Education verification;
  4. Employment history;
  5. Alias search;
  6. Driving history through state Department of Motor Vehicles records;
  7. Background screening of:
    1. State and national criminal history records;
    2. Child abuse and neglect registries;
    3. Licensing history with any other state agencies (i.e., foster care, mental health, nursing homes, etc.);
    4. Fingerprints; and
    5. Sex offender registries;
  8. Court records;
  9. References.

All family members over age ten living in large and small family child care homes should also have background screenings.

Drug tests may also be incorporated into the background screening. Written permission to obtain the background screening (with or without a drug screen) should be obtained from the prospective employee. Consent to the background investigation should be required for employment consideration.

When checking references and when conducting employee or volunteer interviews, prospective employers should specifically ask about previous convictions and arrests, investigation findings, or court cases with child abuse/neglect or child sexual abuse. Failure of the prospective employee to disclose previous history of child abuse/neglect or child sexual abuse is grounds for immediate dismissal.

Persons should not be hired or allowed to work or volunteer in the child care facility if they acknowledge being sexually attracted to children or having physically or sexually abused children, or are known to have committed such acts.

Background screenings should be repeated periodically taking into consideration state laws and/or requirements. Screenings should be repeated more frequently if there are additional concerns.

RATIONALE
To ensure their safety and physical and mental health, children should be protected from any risk of abuse or neglect. Although few persons will acknowledge past child abuse or neglect to another person, the obvious attention directed to the question by the licensing agency or caregiver/teacher may discourage some potentially abusive individuals from seeking employment in child care. Performing diligent background screenings also protects the child care facility against future legal challenges (1). Having a state credentialing system can reduce the time required to ensure all those caring for children have had the required background screening review.
COMMENTS
Directors who are conducting screenings and caregivers/teachers who are asked to submit a background screening record should contact their state child care licensing agency for the appropriate documentation required. Fingerprinting can be secured at local law enforcement offices or the State Bureau of Investigation. Court records are public information and can be obtained from county court offices and some states have statewide online court records. When checking for prior arrests or previous court actions, the facility should check for misdemeanors as well as felonies. Driving records are available from the State Department of Motor Vehicles. A social security trace is a report, derived from credit bureau records that will return all current and reported addresses for the last seven to ten years on a specific individual based on his or her social security number. If there are alternate names (aliases) these are also reported. State child abuse registries can be accessed at http://www.hunter.cuny.edu/socwork/nrcfcpp/downloads/policy-issues/State_Child_Abuse_Registries
.pdf. Sex offender registries can be accessed at http://www
.prevent-abuse-now.com/register.htm. Companies also offer background check services. The National Association of Professional Background Screeners (http://www.napbs.com) provides a directory of their membership.

For more information on state licensing requirements regarding criminal background screenings, see the National Association for Regulatory Administration’s (NARA) current Licensing Study at http://www.naralicensing.org.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Privacy Rights Clearinghouse. 2011. Fact sheet 16: Employment background checks: A jobseeker’s guide. http://www.privacyrights.org/fs/fs16-bck.htm.

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 1.3.3.1: 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
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Three to Thirty-Five Months of Age
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.6 Additional Qualifications for Caregivers/Teachers Serving School-Age Children
1.4.3.1 First Aid and CPR Training for Staff
1.4.3.2 Topics Covered in First Aid Training
1.4.3.3 CPR Training for Swimming and Water Play
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
REFERENCES
  1. 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 1.4.2.2: 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 1.4.3.3: CPR Training for Swimming and Water Play

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

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

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

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

All staff members with food handling responsibilities should obtain training in food service and safety. The director of a center or a large family child care home or the designated supervisor for food service should be a certified food protection manager or equivalent as demonstrated by completing an accredited food protection manager course. Small family child care personnel should secure training in food service and safety appropriate for their setting.

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

Standard 1.4.5.2: Child Abuse and Neglect Education

Caregivers/teachers should use child abuse and neglect prevention education to educate and establish child abuse and neglect prevention and recognition measures for the children, caregivers/teachers, and parents/guardians. The education 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. Caregivers/teachers should be able to identify signs of stress in families and assist families by providing support and linkages to resources when needed. Children with disabilities are at a higher risk of being abused. Special training in child abuse and neglect and children with disabilities should be provided (2).

Caregivers/teachers are mandatory reporters of child abuse or neglect. Caregivers/teachers should be trained in compliance with their state’s child abuse reporting laws. Child abuse reporting requirements are known and available from the child care regulation department in each state.

RATIONALE
Education about the manifestations of child maltreatment can increase the likelihood of appropriate reports to child protection agencies and law enforcement agencies (1-3).
COMMENTS
Child abuse and neglect materials should be designed for non-medical audiences. Resources are available from the American Academy of Pediatrics (AAP) at http://www.aap.org, the Child Welfare Information Gateway at http://www.childwelfare.gov, and Prevent Child Abuse America at http://www.preventchildabuse.org.
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 Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.4.3.3 Training Record
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
REFERENCES
  1. Giardino, A. P., E. R. Giardino. 2002. Recognition of child abuse for the mandated reporter. 3rd ed. St. Louis, MO: G. W. Medical Publishing.
  2. New York State Office of Children and Family Services. Child abuse and children with disabilities: A New York State perspective. http://childabuse.tc.columbia.edu.
  3. American Academy of Pediatrics. Children’s health topics: Child abuse and neglect. http://www.aap.org/healthtopics/
    childabuse.cfm.

Standard 1.5.0.1: Employment of Substitutes

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

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

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

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

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

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

Standard 1.5.0.2: Orientation of Substitutes

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 to include a review of ALL the program’s policies and procedures (listed below is a sample). This training should include the opportunity for an evaluation and a repeat demonstration of the training lesson. In all child care settings the orientation should be documented. 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 if an infant is enrolled in the program;
  2. Any emergency medical procedure/medication needs of the children;
  3. Any nutrition needs of the children.

All substitute caregivers/teachers, during the first week of employment, 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 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 the following:
    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, use and wearing of gloves;
    3. 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 for all ages;
    4. Correct food preparation and storage techniques, if employee prepares food;
    5. Proper handling and storage of human milk when applicable and formula preparation if formula is handled;
    6. Bottle preparation including guidelines for human milk and formula if care is provided to children with bottles;
    7. Proper use of gloves in compliance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations;
    8. Injury prevention and safety including the role of mandatory child abuse reporter to report any suspected abuse/neglect.
  8. Emergency plans and practices;
  9. Access to list of authorized individuals for releasing children.

RATIONALE
Upon employment, substitutes should be able to carry out the duties assigned to them. Because facilities and the children enrolled in them vary, orientation programs for new substitutes can be most productive. Because of frequent staff turnover, child care programs must institute orientation programs as needed that protect the health and safety of children and new staff (1-3).

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 eighteen times (4).

COMMENTS
Anyone who substitutes regularly should be up to date on all basic training as specified in this standard.
TYPE OF FACILITY
Center, Large 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. 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.
  2. Cain, D. W., L. C. Rudd, T. F. Saxon. 2007. Effects of professional development training on joint attention engagement in low-quality childcare centers. Early Child Devel Care 177:159-85.
  3. Crosland, K. A., G. Dunlap, W. Sager, et al. 2008. The effects of staff training on the types of interactions observed at two group homes for foster care children. Research Soc Work 18:410-20.
  4. Gore, J. S. 1997. Does school-age child care staff training make a difference? School-Age Connections, vol. 6. http://www.canr
    .uconn.edu/ces/child/newsarticles/SAC643.html.

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.

Chapter 2 - Program Activities for Healthy Development

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 2.1.2.1: Personal Caregiver/Teacher Relationships for Infants and Toddlers

The facility should practice a relationship-based philosophy that promotes consistency and continuity of caregivers/teachers for infants and toddlers. The facility should limit the number of caregivers/teachers who interact with any one infant (1,2) to no more than five caregivers/teachers across the period that the child is an infant in child care. The caregiver/teacher should:

  1. Hold and comfort children who are upset;
  2. Engage in frequent, multiple, and rich social interchanges such as smiling, talking, touching, singing, and eating;
  3. Be play partners as well as protectors;
  4. Be attuned to children’s feelings and reflect them back;
  5. Communicate consistently with parents/guardians;
  6. Interact with children and develop a relationship in the context of everyday routines (diapering, feeding, etc.)

Opportunities should be provided for each child to develop a personal and affectionate relationship with, and attachment to, that child’s parents/guardians and one or a small number of caregivers/teachers whose care for and responsiveness to the child ensure relief of distress, experiences of comfort and stimulation, and satisfaction of the need for a personal relationship.

RATIONALE
Trustworthy adults who give of themselves as they provide care and learning experiences play a key role in a child’s development as an active, self-knowing, self-respecting, thinking, feeling, and loving person (3,6). Limiting the number of adults with whom an infant interacts fosters reciprocal understanding of communication cues that are unique to each child. This leads to a sense of trust of the adult by the infant that the infant’s needs will be understood and met promptly (5). Studies of infant behavior show that infants have difficulty forming trusting relationships in settings where many adults interact with a child, e.g., in hospitalization of infants when shifts of adults provide care (4,6). This difficulty occurs even if each of the many adults is very caring in their interaction with the child (7). There should be breaks at least every four hours and in accordance with U.S. Department of Labor laws.
COMMENTS
Hugging, holding, and cuddling infants and children are expressions of wholesome love that should be encouraged. Caregivers/teachers should be advised that it is alright to demonstrate affection for children of both sexes. At all times, caregivers/teachers should respect the wishes of children, regardless of their ages, with regard to physical contact and their comfort or discomfort with it. Caregivers/teachers should avoid even “friendly contact” (such as touching the shoulder or arm) with a child if the child is uncomfortable with it.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, IL: Learning Seed.
  2. Lally, R. J. 2000. Infants have their own curriculum: A responsive approach to curriculum planning for infants and toddlers. U.S. Department of Health and Human Services, Administration for Children and Families, Early Childhood Learning and Knowledge Center. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/teaching/eecd/Curriculum/Definition and Requirements/edudev_art_00032_071005.html.
  3. Raikes, H. 1996. A secure base for babies: Applying attachment concepts to the infant care setting. Young Children 51:59-67.
  4. Cassidy J., Shaver, P., eds. 1999. Handbook of attachment: Theory, research and clinical applications, 671-87. 2nd ed. New York: Guilford Press.
  5. Botkin, D., et al. 1991. Children’s affectionate behavior: Gender differences. Early Education Dev 2:270-86.
  6. Theilheimer, R. 2006. Molding to the children: Primary caregiving and continuity of care. Zero to Three 26:50-54.
  7. Creyer, D., S. Hurwitz, M. Wolery. 2003. Continuity of caregiver for infants and toddlers. ERIC Clearinghouse on Elementary and Early Care Education. http://www.ericdigests.org/2004-3/
    infants.html.

Standard 2.2.0.1: Methods of Supervision of Children

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

COMMENTS

ADDITIONAL READINGS:

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

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

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

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

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

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
5.4.1.2 Location of Toilets and Privacy Issues
REFERENCES
  1. 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. National Association for the Education of Young Children. 1996. Position Statement. Prevention of child abuse in early childhood programs and the responsibilities of early childhood professionals to prevent child abuse.
  3. National Program for Playground Safety. 2006. NPPS Website. http://www.playgroundsafety.org.
  4. National Program for Playground Safety. 2006. Playground supervision training for childcare providers. University of Northern Iowa. http://www.playgroundsafety.org/training/online/childcare/course_supervision.htm.

Standard 2.2.0.4: Supervision Near Bodies of Water

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

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

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

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

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

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

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

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

The American Academy of Pediatrics (AAP) recommends:

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

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

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

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

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

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

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

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 Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.1.6 Written Discipline Policies
9.4.1.6 Availability of Documents to Parents/Guardians
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 2.2.0.8: 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
2.2.0.6 Discipline Measures
1.6.0.3 Early Childhood Mental Health Consultants
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.2.0.10 Using Physical Restraint
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

The following behaviors should be prohibited in all child care settings and by all caregivers/teachers:

  1. The use of corporal punishment. Corporal punishment means punishment inflicted directly on the body including, but not limited to:
    1. Hitting, spanking (refers to striking a child with an open hand 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. Compelling a child to eat or have in his/her mouth soap, food, spices, or foreign substances;
    4. Exposing a child to extremes of temperature.
  2. Isolating a child in an adjacent room, hallway, closet, darkened area, play area, or any other area where a child cannot be seen or supervised;
  3. Binding or tying to restrict movement, such as in a car seat (except when travelling) 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 abuse or maltreatment of a child, either as an incident of discipline or otherwise. Any child care program must not tolerate, or in any manner condone, an act of abuse or neglect of a child by an older child, employee, volunteer, or any person employed by the facility or child’s family;
  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 (1);
  10. Physical activity/outdoor time should not be taken away as punishment.

RATIONALE
Corporal punishment may be physical abuse or may easily become abusive. Corporal punishment is clearly prohibited in family child care homes and centers in the majority of states (2-4). Research links corporal punishment with negative effects such as later aggression (5) behavior problems in school (6,7), antisocial and criminal behavior, and impairment of learning (8-12).

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), and increasing liability suits. The American Academy of Pediatrics (AAP) is opposed to the use of corporal punishment (12). Physicians, educators, and caregivers/teachers should neither inflict nor sanction corporal punishment (11).

COMMENTS
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 impose limitations by encouraging activities that distract them from harmful situations. Brief verbal expressions of disapproval help prepare infants and toddlers for later use of reasoning. However, the caregiver/teacher cannot expect infants and toddlers to be controlled by verbal reprimands. Preschoolers have begun to develop an understanding of rules and can be expected to understand “time-out” (out-of-group activity) under adult supervision as a consequence for undesirable behavior. School-age children begin to develop a sense of personal responsibility and self-control and will recognize the removal of privileges (12). This standard covers any behaviors that threaten the safety and security of children. This would include behaviors that occur among or between staff. Children should not see hitting, ridicule, etc. among staff members. Even though adults may state that the behaviors are “playful,” children cannot distinguish this.

“In the wake of well-publicized allegations of child abuse in out-of-home settings and increased concerns regarding 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 touches convey regard and concern for children of any age. Adults should be sensitive to ensuring that their touches (such as pats on the back, hugs, or ruffling the 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 as to acceptable ways for adults to show their respect and support for children in the program” (13).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.6 Discipline Measures
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.10 Using Physical Restraint
REFERENCES
  1. National Association for the Education of Young Children. 1996. Position Statement. Prevention of child abuse in early childhood programs and the responsibilities of early childhood professionals to prevent child abuse.
  2. Straus, M. A., et al. 1997. Spanking by parents and subsequent antisocial behavior of children. Arch Pediatric Adolescent Medicine 151:761-67.
  3. 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.
  4. American Academy of Pediatrics, Committee on Psychological Aspects of Child and Family Health. 2004. Policy statement: Guidance for effective discipline. Pediatrics 114:1126.
  5. American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in schools. Pediatrics 188:1266.
  6. Deater-Deckard, K., et al. 1996. Physical discipline among African American and European American mothers: Links to children’s externalizing behaviors. Dev Psychology 32:1065-72.
  7. Grogan-Kaylor, A. 2005. Corporal punishment and the growth trajectory of children’s antisocial behavior. Child Maltreatment 10:283-92.
  8. Slade, E. P., L. S. Wissow. 2004. Spanking in early childhood and later behavior problems: A prospective study of infants and young toddlers. Pediatrics 113:1321-30.
  9. Gershoff, E. T. 2002. Corporal punishment by parents and associated child behaviors and experiences: A meta-analytic and theoretical review. Psychological Bulletin 128:539-79.
  10. Meadows, A., ed. 1991. Caring for America’s Children. Washington, DC: National Academy of Sciences and National Research Council.
  11. Azer, S., D. Eldred. 1998. Training requirements in child care licensing regulations. Boston, MA: Center for Career Development in Early Care and Education, Wheelock College.
  12. The Children’s Foundation. Family child care licensing study. 2000. Washington, DC: The Children’s Foundation.
  13. New York State Office of Children and Family Services. Child care forms, licensed/ registered provider. http://www.ocfs.state.ny.us/main/forms/day_care/.

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 2.3.3.1: 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.

Chapter 3 - Health Promotion and Protection

Standard 3.1.2.1: Routine Health Supervision and Growth Monitoring

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

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

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

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

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

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

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

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
REFERENCES
  1. Centers for Disease Control and Prevention. 2011. About BMI for children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.
  2. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health.
  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. Kleinman, R. E. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Paige, D. M. 1988. Clinical nutrition. 2nd ed. St. Louis: Mosby.

Standard 3.1.3.1: Active Opportunities for Physical Activity

The facility should promote children’s active play every day. Children should have ample opportunity to do moderate to vigorous activities such as running, climbing, dancing, skipping, and jumping. All children, birth to six years, should participate daily in:

  1. Two to three occasions of active play outdoors, weather permitting (see Standard 3.1.3.2: Playing Outdoors for appropriate weather conditions);
  2. Two or more structured or caregiver/teacher/adult-led activities or games that promote movement over the course of the day—indoor or outdoor;
  3. Continuous opportunities to develop and practice age-appropriate gross motor and movement skills.

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

  1. Outdoor play:
    1. Infants (birth to twelve months of age) should be taken outside two to three times per day, as tolerated. There is no recommended duration of infants’ outdoor play;
    2. Toddlers (twelve months to three years) and preschoolers (three to six years) should be allowed sixty to ninety total minutes of outdoor play. These outdoor times can be curtailed somewhat during adverse weather conditions in which children may still play safely outdoors for shorter periods, but should increase the time of indoor activity, so the total amount of exercise should remain the same;
  2. Total time allotted for moderate to vigorous activities:
    1. Toddlers should be allowed sixty to ninety minutes per eight-hour day for moderate to vigorous physical activity, including running;
    2. Preschoolers should be allowed ninety to one hundred and twenty minutes per eight-hour day (4).

Infants should have supervised tummy time every day when they are awake. Beginning on the first day at the early care and education program, caregivers/teachers should interact with an awake infant on their tummy for short periods of time (three to five minutes), increasing the amount of time as the infant shows s/he enjoys the activity (27).

Time spent outdoors has been found to be a strong, consistent predictor of children’s physical activity (1-3). Children can accumulate opportunities for activity over the course of several shorter segments of at least ten minutes each. Because structured activities have been shown to produce higher levels of physical activity in young children, it is recommended that caregivers/teachers incorporate two or more short structured activities (five to ten minutes) or games daily that promote physical activity.

Opportunities to be actively enjoying physical activity should be incorporated into part-time programs by prorating these recommendations accordingly, i.e., twenty minutes of outdoor play for every three hours in the facility.

Active play should never be withheld from children who misbehave (e.g., child is kept indoors to help another caregiver/teacher while the rest of the children go outside) (5). However, children with out-of-control behavior may need five minutes or less to calm themselves or settle down before resuming cooperative play or activities.

Infants should not be seated for more than fifteen minutes at a time, except during meals or naps. Infant equipment such as swings, stationary activity centers (ex. exersaucers), infant seats (ex. bouncers), molded seats, etc. if used should only be used for short periods of time. A least restrictive environment should be encouraged at all times (5,6,26).

Children should have adequate space for both inside and outside play.

RATIONALE
Free play, active play and outdoor play are essential components of young children’s development (2). Children learn through play, developing gross motor, socio-emotional, and cognitive skills. In outdoor play, children learn about their environment, science, and nature.

Infants’ and young children’s participation in physical activity is critical to their overall health, development of motor skills, social skills, and maintenance of healthy weight (7). Daily physical activity promotes young children’s gross motor development and provides numerous health benefits including improved fitness and cardiovascular health, healthy bone development, improved sleep, and improved mood and sense of well-being. Tummy time prepares infants for the time when they will be able to slide on their bellies and crawl. As infants grow older and stronger they will need more time on their tummies to build their own strength (27).

Daily physical activity is an important part of preventing excessive weight gain and childhood obesity. Some evidence also suggests that children may be able to learn better during or immediately after bursts of physical activity, due to improved attention and focus (8,9).

Numerous reports suggest that children are not meeting daily recommendations for physical activity, and that children spend 70% (10) to 87% (11) of their time in early care and education being sedentary, (i.e., sitting or lying down). Excluding nap time, children are sedentary 83% of the time (11). Children may only spend about 2% to 3% of time being moderately or vigorously active (11).

Very young children are entirely dependent on their caregivers/teachers for opportunities to be active (12-15). Especially for children in full-time care and for children who live in unsafe neighborhoods, the early care and education facility may provide the child’s only daily opportunity for active play. Evidence suggests that physical activity habits learned early in life may track into adolescence and adulthood supporting the importance for children to learn lifelong healthy physical activity habits while in the early care and education program (13,16-25).

COMMENTS
There are many ways to promote tummy time with infants:
  1. Place yourself or a toy just out of the infant’s reach during playtime to get him to reach for you or the toy;
  2. Place toys in a circle around the infant. Reaching to different points in the circle will allow him/her to develop the appropriate muscles to roll over, scoot on his/her belly, and crawl;
  3. Lie on your back and place the infant on your chest. The infant will lift his/her head and use his/her arms to try to see your face (27).

There are a multitude of short, structured activities that are appropriate for toddlers and preschoolers. Structured activities could include popular children’s games such as Simon Says, Mother May I, Red Rover, Get the Wiggles Out, Musical Chairs, or a simple walk through the neighborhood. For training materials and more ideas of effective and age-appropriate games for young children, consider the following resources:

  1. “Nutrition and Physical Activity Self Assessment for Child Care - NAP SACC Program” – http://www
    .napsacc.org;
  2. “Color Me Healthy Preschoolers Moving and Eating” – http://www.colormehealthy.com;
  3. “Let’s Move, Learn, and Have Fun” physical activity curriculum from Kansas State University;
  4. “I am Moving I am Learning: Intervention in Head Start” – http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health/Health/Nutrition/Nutrition Program Staff/
    IamMovingIam.htm;
  5. “Moving and Learning: The Physical Activity Specialists for Birth through Age 8” – http://www
    .movingandlearning.com;
  6. “How to Lower Your Risk for Type 2 Diabetes: National Diabetes Education Program” – http://ndep.nih
    .gov/media/kids-tips-lower-risk.pdf;
  7. “Motion Moments” – http://nrckids.org/Motion
    _Moments/.

Experts disagree about the appropriate amount of physical activity for toddlers and preschoolers, what proportion of children’s physical activity should be structured, and to what extent structured activities are effective in producing children’s physical activity. Researchers do agree that toddlers and preschoolers generally accumulate moderate to vigorous physical activity over the course of the day in very short bursts (fifteen to thirty seconds) (23). For additional recommendations by other national groups and experts, see:

  1. The National Association for Sport and Physical Education’s Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5, 2nd Edition at http://www.aahperd.org/naspe/standards/
    nationalGuidelines/ActiveStart.cfm and Physical Activity for Children: A Statement of Guidelines for Children 5 - 12, 2nd Edition at http://www.aahperd
    .org/naspe/standards/nationalGuidelines/PA
    -Children-5-12.cfm;
  2. U.S. Department of Health and Human Services’ 2008 Physical Activity Guidelines for Americans at http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf;
  3. U.S. Department of Health and Human Services and the U.S. Department of Agriculture’s Dietary Guidelines for Americans, 2010 at http://www.cnpp.usda
    .gov/DGAs2010-DGACReport.htm.
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
5.3.1.10 Restrictive Infant Equipment Requirements
9.2.3.1 Policies and Practices that Promote Physical Activity
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES
  1. American Academy of Pediatrics (AAP). 2008. Back to sleep, tummy to play. Elk Grove Village, IL: AAP. http://www.healthychildcare.org/pdf/SIDStummytime.pdf.
  2. Burdette, H. L., R. C. Whitaker, S. R. Daniels. 2004. Parental report of outdoor playtime as a measure of physical activity in preschool-aged children. Arch Pediatr Adolesc Med 158:353-57.
  3. Bower, J. K., D. P. Hales, D. F. Tate, D. A. Rubin, S. E. Benjamin, D. S. Ward. 2008. The childcare environment and children’s physical activity. Am J Prev Med 34:23-29.
  4. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. The nutrition and physical activity self-assessment for child care (NAP SACC). Rev ed. Raleigh and Chapel Hill, NC: UNC Center for Health Promotion and Disease Prevention, Center of Excellence for Training and Research Translation. http://www.center-trt.org/downloads/obesity_prevention/interventions/napsacc/NAPSACC_Template.pdf.
  5. National Association for Sport and Physical Education (NASPE). 2002. Active start: A statement of physical activity guidelines for children birth to five years. Washington, DC: NASPE.
  6. Patrick, K., B. Spear, K. Holt, D. Sofka, eds. 2001. Bright futures in practice: Physical activity. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures
    .org/physicalactivity/pdf/index.html.
  7. Pellegrini, A., C. Bohn. 2005. The role of recess in children’s cognitive performance and school adjustment. Educ Res 34:13-19.
  8. Mahar, M. T., S. K. Murphy, D. A. Rowe, J. Golden, A. T. Shields, T. D. Raedeke. 2006. Effects of a classroom-based program on physical activity and on-task behavior. Med Sci Sports Exerc 38:2086-94.
  9. Pate, R. R., K. A. Pfeiffer, S. G. Trost, P. Ziegler, M. Dowda. 2004. Physical activity among children attending preschools. Pediatrics 114:1258-63.
  10.  Pate, R. R., K. McIver, M. Dowda, W. H. Brown, A. Cheryl. 2008. Directly observed physical activity levels in preschool children. J Sch Health 78:438-44.
  11. McKenzie, T. L., J. F. Sallis, J. P. Elder, C. C. Berry, P. L. Hoy, P. R. Nader, M. M. Zive, S. L. Broyles. 1997. Physical activity levels and prompts in young children at recess: A two-year study of a bi-ethnic sample. Res Q Exerc Sport 68:195-202.
  12. Sallis, J. F., T. L. McKenzie, J. P. Elder, S. L. Broyles, P. R. Nader. 1997. Factors parents use in selecting play spaces for young children. Arch Pediatr Adolesc Med 151:414-17.
  13. Sallis, J. F., P. R. Nader, S. L. Broyles, J. P. Elder, T. L. McKenzie, J. A. Nelson. 1993. Correlates of physical activity at home in Mexican-American and Anglo-American preschool children. Health Psychol 12:390-98.
  14. Davis, K., K. K. Christoffel. 1994. Obesity in preschool and school-age children: Treatment early and often may be best. Arch Pediatr Adolesc Med 148:1257-61.
  15. Sallis, J. F., C. C. Berry, S. L. Broyles, T. L. McKenzie, P. R. Nader. 1995. Variability and tracking of physical activity over 2 yr in young children. Med Sci Sports Exerc 27:1042-49.
  16. Pate, R. R., T. Baranowski, S. G. Trost. 1996. Tracking of physical activity in young children. Med Sci Sports Exerc 28:92-96.
  17. Birch, L. L., J. O. Fisher. 1998. Development of eating behaviors among children and adolescents. Pediatrics 101:539-49.
  18. Sallis, J. F., J. J. Prochaska, W. C. Taylor. 2000. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc 32:963-75.
  19. Skinner, J. D., B. R. Carruth, W. Bounds, P. Ziegler, K. Reidy. 2002. Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? J Nutr Educ Behav 34:310-15.
  20. Skinner, J. D., B. R. Carruth, B. Wendy, P. J. Ziegler. 2002. Children’s food: A longitudinal analysis. J Am Diet Assoc 102:1638-47.
  21. Oliver, M., G. M. Schofield, G. S. Kolt. 2007. Physical activity in preschoolers: Understanding prevalence and measurement issues. Sports Med 37:1045-70.
  22. American Academy of Pediatrics, Council on Sports Medicine and Fitness, and Council on School Health. 2006. Active healthy living: Prevention of childhood obesity through increased physical activity. Pediatrics 117:1834-42.
  23. Physical Activity Guidelines Advisory Committee. 2008. Physical activity guidelines advisory committee report, 2008. Washington, DC: U.S. Department of Health and Human Services. http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf.
  24. American Physical Therapy Association. 2008. Lack of time on tummy shown to hinder achievement of developmental milestones, say physical therapists. News Release.
  25. Burdette, H. L., R. C. Whitaker. 2005. Resurrecting free play in young children: Looking beyond fitness and fatness to attention, affiliation, and affect. Arch Pediatr Adolesc Med 159:46-50.
  26. 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

Standard 3.1.3.2: Playing Outdoors

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

Children should play outdoors when the conditions do not pose a safety risk, individual child health risk, or significant health risk of frostbite or of 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. Outdoor play for infants may include riding in a carriage or stroller; however, infants should be offered opportunities for gross motor play outdoors, as well.

Weather that poses a significant health risk should include wind chill factor at or below minus 15°F and heat index at or above 90°F, as identified by the National Weather Service (NWS).

Sunny weather:

  1. Children should be protected from the sun by using shade, sun-protective clothing, and sunscreen with UVB-ray and UVA-ray protection of SPF 15 or higher, with permission from parents/guardians;
  2. Children should wear sun-protective clothing, such as hats, when playing outdoors between the hours of 10 AM and 4 PM.

Warm weather:

  1. Children should be well hydrated before engaging in prolonged periods of physical activity and encouraged to drink water during periods of prolonged physical activity;
  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 six 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 precipitation is present, such as rain or snow;
    2. Children should wear a hat, coat, and gloves/mittens kept snug at the wrist;
    3. Caregivers/teachers should check children’s extremities for maintenance of normal color and warmth at least every fifteen minutes.

Caregivers/teachers should also be aware of environmental hazards such as contaminated 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 secure and away from heavy traffic areas.

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 (2). Short exposure of the skin to sunlight promotes the production of vitamin D that growing children require.

Open spaces in outdoor areas, even those confined to 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. Wind chill conditions that pose a risk of frostbite as well as heat and humidity that pose a significant risk of heat-related illness are defined by the NWS and are announced routinely.

Heat-induced illness and cold injury are preventable. Children have 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 (1).

Generally, infectious disease organisms are less concentrated in outdoor air than indoor air.

COMMENTS
Wind chill temperature is the temperature it “feels like” outside and is based on the rate of heat loss from exposed skin caused by the effects of wind and cold. As the wind increases, the body is cooled at a faster rate causing the skin temperature to drop. Many layers of clothing traps air between the layers and provides better insulation than one thick layer of clothing.

The NWS provides up to date weather information and warnings. The NWS Website will inform the public when wind chill conditions reach critical thresholds. A Wind Chill Warning is issued when wind chill temperatures are life threatening. A Wind Chill Advisory is issued when wind chill temperatures are potentially hazardous.

The NWS provides convenient color-coded guides for caregivers/teachers to use to determine which weather conditions are comfortable for outdoor play, which require caution, and which are dangerous. These guides are available on the NWS Website at http://www.nws.noaa.gov/om/windchill/index.shtml for wind chill and http://www.nws
.noaa.gov/om/heat/index.shtml for heat index.

The National Oceanic and Atmospheric Administration (NOAA) Weather Radio All Hazards (NWR) broadcasts continuous weather information twenty-four hours a day, seven days a week, directly from the nearest NWR office. NWR is an “All Hazards” radio network, making it a single source for comprehensive weather and emergency information. In conjunction with Federal, State, and Local Emergency Managers and other public officials, NWR also broadcasts warning and post-event information for all types of hazards – including natural (such as earthquakes or avalanches), environmental (such as chemical releases or oil spills), and public safety (such as AMBER alerts or 9-1-1 telephone outages). NWR requires a special radio receiver or scanner capable of picking up the signal. NWR radios/receivers can usually be found in most electronic store chains across the country or you can also purchase NOAA weather radios online at http://www.noaaweatherradios.com.

Email and Text Message Weather Alerts: These weather alert services send out weather warnings, watches, and hurricane information. Alerts are sent to subscribers in the warned areas via text messages and email. Select a service that sends warnings based on county, state, or national advisories. Some alerts may be delayed or missed because of problems on the Internet or the cell-phone network. Thus, do not rely solely on this system. Weather radio or local news affiliates should also be monitored for weather warnings.

Some flexibility is needed depending on the location of the program. For example, in some climates where children do not have warm winter clothing even 20°F could be too cold. In some southern climates it is always above 90°F, but older children are acclimated and can play in shaded areas.

To access the latest local weather information and warnings, contact the National Weather Service at http://www.weather.gov.

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, ear lobes, or 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 re-warmed by immersing frozen areas in warm water (around 100° Fahrenheit) or apply warm compresses for thirty minutes. If warm water is not available, wrap gently in warm blankets (4).

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 (3). Call 9-1-1 if a child has these symptoms.

Winter can be problematic for children with asthma for two reasons. Indoor allergens such as dust and dust mites are common triggers for asthma symptoms and levels of these allergens can become elevated during the winter, when doors and windows are kept shut to keep out cold air. Cold temperatures also may, in some cases, serve as a trigger to asthma symptoms for children with asthma. Children for whom cold weather is an asthma trigger may be helped by wearing a scarf during periods of cold weather. All children with asthma can safely play outdoors as long as their asthma is well controlled, and the parents/guardians of children with asthma should be encouraged to work with their child’s primary care provider to develop a plan the child can self-manage that incorporates opportunities for outdoor play.

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, 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.

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. Kids Health. 2008. Frostbite. Nemours. http://kidshealth.org/parent/firstaid_safe/emergencies/frostbite.html.
  2. Mayo Clinic. 2009. Hypothermia: Symptoms. http://www.mayoclinic.com/health/hypothermia/DS00333/.
  3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting physical activity. In Bright futures: Guidelines for health supervision of infants, children, and adolescents, 147-54. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  4. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. 2007. Policy statement: Climatic heat stress and the exercising child and adolescent. Pediatrics 120:683-84.
NOTES

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

Standard 3.1.4.1: Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction

Content in the STANDARD was modified on 12/05/2011 and on 12/1/2016.

Safe sleep practices help reduce the risk of sudden unexpected infant deaths (SUIDs). Facilities should develop a written policy describing the practices to be used to promote safe sleep for infants. The policy should explain that these practices aim to reduce the risk of SUIDs, including sudden infant death syndrome (SIDS), suffocation and other deaths that may occur when an infant is in a crib or asleep. About 3,500 SUIDs occurred in the U.S. in 2014 (1). 

All staff, parents/guardians, volunteers and others approved to enter rooms where infants are cared for should receive a copy of the Safe Sleep Policy and additional educational information and training on the importance of consistent use of safe sleep policies and practices before they are allowed to care for infants (i.e., first day as an employee/volunteer/subsitute). Documentation that training has occurred and that these individuals have received and reviewed the written policy before they care for children should be kept on file. Additional educational materials can be found at https://www.nichd.nih.gov/sts/materials/Pages/default.aspx

All staff, parents/guardians, volunteers and others who care for infants in the child care setting should follow these required safe sleep practices as recommended by the American Academy of Pediatrics (AAP) (2):

  1. Infants up to twelve months of age should be placed for sleep in a supine position (wholly on their back) for every nap or sleep time unless an infant’s primary health care provider has completed a signed waiver indicating that the child requires an alternate sleep position;
  2. Infants should be placed for sleep in safe sleep environments; which include a firm crib mattress covered by a tight-fitting sheet in a safety-approved crib (the crib should meet the standards and guidelines reviewed/approved by the U.S. Consumer Product Safety Commission [CPSC] (3) and ASTM International [ASTM]). No monitors or positioning devices should be used unless required by the child’s primary health care provider, and no other items should be in a crib occupied by an infant except for a pacifier;
  3. Infants should not nap or sleep in a car safety seat, bean bag chair, bouncy seat, infant seat, swing, jumping chair, play pen or play yard, highchair, chair, futon, sofa/couch, or any other type of furniture/equipment that is not a safety-approved crib (that is in compliance with the CPSC and ASTM safety standards) (3);
  4. If an infant arrives at the facility asleep in a car safety seat, the parent/guardian or caregiver/teacher should immediately remove the sleeping infant from this seat and place them in the supine position in a safe sleep environment (i.e., the infant’s assigned crib);
  5. If an infant falls asleep in any place that is not a safe sleep environment, staff should immediately move the infant and place them in the supine position in their crib;
  6. Only one infant should be placed in each crib (stackable cribs are not recommended);
  7. Soft or loose bedding should be kept away from sleeping infants and out of safe sleep environments. These include, but are not limited to: bumper pads, pillows, quilts, comforters, sleep positioning devices, sheepskins, blankets, flat sheets, cloth diapers, bibs, etc. Also, blankets/items should not be hung on the sides of cribs. Loose or ill-fitting sheets have caused infants to be strangled or suffocated (2). 
  8. Swaddling infants when they are in a crib is not necessary or recommended, but rather one-piece sleepers should be used (see Standard 3.1.4.2 for more detailed information on swaddling) (2);
  9. Toys, including mobiles and other types of play equipment that are designed to be attached to any part of the crib should be kept away from sleeping infants and out of safe sleep environments;
  10. When caregivers/teachers place infants in their crib for sleep, they should check to ensure that the temperature in the room is comfortable for a lightly clothed adult, check the infants to ensure that they are comfortably clothed (not overheated or sweaty), and that bibs, necklaces, and garments with ties or hoods are removed. (Safe clothing sacks or other clothing designed for safe sleep can be used in lieu of blankets.);
  11. Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking up;
  12. Bedding should be changed between children, and if mats are used, they should be cleaned between uses.

The lighting in the room must allow the caregiver/teacher to see each infant’s face, to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier (if used).

A caregiver/teacher trained in safe sleep practices and approved to care for infants should be present in each room at all times where there is an infant. This caregiver/teacher should remain alert and should actively supervise sleeping infants in an ongoing manner. Also, the caregiver/teacher should check to ensure that the infant’s head remains uncovered and re-adjust clothing as needed.

The construction and use of sleeping rooms for infants separate from the infant group room is not recommended due to the need for direct supervision. In situations where there are existing facilities with separate sleeping rooms, facilities have a plan to modify room assignments and/or practices to eliminate placing infants to sleep in separate rooms.

Facilities should follow the current recommendation of the AAP about pacifier use (2). If pacifiers are allowed, facilities should have a written policy that describes relevant procedures and guidelines. Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.
The facilty should encourage, provide arrangements for, and support breastfeeding. Breastfeeing or feeding an infant with their mother's expressed breast milk is also associated with a reduced risk of sleep-related infant deaths (2). 

RATIONALE
Despite the decrease in deaths attributed to sleeping practices and the decreased frequency of prone (tummy) infant sleep positioning over the past two decades, some caregivers/teachers continue to place infants to sleep in positions or environments that are not safe. Most sleep-related deaths in child care facilities occur in the first day or first week that an infant starts attending a child care program (4). Many of these deaths appear to be associated with prone positioning, especially when the infant is unaccustomed to being placed in that position (2). Training that includes observations and addresses barriers to changing caregiver/teacher practices would be most effective. Use of safe sleep policies, continued education of parents/guardians, expanded training efforts for child care professionals, statewide regulations and mandates, and increased monitoring and observation of intants while they are sleeping are critical to reduce the risk of SUIDs in child care (2). 

Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk of SUID (4,5). Recent research and demonstration projects (6,7) have revealed that:

  1. Caregivers/teachers are unaware of the dangers or risks associated with prone or side infant sleep positioning, and many believe that they are using the safest practices possible, even when they are not;
  2. Although training programs are effective in improving the knowledge of caregivers/teachers, these programs alone do not always lead to changes in caregiver/teacher practices, beliefs, or attitudes; and 
  3. Caregivers/teachers report the following major barriers to implementing safe sleep practices:They have been misinformed about methods shown to reduce the risk of SUID;
1) Facilities do not have or use written “safe sleep” policies or guidelines;
2) State child care regulations do not mandate the use of supine (wholly on their back) sleep position for infants in child care and/or training for infant caregivers/teachers;
3) Other caregivers/teachers or parents/guardians have objections to use of safe sleep practices, either because of their concern for choking or aspiration, and/or their concern that some infants do not sleep well in the supine position; and
4) Parents/guardians model their practices after what happens in the hospital or what others recommend. Infants who were placed to sleep in other positions in the hospital or home environments may have difficulty transitioning to supine positioning at home and later in child care.
COMMENTS
Background: Deaths of infants who are asleep in child care may be under-reported because of the lack of consistency in training and regulating death scene investigations and determining and reporting cause of death. Not all states require documentation that clarifies that an infant died while being cared for by someone other than their parents/guardians.

Although the cause of many sudden infant deaths may not be known, researchers believe that some infants develop in a manner that makes it challenging for them to be aroused or to breathe when they experience a life-threatening challenge during sleep. Although some state regulations require that caregivers/teachers “check on” sleeping infants every ten, fifteen, or thirty minutes, an infant can suffocate or die in only a few minutes. It is for this reason that the standards above discourage toys or mobiles in cribs and recommend direct, active, and ongoing supervision when infants are falling to sleep, are sleeping, or are becoming awake. This is also why Caring for Our Children describes a safe sleep environment as one that includes a safety-approved crib, firm mattress, firmly fitted sheet, and the infant placed on their back at all times, in comfortable, safe garments, but nothing else – not even a blanket.

When infants are being dropped off, staff may be busy. Requiring parents/guardians to remove the infant from the car seat and re-position them in the supine position in their crib (if they are sleeping), will reinforce safe sleep practices and reassure parents/guardians that their child is in a safe position before they leave the facility.

Challenges: National recommendations for reducing the risk of SUIDs are provided for use in the general population. Most research reviewed to guide the development of these recommendations was not conducted in child care settings. Because infants are at increased risk for dying from sleep-related causes in child care (4,5), caregivers/teachers must provide the safest sleep environment for the infants in their care.

When hospital staff or parents/guardians of infants who may attend child care place the infant in a position other than supine for sleep, the infant becomes accustomed to this and can have a more difficult time adjusting to child care, especially when they are placed for sleep in a new unfamiliar position.

Parents/guardians and caregivers/teachers want infants to transition to child care facilities in a comfortable and easy manner. It can be challenging for infants to fall asleep in a new environment because there are different people, equipment, lighting, noises, etc. When infants sleep well in child care, adults feel better. Placing personal items in cribs with infants and covering or wrapping infants with blankets may help the adults to believe that the child is more comfortable or feels comforted. However, this may or may not be true. These practices are not the safest practices for infants in child care, and they should not be allowed. Efforts to educate the public about the risk of sleep-related deaths promoting the use of consistent safe sleep practices need to continue.

Special Care Plans: Some facilities require staff to place infants in a supine position for sleep unless there is documentation in a child’s special care plan indicating a medical need for a different position. This can provide the caregiver/teacher with more confidence in implementing the safe sleep policy and refusing parental demands that are not consistent with safe sleep practices. It is likely that an infant will be unaccustomed to sleeping supine if his or her parents/guardians object to the supine position (and are therefore placing the infant prone to sleep at home). By providing educational information on the importance of consistent use of safe sleep policies and practices to expectant parents, facilities will help raise awareness of these issues, promote infant safety, and increase support for proper implementation of safe sleep policies and practices in the future.

Use of Pacifiers: Caregivers/teachers should be aware of the current recommendation of the AAP about pacifier use to reduce the risk of SUIDs (2). While using pacifiers to reduce the risk of SIDS seems prudent (especially if the infant is already sleeping with a pacifier at home), pacifier use has also been shown to be associated with an increased risk of ear infections. Keeping pacifiers clean and limiting their use to sleep time is best. Using pacifiers in a sanitary and safe fashion in group care settings requires special diligence.

Pacifiers should be inspected for tears before use. Pacifiers should not be clipped to an infant’s clothing or tied around an infant’s neck.

For children in the general population, the AAP recommends the following:

  1. Child care faciltites require written permission from the child’s parent/guardian for pacifier use;
  2. Consider offering a pacifier when placing the infant down for nap and sleep time;
  3. If the infant refuses the pacifier, s/he should not be forced to take it;
  4. If the infant falls asleep and the pacifier falls out of the infant’s mouth, it should be removed from the crib and does not need to be reinserted. A pacifier has been shown to reduce the risk of SIDS, even if the pacifier falls out during sleep (2);
  5. Pacifiers should not be coated in any sweet solution, and they should be cleaned and replaced regularly; and
  6. For breastfed infants, delay pacifier introduction until fifteen days of age to ensure that breastfeeding is well-established (2).

Swaddling: Hospital personnel or physicians, particularly those who work in neonatal intensive care units or infant nurseries in hospitals may recommend that newborns be swaddled in the hospital setting. Although parents/guardians may choose to continue this practice at home, swaddling infants when they are being placed to sleep or are sleeping in a child care facility is not necessary or recommended. See Standard 3.1.4.2 for more detailed information.

Concern about Plagiocephaly: If parents/guardians or caregivers/teachers are concerned about positional plagiocephaly (flat head or flat spot on head), they can continue to use safe sleep practices but also do the following:

  1. Offer infants opportunities to be held upright and participate in supervised “tummy time” when they are awake;
  2. Alter the position of the infant, and thereby alter the supine position of the infant’s head and face. This can easily be accomplished by alternating the placement of the infant in the crib – place the infant to sleep with their head facing to one side for a week and then turning the infant so that their head and face are placed the other way. Infants typically turn their head to one side toward the room or door, so if they are placed with their head toward one side of the bed for one sleep time and then placed with their head toward the other side of the bed the next time, this changes the area of the head that is in contact with the mattress.

A common question among caregivers/teachers and parents/guardians is whether they should return the infant to the supine position if they roll onto their side or their tummies. Infants up to twelve months of age should be placed wholly supine for sleep every time. In fact, all children should be placed (or encouraged to lie down) on their backs to sleep. When infants are developmentally capable of rolling comfortably from their backs to their fronts and back again, there is no evidence to suggest that they should be re-positioned into the supine position.

The California Childcare Health Program has available a Safe Sleep Policy for Infants in Child Care Programs. AAP provides a free online course on safe sleep practices.

 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
2.2.0.1 Methods of Supervision of Children
3.1.4.2 Swaddling
3.1.4.3 Pacifier Use
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.6.1 Strangulation Hazards
3.6.4.5 Death
4.3.1.1 General Plan for Feeding Infants
4.5.0.3 Activities that Are Incompatible with Eating
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
6.4.1.3 Crib Toys
REFERENCES
  1. Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-79.
  2. Centers for Disease Control and Prevention. 2013. Sudden infant death syndrome (SIDS). http://www.cdc.gov/features/sidsawarenessmonth/.
  3. UCSF California Childcare Health Program (CCHP). 2016. Safe sleep policy for infants in child care programs. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-Policy.
  4. Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe sleep ® campaign materials. 2014. https://www.nichd.nih.gov/sts/materials/Pages/default.aspx.
  5. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep: Reducing the Risk of Sudden Infant Death Syndrome (SIDS). UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-FAM
  6. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep for Infants in Child Care Programs: Reducing the Risk of SIDS and SUID. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/SIDS-Note
  7. Healthy Child Care America. 2012. A child care provider’s guide to safe sleep. Helping you to reduce the risk of SIDS. http://www.healthychildcare.org/PDF/SIDSchildcaresafesleep.pdf
  8. First Candle. 2016. SIDS and daycare: A fatal combination. http://www.firstcandle.org/sids-and-daycare-a-fatal-combination/
  9. U.S. Consumer Product Safety Commission (CPSC). 2012. Cribs. https://www.cpsc.gov/safety-education/safety-guides/kids-and-babies/cribs.
  10. U.S. Centers for Disease Control and Prevention. 2016. About SUID and SIDS. http://www.cdc.gov/sids/aboutsuidandsids.htm
  11. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.2016;138(6):e20162938. 
    https://pediatrics.aappublications.org/content/138/5/e20162938.
  12. Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and Breastfeeding Trial Group. 2009. Does the recommendation to use a pacifier influence the prevalence of breastfeeding? Pediatrics 155:350-54.
  13. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
NOTES

Content in the STANDARD was modified on 12/05/2011 and on 12/1/2016.

Standard 3.1.5.1: Routine Oral Hygiene Activities

Content in the STANDARD was modified on 3/10/2016.

 

Caregivers/teachers should promote the habit of regular tooth brushing. All children with teeth should brush or have their teeth brushed with a soft toothbrush of age-appropriate size at least once during the hours the child is in child care. Children under three years of age should have only a small smear (grain of rice) of fluoride toothpaste on the brush when brushing. Those children ages three and older should use a pea-sized amount of fluoride toothpaste (1). An ideal time to brush is after eating. The caregiver/teacher should either brush the child’s teeth or supervise as the child brushes his/her own teeth. Disposable gloves should be worn by the caregiver/teacher if contact with a child’s oral fluids is anticipated. The younger the child, the more the caregiver/teacher needs to be involved. The caregiver/teacher should teach the child the correct method of tooth brushing. Young children want to brush their own teeth, but they need help until about age 7 or 8. The caregiver/teacher should monitor the tooth brushing activity and thoroughly brush the child’s teeth after the child has finished brushing, preferably for a total of two minutes. Children whose teeth are properly brushed with fluoride toothpaste at home twice a day and are at low risk for dental caries may be exempt since additional brushing with fluoride toothpaste may expose a child to excess fluoride toothpaste.

The cavity-causing effect of exposure to foods or drinks containing sugar (like juice) may be reduced by having children rinse with water after snacks and meals when tooth brushing is not possible. Local dental health professionals can facilitate compliance with these activities by offering education and training for the child care staff and providing oral health presentations for the children and parents/guardians.

RATIONALE
Regular tooth brushing with fluoride toothpaste is encouraged to reinforce oral health habits and prevent gingivitis and tooth decay. There is currently no (strong) evidence that shows any benefit to wiping the gums of a baby who has no teeth. However, before the first tooth erupts, wiping a baby’s gums with clean gauze or a soft wet washcloth as part of a daily routine may make the transition to tooth brushing easier. Good oral hygiene is as important for a six-month-old child with one tooth as it is for a six-year-old with many teeth (2). Tooth brushing with fluoride toothpaste at least once a day reduces build-up of decay-causing plaque (2,3). The development of tooth decay-producing plaque begins when an infant’s first tooth appears in his/her mouth (4). Tooth decay cannot develop without this plaque which contains the acid-producing bacteria in a child’s mouth. The ability to do a good job brushing the teeth is a learned skill, improved by practice and age. There is general consensus that children do not have the necessary hand eye coordination for independent brushing until around age seven or eight so either caregiver/teacher brushing or close supervision is necessary in the preschool child. Tooth brushing and activities at home may not suffice to develop this skill or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care.
COMMENTS
The caregiver/teacher should use a small smear (grain of rice) of fluoride toothpaste spread across the width of the toothbrush for children under three years of age and a pea-sized amount for children ages three years of age and older (1). Children should attempt to spit out excess toothpaste after brushing. Fluoride is the single most effective way to prevent tooth decay. Brushing teeth with fluoride toothpaste is the most efficient way to apply fluoride to the teeth. Young children may occasionally swallow a small amount of toothpaste and this is not a health risk. However, if children swallow more than recommended amounts of fluoride toothpaste on a consistent basis, they are at risk for fluorosis, a cosmetic condition (discoloration of the teeth) caused by over exposure to fluoride during the first eight years of life (5). Other products such as fluoride rinses can pose a poisoning hazard if ingested (6).

The children can rinse with water after a snack or a meal if their teeth have been brushed with fluoride toothpaste earlier. Rinsing with water helps to remove food particles from teeth and may help prevent tooth decay.

A sink is not necessary to accomplish tooth brushing in child care. Each child can use a cup of water for tooth brushing. The child should wet the brush in the cup, brush and then spit excess toothpaste into the cup.

Caregivers/teachers should encourage replacement of toothbrushes when the bristles become worn or frayed or approximately every three to four months (7,8).

Caregivers/teachers should encourage parents/guardians to establish a dental home for their child within six months after the first tooth erupts or by one year of age, whichever is earlier (4). The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way. Currently there are insufficient numbers of dentists who incorporate infants and toddlers into their practices so primary care providers may provide oral health screening during well child care in this population while promoting the establishment of a dental home (2).

Fluoride varnish applied to all children every 3-6 months at primary care visits or at their dental home reduces tooth decay rates, and can lead to significant cost savings in restorative dental care and associated hospital costs. Coupled with parent/guardian and caregiver/teacher education, fluoride varnish is an important tool to improve children’s health (9-11).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records
REFERENCES
  1. American Academy of Pediatric Dentistry. 2006. Talking points: AAPD perspective on physicians or other non-dental providers applying fluoride varnish. Dental Home Resource Center.http://www.aapd.org/dentalhome/1225.pdf.
  2. Marinho, V.C., et al. 2002. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database System Rev 3, no.  CD002279. http://www.ncbi.nlm.nih.gov/pubmed/12137653
  3. Centers for Disease Control and Prevention. 2013. Community water fluoridation. http://www.cdc.gov/fluoridation/faqs/http://www.cdc.gov/fluoridation/faqs/
  4. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845.
  5. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry30:112-18.
  6. American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.
  7. American Academy of Pediatrics, Section on Oral Health. 2014. Maintaining and improving the oral health of young children. http://pediatrics.aappublications.org/content/134/6/1224
  8. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine.2016. Policy statement: 2016 Recommendations for preventive pediatric health care. http://pediatrics.aappublications.org/content/early/2015/12/07/peds.2015-3908  
  9. American Dental Association. ADA positions and statements. ADA statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx.
  10. American Academy of Pediatric Dentistry. Early childhood caries. Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf.
  11. Centers for Disease Control and Prevention, Fluoride Recommendations Work Group. 2001. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR50(RR14): 1-42.
NOTES

Content in the STANDARD was modified on 3/10/2016.

 

Standard 3.2.1.4: Diaper Changing Procedure

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Is the recommendation for an Environmental Protection Agency (EPA)-registered disinfectant different from the previous cleaning and sanitizing definitions?  What’s the difference between a disinfectant and sanitizing agent?

Answer:

For some surfaces it is important to disinfect to be healthy and safe (this is the deepest “clean”). For some surfaces sanitizing is enough to be healthy and safe, and for some surfaces cleaning is adequate. Remember that before some surfaces are disinfected or sanitized, the visible “dirt” must first be cleaned off.

Please see Appendix J, Selecting an Appropriate Sanitizer or Disinfectant for more information.

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 11/22/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
What is the rationale for requiring hand washing before diaper changing?

Answer:
The diaper changing process may require many interactions with the child before the process, for example evaluating whether the diaper contains stool.  Because of the potential for contamination of hands during this process, hand hygiene should be performed before collection of diaper supplies and further handling of the child to avoid contaminating the remaining diaper supplies.  However, activities in child care do not occur in isolation.  If hand hygiene has been done for another reason prior to a diaper changing event, the process does not have to be repeated if no contamination of hands has occurred.

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.1.4

Date: 7/21/2014

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Step 6 of Standard 3.2.1.4: Diaper Changing Procedure states to "Use soap and warm water, between 60°F and 120°F, at a sink to wash the child’s hands, if you can." If the child is too heavy to hold at the sink, or has a special health care need that prevents him/her from standing at the sink, it is OK to use several wipes (one after the other) to clean the child's hands?

Answer:
Wipes that have chemicals should not be used as a replacement for washing an infant's/toddler's hands.

However, Managing Infectious Diseases in Child Care and Schools, 4th Edition and Model Child Care Health Policies, 5th Edition offers an alternative method to washing the hands of an infant/toddler at the sink if they are too heavy to hold or have a special need that prevents standing at the sink. This ”three paper towel” method is as follows:

1. Wipe the child’s hands with a damp paper towel moistened with a drop of liquid soap.
2. Wipe the child’s hands with a 2nd paper towel wet with clear water.
3. Dry the child’s hands with a 3rd paper towel.

Additionally, as stated in CFOC3 Standard 3.2.2.5: Hand Sanitizers, the use of hand sanitizers by children over twenty-four months of age and adults in child care programs is an appropriate alternative to the use of traditional handwashing with soap and water if the hands are not visibly soiled.

Last, please remember to check your local and/or state regulations before implementing this strategy.

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

The following diaper changing procedure should be posted in the changing area, should be followed for all diaper changes, and should be used as part of staff evaluation of caregivers/teachers who diaper. The signage should be simple and should be in multiple languages if caregivers/teachers who speak multiple languages are involved in diapering. All employees who will diaper should undergo training and periodic assessment of diapering practices. Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the diaper changing table. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.

Use a fragrance-free bleach that is EPA-registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA-registered (1).

All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting.

Step 1: Get organized. Before bringing the child to the diaper changing area, perform hand hygiene, gather and bring supplies to the diaper changing area:

  1. Non-absorbent paper liner large enough to cover the changing surface from the child’s shoulders to beyond the child’s feet;
  2. Unused diaper, clean clothes (if you need them);
  3. Wipes, dampened cloths or wet paper towels for cleaning the child’s genitalia and buttocks readily available;
  4. A plastic bag for any soiled clothes or cloth diapers;
  5. Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers) and remove them before handling clean diapers and clothing;
  6. A thick application of any diaper cream (e.g., zinc oxide ointment), when appropriate, removed from the container to a piece of disposable material such as facial or toilet tissue.

Step 2: Carry the child to the changing table, keeping soiled clothing away from you and any surfaces you cannot easily clean and sanitize after the change.

  1. Always keep a hand on the child;
  2. If the child’s feet cannot be kept out of the diaper or from contact with soiled skin during the changing process, remove the child’s shoes and socks so the child does not contaminate these surfaces with stool or urine during the diaper changing.

Step 3: Clean the child’s diaper area.

  1. Place the child on the diaper change surface and unfasten the diaper, but leave the soiled diaper under the child;
  2. If safety pins are used, close each pin immediately once it is removed and keep pins out of the child’s reach (never hold pins in your mouth);
  3. Lift the child’s legs as needed to use disposable wipes, or a dampened cloth or wet paper towel to clean the skin on the child’s genitalia and buttocks and prevent recontamination from a soiled diaper. Remove stool and urine from front to back and use a fresh wipe, or a dampened cloth or wet paper towel each time you swipe. Put the soiled wipes or paper towels into the soiled diaper or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm’s reach of diaper changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.

Step 4: Remove the soiled diaper and clothing without contaminating any surface not already in contact with stool or urine.

  1. Fold the soiled surface of the diaper inward;
  2. Put soiled disposable diapers in a covered, plastic-lined, hands-free covered can. If reusable cloth diapers are used, put the soiled cloth diaper and its contents (without emptying or rinsing) in a plastic bag or into a plastic-lined, hands-free covered can to give to parents/guardians or laundry service;
  3. Put soiled clothes in a plastic-lined, hands-free plastic bag;
  4. Check for spills under the child. If there are any, use the corner of the paper to fold the paper that extends under the child's feet over the soiled area so a fresh, unsoiled paper surface is now under the child's buttocks;
  5. If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can;
  6. Whether or not gloves were used, use a fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child's hands. Put the wipes into the plastic-lined, hands-free covered can.
Step 5: Put on a clean diaper and dress the child.
  1. Slide a fresh diaper under the child;
  2. Use a facial or toilet tissue or wear clean disposable glove to apply any necessary diaper creams, discarding the tissue or glove in a covered, plastic-lined, hands-free covered can;
  3. Note and plan to report any skin problems such as redness, skin cracks, or bleeding;
  4. Fasten the diaper; if pins are used, place your hand between the child and the diaper when inserting the pin.

Step 6: Wash the child’s hands and return the child to a supervised area.

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

Step 7: Clean and disinfect the diaper-changing surface.

  1. Dispose of the disposable paper liner used on the diaper changing surface in a plastic-lined, hands-free covered can;
  2. If clothing was soiled, securely tie the plastic bag used to store the clothing and send home;
  3. Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, rinse;
  4. Wet the entire changing surface with a disinfectant that is appropriate for the surface material you are treating. Follow the manufacturer’s instructions for use;
  5. Put away the disinfectant. Some types of disinfectants may require rinsing the change table surface with fresh water afterwards.

Step 8: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the diaper change in the child’s daily log.

  1. In the daily log, record what was in the diaper and any problems (such as a loose stool, an unusual odor, blood in the stool, or any skin irritation), and report as necessary (2).

RATIONALE
The procedure for diaper changing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (3). Posting the multi-step procedure may help caregivers/teachers maintain the routine.

Assembling all necessary supplies before bringing the child to the changing area will ensure the child’s safety, make the change more efficient, and reduce opportunities for contamination. Taking the supplies out of their containers and leaving the containers in their storage places reduces the likelihood that the storage containers will become contaminated during diaper changing.

Commonly, caregivers/teachers do not use disposable paper that is large enough to cover the area likely to be contaminated during diaper changing. If the paper is large enough, there will be less need to remove visible soil from surfaces later and there will be enough paper to fold up so the soiled surface is not in contact with clean surfaces while dressing the child.

If the child’s foot coverings are not removed during diaper changing, and the child kicks during the diaper changing procedure, the foot coverings can become contaminated and subsequently spread contamination throughout the child care area.

Some experts believe that commercial baby wipes may cause irritation of a baby’s sensitive tissues, such as inside the labia, but currently there is no scientific evidence available on this issue. Wet paper towels or a damp cloth may be used as an alternative to commercial baby wipes.

If the child’s clean buttocks are put down on a soiled surface, the child’s skin can be resoiled.

Children’s hands often stray into the diaper area (the area of the child’s body covered by diaper) during the diapering process and can then transfer fecal organisms to the environment. Washing the child’s hands will reduce the number of organisms carried into the environment in this way. Infectious organisms are present on the skin and diaper even though they are not seen. To reduce the contamination of clean surfaces, caregivers/teachers should use a fresh wipe to wipe their hands after removing the gloves, or, if no gloves were used, before proceeding to handle the clean diaper and the clothing.

Some states and credentialing organizations may recommend wearing gloves for diaper changing. Although gloves may not be required, they may provide a barrier against surface contamination of a caregiver/teacher’s hands. This may reduce the presence of enteric pathogens under the fingernails and on hand surfaces. Even if gloves are used, caregivers/teachers must perform hand hygiene after each child’s diaper changing to prevent the spread of disease-causing agents. To achieve maximum benefit from use of gloves, the caregiver/teacher must remove the gloves properly after cleaning the child’s genitalia and buttocks and removing the soiled diaper. Otherwise, retained contaminated gloves could transfer organisms to clean surfaces. Note that sensitivity to latex is a growing problem. If caregivers/teachers or children who are sensitive to latex are present in the facility, non-latex gloves should be used. See Appendix D, for proper technique for removing gloves.

A safety strap cannot be relied upon to restrain the child and could become contaminated during diaper changing. Cleaning and disinfecting a strap would be required after every diaper change. Therefore safety straps on diaper changing surfaces are not recommended.

Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, application and storage. If the disinfectant is applied using a spray bottle, always assume that the outside of the spray bottle could be contaminated. Therefore, the spray bottle should be put away before hand hygiene is performed, (the last and essential part of every diaper change) (5).

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

If parents/guardians use the diaper changing area, they should be required to follow the same diaper changing procedure to minimize contamination of the diaper changing area and child care.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
5.2.7.4 Containment of Soiled Diapers
5.4.4.2 Location of Laundry Equipment and Water Temperature for Laundering
Appendix D: Gloving
Appendix J: Selecting an Appropriate Sanitizer or Disinfectant
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Early Childhood Education Linkage System. Healthy Child Care Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster.
  2. Red Book: 2015 Report of the Committee on Infectious Diseases, 30th Edition American Academy of Pediatrics Committee on Infectious Diseases; Editor: David W. Kimberlin, MD, FAAP; Associate Editors: Michael T. Brady, MD, FAAP; Mary Anne Jackson, MD, FAAP; and Sarah S. Long, MD, FAAP.

  3. University of California, San Francisco School of Nursing’s Institute for Health & Aging, University of California, Berkeley’s Center for Environmental Research and Children's Health, and Informed Green Solutions, California Department of Pesticide Regulation. 2013. Green cleaning, sanitizing, and disinfecting: A checklist for early care and education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf
  4. National Association for the Education of Young Children. 2012. Healthy Young Children, A Manual for Programs. Fifth edition. Editor. Susan Aronson Washington, DC. 
  5. Children’s Environmental Health Network. 2016. Household chemicals. http://www.cehn.org/wp-content/uploads/Household_chemicals_1_16.pdf.
NOTES

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

Standard 3.2.2.1: Situations that Require Hand Hygiene

Content in the STANDARD was modified on 8/23/2016 and 8/9/2017.

 

All staff, volunteers, and children should follow the procedure in Standard 3.2.2.2 for hand hygiene at the following times:

  1. Upon arrival for the day, after breaks, or when moving from one child care group to another;
  2. Before and after:
    1. Preparing food or beverages;
    2. Eating, handling food, or feeding a child;
    3. Giving medication or applying a medical ointment or cream in which a break in the skin (e.g., sores, cuts, or scrapes) may be encountered;
    4. Playing in water (including swimming) that is used by more than one person;
    5. Diapering;
  3. After:
    1.    Using the toilet or helping a child use a toilet;
    2.    Handling bodily fluid (mucus, blood, vomit), from sneezing, wiping and blowing noses, from
            mouths, or from sores;
    3.    Handling animals or cleaning up animal waste;
    4.    Playing in sand, on wooden play sets, and outdoors;
    5.    Cleaning or handling the garbage;
    6.    Applying sunscreen and/or insect repellent.

Situations or times that children and staff should perform hand hygiene should be posted in all food preparation, hand hygiene, diapering, and toileting areas. Also, if caregivers/teachers smoke off premises before starting work, they should wash their hands before caring for children to prevent children from receiving third-hand smoke exposure (1).

RATIONALE
Hand hygiene is the most important way to reduce the spread of infection. Many studies have shown that improperly cleansed hands are the primary carriers of infections. Deficiencies in hand hygiene have contributed to many outbreaks of diarrhea among children and caregivers/teachers in child care centers (2).

Child care centers that have implemented good hand hygiene techniques have consistently demonstrated a reduction in diseases transmission (2). When frequent and proper hand hygiene practices are incorporated into a child care center’s curriculum, there is a decrease in the incidence of acute respiratory tract diseases (3).

Hand hygiene after exposure to soil and sand will reduce opportunities for the ingestion of zoonotic parasites that could be present in contaminated sand and soil (4).

Thorough handwashing with soap for at least twenty seconds using clean running water at a comfortable temperature removes organisms from the skin and allows them to be rinsed away (5). Hand hygiene with an alcohol-based sanitizer is an alternative to traditional handwashing with soap and water when visible soiling is not present.
 
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately (6).

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount (6). As with any hand hygiene product, supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes (6).
Infectious organisms may be spread in a variety of ways:
  1. In human waste (urine, stool);
  2. In body fluids (saliva, nasal discharge, secretions from open injuries; eye discharge, blood);
  3. Cuts or skin sores;
  4. By direct skin-to-skin contact;
  5. By touching an object that has live organisms on it;
  6. In droplets of body fluids, such as those produced by sneezing and coughing, that travel through the air.
Since many infected people carry infectious organisms without symptoms and many are contagious before they experience a symptom, caregivers/teachers routine hand hygiene is the safest practice (1).
COMMENTS
While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms) (1). These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene. 
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
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
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
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. Centers for Disease Control and Prevention. 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
  3. Palmer, S. R., L. Soulsby, D. I. H. Simpson, eds. 1998. Zoonoses: Biology, clinical practice, and public health control. New York: Oxford University Press.
  4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5
  5. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Children in out-of-home child care. In: Red book: 2015 report to the committee of infectious diseases.  30th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
  6. Mayo Clinic. 2010. Secondhand smoke: Avoid dangers in the air. http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/secondhand-smoke/art-20043914.
NOTES

Content in the STANDARD was modified on 8/23/2016 and 8/9/2017.

 

Standard 3.2.2.2: Handwashing Procedure

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.2.2.2

Date: 10/13/2011

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Standard 3.2.2.3: Assisting Children with Hand Hygiene

Caregivers/teachers should provide assistance with handwashing at a sink for infants who can be safely cradled in one arm and for children who can stand but not wash their hands independently. A child who can stand should either use a child-height sink or stand on a safety step at a height at which the child’s hands can hang freely under the running water. After assisting the child with handwashing, the staff member should wash his or her own hands. Hand hygiene with an alcohol-based sanitizer is an alternative to handwashing with soap and water by children over twenty-four months of age and adults when there is no visible soiling of hands (1).

RATIONALE
Encouraging and teaching children good hand hygiene practices must be done in a safe manner. A “how to” poster that is developmentally appropriate should be placed wherever children wash their hands.

For examples of handwashing posters, see:

California Childcare Health Program at http://www.ucsfchildcarehealth.org;

North Carolina Child Care Health and Safety Resource Center at http://www.healthychildcarenc.org/training_materials.htm.

RELATED STANDARDS
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.5 Hand Sanitizers
REFERENCES
  1. Centers for Disease Control and Prevention. 2013. Information for schools and childcare providers. http://www.cdc.gov/flu/school/index.htm

Standard 3.2.3.4: Prevention of Exposure to Blood and Body Fluids

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

In child care settings:

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

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

Procedures for Standard Precautions should include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting

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

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

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

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

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

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

Task

Purpose

Clean

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

Sanitize

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

Disinfect

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

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

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

Employers should provide staff with hazard information, including access to and review of the Safety Data Sheets (SDS) as required by the Occupational Safety and Health Administration (OSHA), about the presence of toxic substances such as, cleaning, sanitizing and disinfecting supplies in use in the facility. The SDS explain the risk of exposure to products so that appropriate precautions may be taken.

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

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

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.4.1.1

Date: 11/7/2012

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

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

Answer:

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

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

U.S. FDA, 2013 article

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

 

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

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

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

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

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

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

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

    Centers for Disease Control and Prevention. 2009. Facts: Preventing residential fire injuries. http://www.cdc.gov/injury/pdfs/Fires2009CDCFactSheet-FINAL-a.pdf
     
    American Lung Association. E-cigarettes and Lung Health. 2016. http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html?referrer=https://www.google.com/.
     
    Children’s Hospital Colorado. 2016. Acute marijuana intoxication. https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/acute-marijuana-intoxication/.
  2. Dale, L. 2014. What is thirdhand smoke, and why is it a concern? http://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/third-hand-smoke/faq-20057791
  3. Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, M. F. Hovell, R. C. McMillen. 2009. Beliefs about the health effects of “thirdhand” smoke and home smoking bans. Pediatrics 123: e74-e79.
  4. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf.
  5. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf
  6. Schwartz, J., K. L. Timonen, J. Pekkanen. 2000. Respiratory effects of environmental tobacco smoke in a panel study of asthmatic and symptomatic children. Am J Resp Crit Care Med 161:802-6.
  7. U.S. Department of Health and Human Services. 2007. Children and secondhand smoke exposure. Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
  8. American Academy of Pediatrics. Healthychildren.org. 2015. The dangers of secondhand smoke. https://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/Dangers-of-Secondhand-Smoke.aspx
  9. Centers for Disease Control and Prevention. 2016. Health effects of secondhand smoke. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/
  10. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommenations for a safe infant sleeping environment. Pediatrics. 2016;138(6):e20162938.
    http://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938
NOTES

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

 

Standard 3.4.3.1: 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 3.4.3.3: Response to Fire and Burns

Children who are developmentally able to understand, should be instructed to STOP, DROP, and ROLL when garments catch fire. Children should be instructed to crawl on the floor under the smoke if necessary when they evacuate the building. This instruction is part of ongoing health and safety education and fire drills/exercise.

Cool water should be applied to burns immediately. The injury should be covered with a loose bandage or clean, dry cloth. Medical assessment/care should be immediate.

RATIONALE
Running when garments have been ignited will fan the fire. Removing heat from the affected area will prevent continued burning and aggravation of tissue damage. Asphyxiation causes more deaths in house fires than does thermal injury (1).
COMMENTS
For resources for children: see Stop, Drop, and Roll – A Jessica Worries Book: Fire Safety.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
Appendix P: Situations that Require Medical Attention Right Away
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2000. Reducing the number of deaths and injuries from residential fires. Pediatrics 105:1355-57.

Standard 3.4.4.1: Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation

Each facility should have a written policy for reporting child abuse and neglect. Caregivers/teachers are mandated reporters of child abuse and neglect. The facility should report to the child abuse reporting hotline, department of social services, child protective services, or police as required by state and local laws, in any instance where there is reasonable cause to believe that child abuse and neglect has occurred. Every staff person should be oriented to what and how to report. Phone numbers and reporting system as required by state or local agencies should be clearly posted by every phone.

Caregivers/teachers should receive initial and ongoing training to assist them in preventing child abuse and neglect and in recognizing signs of child abuse and neglect. Programs are encouraged to partner with primary care providers, child care health consultants and/or child protection advocates to provide training and to be available for consultation.

Employees and volunteers in centers and large family child care homes should receive an instruction sheet about child abuse and neglect reporting that contains a summary of the state child abuse reporting statute and a statement that they will not be discharged/disciplined solely because they have made a child abuse and neglect report. Some states have specific forms that are required to be completed when abuse and neglect is reported. Some states have forms that are not required but assist mandated reporters in documenting accurate and thorough reports. In those states, facilities should have such forms on hand and all staff should be trained in the appropriate use of those forms.

Parents/guardians should be notified upon enrollment of the facility’s child abuse and neglect reporting requirement and procedures.

RATIONALE
While caregivers/teachers are not expected to diagnose or investigate child abuse and neglect, it is important that they be aware of common physical and emotional signs and symptoms of child maltreatment (see Appendix M, Clues to Child Abuse and Neglect) (1,2,4).

All states in the U.S. have laws mandating the reporting of child abuse and neglect to child protection agencies and/or police. Laws about when and to whom to report vary by state (3). Failure to report abuse and neglect is a crime in all states and may lead to legal penalties.

COMMENTS
Child abuse includes physical, sexual, psychological, and emotional abuse. Other components of abuse include shaken baby syndrome/acute head trauma and repeated exposure to violence including domestic violence. Neglect occurs when the parent/guardian does not meet the child’s basic needs and includes physical, medical, educational, and emotional neglect (5). Caregivers/teachers and health professionals may contact individual state hotlines where available. While almost all states have hotlines, they may not operate twenty-four-hours a day, and some toll free numbers may only be accessible within that particular state. ChildHelp USA provides a national hotline: 1-800-4-A-CHILD or 1-800-422-4453.

Many health departments will be willing to provide contact for experts in child abuse and neglect prevention and recognition. The American Academy of Pediatrics (AAP), http://www.aap.org, can also assist in recruiting and identifying physicians who are skilled in this work.

The caregiver/teacher is still liable for reporting even when their supervisor indicates they don’t need to or says that someone else will report it. Caregivers/teachers who report in good faith may do so confidentially and are protected by law.

For more information on Mandated Reporting, go to the Child Welfare Information Gateway, Mandated Reporting at http://www.childwelfare.gov/responding/mandated.cfm. Information regarding specific state laws is accessible via the Child Welfare Information Gateway at https://www.childwelfare.gov/topics/responding/reporting/mandated/.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
1.7.0.5 Stress
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Been Abused/Neglected
9.4.1.9 Records of Injury
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect
REFERENCES
  1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care
  2. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, and Children’s Bureau. Child welfare information gateway: State statutes. https://www.childwelfare.gov/topics/systemwide/laws-policies/state/
  3. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, and Children’s Bureau. What is child abuse and neglect? Child Welfare Information Gateway. http://www.childwelfare.gov/pubs/factsheets/whatiscan.cfm.
  4. Jenny, C. 2007. Recognizing and responding to medical neglect. Pediatrics 120:1385-89.
  5. Hussey, J. M., J. J. Chang, J. B. Kotch. 2006. Child maltreatment in the United States: Prevalence, risk factors, and adolescent health consequences. Pediatrics 118:933-42.

Standard 3.4.4.3: Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma

All child care facilities should have a policy and procedure to identify and prevent shaken baby syndrome/abusive head trauma. All caregivers/teachers who are in direct contact with children including substitute caregivers/teachers and volunteers, should receive training on preventing shaken baby syndrome/abusive head trauma, recognition of potential signs and symptoms of shaken baby syndrome/abusive head trauma, strategies for coping with a crying, fussing or distraught child, and the development and vulnerabilities of the brain in infancy and early childhood.

RATIONALE
Over the past several years there has been increasing recognition of shaken baby syndrome/abusive head trauma which is the occurrence of brain injury in young children under three years of age due to shaking a child. Even mild shaking can result in serious, permanent brain damage or death. The brain of the young child may bounce inside of the skull resulting in brain damage, hemorrhaging, blindness, or other serious injuries or death. There have been several reported incidents occurring in child care (1). Caregivers/teachers experience young children who may be fussy or constantly crying. It is important for caregivers/teachers to be educated about the risks of shaking and provided with strategies to cope if they are frustrated (3). Many states have passed legislation requiring education and training for caregivers/teachers. Caregivers/teachers should check their individual state’s specific requirements (2). Staff can also recognize the signs and symptoms of shaken baby syndrome/abusive head trauma in children in their care.
COMMENTS
For more information and resources on shaken baby syndrome/abusive head trauma, contact the National Center on Shaken Baby Syndrome at http://www.dontshake.org.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
REFERENCES
  1. American Academy of Pediatrics, Committee on Child Abuse and Neglect. 2009. Abusive head trauma in infants and children. Pediatrics 123:1409-11.
  2. National Resource Center for Health and Safety in Child Care and Early Education. State licensing database. http://nrckids.org/STATES/states.htm.
  3. Calm a Crying Baby. Shaken baby syndrome prevention. http://www.calmacryingbaby.com.

Standard 3.4.5.1: Sun Safety Including Sunscreen

Frequently Asked Questions/CFOC3 Clarifications

Reference: 3.4.5.1

Date: 2/17/2012

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 3.4.6.1: Strangulation Hazards

Strings and cords (such as those that are parts of toys and those found on window coverings) long enough to encircle a child’s neck should not be accessible to children in child care. Miniblinds and venetian blinds should not have looped cords. Vertical blinds, continuous looped blinds, and drapery cords should have tension or tie-down devices to hold the cords tight. Inner cord stops should be installed. Shoulder straps on guitars and chin straps on hats should be removed (1).

Straps/handles on purses/bags used for dramatic play should be removed or shortened. Ties, scarves, necklaces, and boas used for dramatic play should not be used for children under three years. If used by children three years and over, children should be supervised.

Pacifiers attached to strings or ribbons should not be placed around infants’ necks or attached to infants’ clothing.

Hood and neck strings from all children’s outerwear, including jackets and sweatshirts, should be removed. Drawstrings on the waist or bottom of garments should not extend more than three inches outside the garment when it is fully expanded. These strings should have no knots or toggles on the free ends. The drawstring should be sewn to the garment at its midpoint so the string cannot be pulled out through one side.

RATIONALE
Window covering cords are associated with strangulation of young children under (2,4). Infants can become entangled in cords from window coverings near their cribs. Since 1990, more than 200 infants and young children have died from unintentional strangulation in window cords (5).

Cords and ribbons tied to pacifiers can become tightly twisted, or can catch on crib cornerposts or other protrusions, causing strangulation.

Clothing strings on children’s clothing, necklaces and scarves can catch on playground equipment and strangle children. The U.S. Consumer Product Safety Commission (CPSC) has reported deaths and injuries involving the entanglement of children’s clothing drawstrings (3).

COMMENTS
Children’s outerwear that has alternative closures (e.g., snaps, buttons, hook and loop, and elastic) are recommended (3).

It is advisable that caregivers avoid wearing necklaces or clothing with drawstrings that could cause entanglement.

For additional information regarding the prevention of strangulation from strings on toys, window coverings, clothing, contact the CPSC. See http://www.windowcoverings.org for the latest blind cord safety information.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.3.1.1 Safety of Equipment, Materials, and Furnishings
REFERENCES
  1. Window Covering Safety Council. Basic cord safety. http://www.prnewswire.com/news-releases/new-study-released-on-window-cord-safety-awareness-115561629.html.
  2. U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe? Washington, DC: CPSC.
  3. U.S. Consumer Product Safety Commission (CPSC). 1999. Guidelines for drawstrings on children’s outerwear. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/208.pdf.
  4. Window Covering Safety Council. 2011. New study released on window covering safety awareness. http://www.windowcoverings.org/about-2/
  5. U.S. Consumer Products Safety Commission. Strings and straps on toys can strangle young children. http://www.cpsc.gov//PageFiles/122499/5100.pdf

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. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
NOTES

Content in the STANDARD was modified on 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
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
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. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
NOTES

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

Standard 3.6.1.4: Infectious Disease Outbreak Control

During the course of an identified outbreak of any reportable illness at the facility, a child or staff member should be excluded if the health department official or primary care provider suspects that the child or staff member is contributing to transmission of the illness at the facility, is not adequately immunized when there is an outbreak of a vaccine preventable disease, or the circulating pathogen poses an increased risk to the individual. The child or staff member should be readmitted when the health department official or primary care provider who made the initial determination decides that the risk of transmission is no longer present.

RATIONALE
Secondary spread of infectious disease has been proven to occur in child care. Control of outbreaks of infectious diseases in child care may include age-appropriate immunization, antibiotic prophylaxis, observing well children for signs and symptoms of disease and for decreasing opportunities for transmission of that may sustain an outbreak. Removal of children known or suspected of contributing to an outbreak may help to limit transmission of the disease by preventing the development of new cases of the disease (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
3.6.4.1 Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease
3.6.4.2 Infectious Diseases That Require Parent/Guardian Notification
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
REFERENCES
  1. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.

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
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.2.9 Information Required for Children Who Are Ill
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 3.6.3.2: Labeling, Storage, and Disposal of Medications

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

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

All medications, refrigerated or unrefrigerated, should:

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

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

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

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

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.3.1 Medication Administration
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
REFERENCES
  1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
  2. U.S. Environmental Protection Agency. 2009. Pharmaceuticals and personal care products as pollutants (PPCPs). http://www.epa
    .gov/ppcp/.
  3. U.S. Food and Drug Administration. 2010. Disposal by flushing of certain unused medicines: What you should know. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
    EnsuringSafeUseofMedicine/SafeDisposalofMedicines/
    ucm186187.htm.

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.

Chapter 4 - Nutrition and Food Service

Standard 4.2.0.3: Use of US Department of Agriculture Child and Adult Care Food Program Guidelines

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

 

All meals and snacks and their preparation, service, and storage should meet the requirements for meals (7 CFR §226.20) of the child care component of the US Department of Agriculture Child and Adult Care Food Program (CACFP) (1-3).

RATIONALE
The CACFP regulations, policies, and guidance materials on meal requirements provide basic guidelines for sound nutrition and sanitation practices. The CACFP guidance for meals and snack patterns ensures that the nutritional needs of infants and children, including school-aged children through 12 years, are met based on the Dietary Guidelines for Americans (4,5) as well as other evidence-based recommendations (6,7). Programs not eligible for reimbursement under the regulations of CACFP should still use the CACFP food guidance.

COMMENTS
Staff should use information about the child’s growth and CACFP meal patterns to develop individual feeding plans (6).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
REFERENCES
  1. Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. 2nd ed. Arlington, VA: Zero to Three; 2008
  2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Regulations. https://www.fns.usda.gov/cacfp/regulations. Updated September 7, 2017. Accessed September 7, 2017
  3. US Department of Agriculture, Food and Nutrition Service. Requirements for meals. US Government Publishing Office Web site. https://www.ecfr.gov/cgi-bin/text-idx?SID=9c3a6681dbf6aada3632967c4bfeb030&mc=true&node=pt7.4.226&rgn=div5#se7.4.226_120. Accessed September 7, 2017
  4. ADDITIONAL RESOURCE
    US Department of Agriculture. Child and Adult Care Food Program: best practices. US Department of Agriculture, Food and Nutrition Service Web site. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf. Accessed September 7, 2017

  5. US Department of Agriculture, Healthy Meals Resource System, Team Nutrition. CACFP wellness resources for child care providers. https://healthymeals.fns.usda.gov/cacfp-wellness-resources-child-care-providers. Accessed September 7, 2017
  6. US Department of Agriculture, Food and Nutrition Service. Child and Adult Food Program (CACFP). Nutrition standards for CACFP meals and snacks. https://www.fns.usda.gov/cacfp/meals-and-snacks. Updated March 27, 2017. Accessed September 7, 2017
  7. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 7, 2017
  8. US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 7, 2017
NOTES

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

 

Standard 4.2.0.6: Availability of Drinking Water

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

 

Clean, sanitary drinking water should be readily available, in indoor and outdoor areas, throughout the day (1). Water should not be a substitute for milk at meals or snacks where milk is a required food component unless recommended by the child’s primary health care provider. 

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 after birth (1). Infants receiving formula and water can be given additional formula in a bottle. Toddlers and older children will need additional water as physical activity and/or hot temperatures cause their needs to increase. Children should learn to drink water from a cup or drinking fountain without mouthing the fixture. They should not be allowed to have water continuously in hand in a sippy cup or bottle. Permitting toddlers to suck continuously on a bottle or sippy cup filled with water, to soothe themselves, may cause nutritional or, in rare instances, electrolyte imbalances. When toothbrushing is not done after a feeding, children should be offered water to drink to rinse food from their teeth.

 

RATIONALE
When children are thirsty between meals and snacks, water is the best choice. Drinking water during the day can reduce extra caloric intake if the water replaces high-caloric beverages, such as fruit drinks/nectars and sodas, which are associated with overweight and obesity (2). Drinking water helps maintain a child’s hydration and overall health. Water can also decrease the likelihood of early childhood caries if consumed throughout the day, especially between meals and snacks (3,4). Personal and environmental factors, such as age, weight, gender, physical activity level, outside air temperature, heat, and humidity, can affect individual water needs (5).
COMMENTS
Having clean, small pitchers of water and single-use paper cups available in classrooms and on playgrounds allows children to serve themselves water when they are thirsty. Drinking fountains should be kept clean and sanitary and maintained to provide adequate drainage.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.3.2 Playing Outdoors
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
REFERENCES
  1. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
  2. Muckelbauer R, Sarganas G, Grüneis A, Müller-Nordhorn J. Association between water consumption and body weight outcomes: a systematic review. Am J Clin Nutr. 2013;98(2):282–299
  3. 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 September 19, 2017
  4. Mullen M, Shield JE. Water: how much do kids need? Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/fitness/sports-and-performance/hydrate-right/water-go-with-the-flow. Published May 2, 2017. Accessed September 19, 2017
  5. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017 
NOTES

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

 

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 4.2.0.10: 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 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.3.1.3

Date: 10/17/2011

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

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

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

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

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

 

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

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

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

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

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

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

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

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

 

Guidelines for Storage of Human Milk

Location

Temperature

Duration

Comments

Countertop, table

Room temperature (up to 77°F or 25°C)

6-8 hours

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

Insulated cooler bag

5°F – 39°F or -15°C – 4°C

24 hours

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

Refrigerator

39°F or 4°C

5 days

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

Freezer compartment of a refrigerator

5°F or -15°C

2 weeks

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

Freezer compartment of refrigerator with separate doors

0°F or -18°C

3-6 months

Chest or upright deep freezer

-4°F or -20°C

6-12 months

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

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


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

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

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

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

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

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

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

 

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

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

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

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

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

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

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

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

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

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

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

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

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

Standard 4.3.1.9: Warming Bottles and Infant Foods

Frequently Asked Questions/CFOC3 Clarifications

Reference: 4.3.1.9

Date: 10/13/2011

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

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

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

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

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

Bottles and infant foods can be served cold from the refrigerator and do not have to be warmed. If a caregiver/teacher chooses to warm them, bottles should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 120°F. Bottles should not be left in a pot of water to warm for more than five minutes. Bottles and infant foods should never be warmed in a microwave oven.

Infant foods should be stirred carefully to distribute the heat evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way. Only BPA-free plastic, plastic labeled #1, #2, #4 or #5, or glass bottles should be used.

If a slow-cooking device, such as a crock pot, is used for warming infant formula, human milk, or infant food, this slow-cooking device (and cord) should be out of children’s reach; should contain water at a temperature that does not exceed 120°F; and should be emptied, cleaned, sanitized, and refilled with fresh water daily.

If a bottle warmer is used for warming infant formula, human milk, or infant food, it should be out of children’s reach and used according to manufacturer’s instructions. For both slow-cooking devices and bottle warmers, glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics, such as polypropylene or polyethylene, should be used.  
 

RATIONALE
Bottles of human milk or infant formula that are warmed at room temperature or in warm water for an extended time provide an ideal medium for bacteria to grow. Infants have received burns from hot water dripping from an infant bottle that was removed from a crock pot or by pulling the crock pot down on themselves by a dangling cord. Caution should be exercised to avoid raising the water temperature above a safe level for warming infant formula or infant food. Human milk, formula, or food fed to infants should never be heated in a microwave oven as uneven hot spots in milk and/or food may burn the infant (1,2).

Avoid bottles made of plastics containing bisphenol A (BPA) (3) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene  (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
REFERENCES
  1. Dixon J. J., D. A. Burd, D. G. Roberts. 1997. Severe burns resulting from an exploding teat on a bottle of infant formula milk heated in a microwave oven. Burns 23:268-69.
  2. Nemethy, M., E. R. Clore. 1990. Microwave heating of infant formula and breast milk. J Pediatr Health Care 4:131-35.
  3. Harley, K.G., Gunier, R.B., Kogut, K., Johnson, C., et al. 2013. Prenatal and early childhood bisphenol a concentrations and behavior in school-aged children. Environ Res. 126: 43-50.
NOTES

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

Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infants

A plan to introduce age-appropriate solid foods (complementary foods) to infants should be made in consultation with the child’s parent/guardian and primary care provider. Age-appropriate solid foods may be introduced no sooner than when the child has reached the age of four months, but preferably six months and as indicated by the individual child’s nutritional and developmental needs.

For breastfed infants, gradual introduction of iron-fortified foods may occur no sooner than around four months, but preferably six months and to complement the human milk. Modification of basic food patterns should be provided in writing by the child’s primary care provider.

Evidence for introducing complementary foods in a specific order or rate is not available. The current best practice is that the first solid foods should be single-ingredient foods and should be introduced one at a time at two- to seven-day intervals (1).

RATIONALE
Early introduction of age-appropriate solid food and fruit juice interferes with the intake of human milk or iron-fortified formula that the infant needs for growth. Age-appropriate solid food given before an infant is developmentally ready may be associated with allergies and digestive problems (2,8). Around about six months of age, breastfed infants may require an additional source of iron. Vitamin drops with iron may be needed. Infants who are not exclusively fed human milk should consume iron-fortified formula as the substitute for human milk (9). In the United States, major non-milk sources of iron in the infant diet are iron-fortified cereal and meats (2). Zinc is important for healthy growth and proper immune function. Infant stores of zinc may subsidize the intake from human milk for several months. Age-appropriate solid foods such as meat (a good source of zinc) are needed beginning at six months (2). A full daily allowance of vitamin C is found in human milk (3). The American Academy of Pediatrics (AAP) recommends that all breastfed or partially breastfed infants receive a minimum daily intake of 400 IU of vitamin D supplementation beginning soon after birth until they consume sufficient vitamin D fortified milk (about one quart per day) to meet the 400 IU daily requirements (4). These supplements should be given at home by the parents/guardians to take the burden off the caregiver/teacher.

The transitional phase of feeding age-appropriate solid foods which occurs no sooner than four months and preferably six months of age is a critical time for development of gross, fine, and oral motor skills. When an infant is able to hold his/her head steady, open her/his mouth, lean forward in anticipation of food offered, close the lips around a spoon, and transfer from front of the tongue to the back and swallow, s/he is ready to eat semi-solid foods. The process of learning a more mature style of eating begins because of physical growth occurring concurrently with social, cultural, sociological, and physiological development.

COMMENTS
Many infants find fruit juices appealing and may be satisfied by the calories in age-appropriate solid foods so that they subsequently drink less human milk or formula. When fruit juice is introduced at one year of age, it should be by cup rather than a bottle or other container (such as a box) to decrease the occurrence of dental caries. Infants, birth up to one year of age, should not be served juice. Whole fruit, mashed or pureed, is appropriate for infants seven months up to one year of age. Children one year of age through age six should be limited to a total of four to six ounces of juice per day.

Many people believe that infants sleep better when they start to eat age-appropriate solid foods, however research shows that longer sleeping periods are developmentally and not nutritionally determined in mid-infancy (2,5).

An important goal of early childhood nutrition is to ensure children’s present and future health by fostering the development of healthy eating behaviors (2,9). Caregivers/teachers are responsible for providing a variety of nutritious foods, defining the structure and timing of meals and creating a mealtime environment that facilitates eating and social exchange (7). Children are responsible for participating in choices about food selection and should be allowed to take responsibility for determining how much is consumed at each eating occasion (2).

Good communication between the caregiver/teacher and the parents/guardians cannot be over-emphasized and is essential for successful feeding in general, including when and how to introduce age-appropriate solid foods. The decision to feed specific foods should be made in consultation with the parent/guardian. Caregivers/teachers should be given written instructions on the introduction and feeding of foods from the infant’s parent/guardian and primary care provider. Caregivers/teachers can use or develop a take-home sheet for parents/guardians in which the caregiver/teacher records the food consumed, how much, and other important notes on the infant, each day. Caregivers/teachers should continue to consult with each infant’s parents/guardians concerning which foods they have introduced and are feeding. This schedule of introducing new foods one at a time, followed by waiting two to seven days before introducing another new food, enables parents and caregivers/teachers to pinpoint any problems a child might have with any specific food (10). Following this schedule for introducing new foods, the caregiver/teacher can more easily identify an infant’s possible food allergy or intolerance. 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 (6,8).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.2.0.10 Care for Children with Food Allergies
4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.12 Vegetarian/Vegan Diets
4.5.0.8 Experience with Familiar and New Foods
REFERENCES
  1. U.S. Department of Agriculture, Food and Nutrition Service (FNS). 2002. Feeding infants: A guide for use in the child nutrition programs. Rev ed. Alexandria, VA: FNS. http://www.fns.usda.gov/tn/resources/feeding_infants.pdf.
  2. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  3. 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.
  4. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  5. Lawrence, R. A., R. Lawrence. 2005. Breast feeding: A guide for the medical profession. 6th ed. St. Louis: Mosby.
  6. Branscomb, K. R., C. B. Goble. 2008. Infants and toddlers in group care: Feeding practices that foster emotional health. Young Children 63:28-33.
  7. Grummer-Strawn, L. M., K. S. Scanlon, S. B. Fein. 2008. Infant feeding and feeding transitions during the first year of life. Pediatrics 122: S36-S42.
  8. Griffiths, L. J., L. Smeeth, S. S. Hawkins, T. J. Cole, C. Dezateux. 2008. Effects of infant feeding practice on weight gain from birth to 3 years. Arch Dis Child (November): 1-17.
  9. Wagner, C. L., F. R. Greer, Section on Breastfeeding, Committee on Nutrition. 2008. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics 122:1142–52.
  10. Hagan, Jr., J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting healthy nutrition. In Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. http://brightfutures.aap.org/pdfs/Guidelines_PDF/6-Promoting_Healthy_Nutrition.pdf.

Standard 4.5.0.6: Adult Supervision of Children Who Are Learning to Feed Themselves

Children in mid-infancy who are learning to feed themselves should be supervised by an adult seated within arm’s reach of them at all times while they are being fed. Children over twelve months of age who can feed themselves should be supervised by an adult who is seated at the same table or within arm’s reach of the child’s highchair or feeding table. When eating, children should be within sight of an adult at all times.

RATIONALE
A supervising adult should watch for several common problems that typically occur when children in mid-infancy begin to feed themselves. “Squirreling” of several pieces of food in the mouth increases the likelihood of choking. A choking child may not make any noise, so adults must keep their eyes on children who are eating. Active supervision is imperative. Supervised eating also promotes the child’s safety by discouraging activities that can lead to choking (1). For best practice, children of all ages should be supervised when eating. Adults can monitor age-appropriate portion size consumption.
COMMENTS
Adults can help children while they are learning, by modeling active chewing (i.e., eating a small piece of food, showing how to use their teeth to bite it) and making positive comments to encourage children while they are eating. Adults can demonstrate how to eat foods on the menu, how to serve food, and how to ask for more food as a way of helping children learn the names of foods (e.g., “please pass the bowl of noodles”).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Standard 4.5.0.9: Hot Liquids and Foods

Adults should not consume hot liquids above 120°F in child care areas (3). Hot liquids and hot foods should be kept out of the reach of infants, toddlers, and preschoolers. Hot liquids and foods should not be placed on a surface at a child's level, at the edge of a table or counter, or on a tablecloth that could be yanked down. Appliances containing hot liquids, such as coffee pots and crock pots, should be kept out of the reach of children. Electrical cords from any appliance, including coffee pots, should not be allowed to hang within the reach of children. Food preparers should position pot handles toward the back of the stove and use only back burners when possible.

RATIONALE
The most common burn suffered by young children is scalding from hot liquids tipped over in the kitchen (1). The skin of young children is much thinner than that of adults and can burn at temperatures that adults find comfortable (2). In a recent study, 90.4% of scald injuries to children under age five were related to hot cooking or drinking liquids (4).
COMMENTS
Hot liquids can cause burns to young children at the following rates of contact: one second at 156°F, two seconds at 149°F, five seconds at 140°F, fifteen seconds at 133°F, five minutes at 120°F (2).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Lowell, G., K. Quinlan, L. J. Gottlieb. 2008. Pediatrics 122:799-804.
  2. Turner, C., A. Spinks, R. J. McClure, J. Nixon. 2004. Community-based interventions for the prevention of burns and scalds in children. Cochrane Database Systematic Rev (2).
  3. Children’s Safety Association of Canada. Safety fact sheet: Scald burns. http://www.safekid.org/scald.htm.
  4. Ring, L. M. 2007. Kids and hot liquids-A burning reality. J of Pediatric Health Care 21:192-94.

Standard 4.5.0.10: Foods that Are Choking Hazards

Caregivers/teachers should not offer to children under four years of age foods that are associated with young children’s choking incidents (round, hard, small, thick and sticky, smooth, compressible or dense, or slippery). Examples of these foods are hot dogs and other meat sticks (whole or sliced into rounds), raw carrot rounds, whole grapes, hard candy, nuts, seeds, raw peas, hard pretzels, chips, peanuts, popcorn, rice cakes, marshmallows, spoonfuls of peanut butter, and chunks of meat larger than can be swallowed whole. Food for infants should be cut into pieces one-quarter inch or smaller, food for toddlers should be cut into pieces one-half inch or smaller to prevent choking. In addition to the food monitoring, children should always be seated when eating to reduce choking hazards. Children should be supervised while eating, to monitor the size of food and that they are eating appropriately (for example, not stuffing their mouths full).

RATIONALE
High-risk foods are those often implicated in choking incidents (1,9,10). Almost 90% of fatal choking occurs in children younger than four years of age (2-7). Peanuts may block the lower airway. A chunk of hot dog or a whole seedless grape may completely block the upper airway (2-8,10). The compressibility or density of a food item is what allows the food to conform to and completely block the airway. Hot dogs are the foods most commonly associated with fatal choking in children.
COMMENTS
To reduce the risk of choking, menus should reflect the developmental abilities of the age of children served. Because it is normal for children to get their first teeth at a widely variable age, menus must take into account not only the ages of children but also their teeth, or lack thereof. This becomes particularly important with those whose teeth come in late. Foods considered otherwise appropriate for one year-olds with a full complement of teeth may need to be reevaluated for the child whose first tooth has just emerged. Lists of high-risk foods should be made available. The presence of molars is a good indication of a healthy child’s ability to chew hard foods that are likely to cause choking (such as raw carrot rounds). To date, raisins appear to be safe, but, as when eating all foods, children should be seated and supervised.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
  2. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  3. U.S. Department of Agriculture (USDA), Child and Adult Care Food Program (CACFP). 2002. Menu magic for children: A menu planning guide for child care. Washington, DC: USDA. http://www.fns.usda.gov/tn/resources/menu_magic.pdf.
  4. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
  5. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
  6. Morley, R. E., J. P. Ludemann, J. P. Moxham, F. K. Kozak, K. H. Riding. 2004. Foreign body aspiration in infants and toddlers: Recent trends in British Columbia. J Otolaryngology 33:37-41.
  7. Baker, S. B., R. S. Fisher. 1980. Childhood asphyxiation by choking or suffocation. JAMA 244:1343-46.
  8. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
  9. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.
  10. Rimell, F. L., A. Thome Jr., S. Stool, et al. 1995. Characteristics of objects that cause choking in children. JAMA 274:1763-66.

Standard 4.8.0.1: Food Preparation Area

The food preparation area of the kitchen should be separate from eating, play, laundry, toilet, and bathroom areas and from areas where animals are permitted. The food preparation area should not be used as a passageway while food is being prepared. Food preparation areas should be separated by a door, gate, counter, or room divider from areas the children use for activities unrelated to food, except in small family child care homes when separation may limit supervision of children.

Infants and toddlers should not have access to the kitchen in child care centers. Access by older children to the kitchen of centers should be permitted only when supervised by staff members who have been certified by the nutritionist/registered dietitian or the center director as qualified to follow the facility’s sanitation and safety procedures.

In all types of child care facilities, children should never be in the kitchen unless they are directly supervised by a caregiver/teacher. Children of preschool-age and older should be restricted from access to areas where hot food is being prepared. School-age children may engage in food preparation activities with adult supervision in the kitchen or the classroom. Parents/guardians and other adults should be permitted to use the kitchen only if they know and follow the food safety rules of the facility. The facility should check with local health authorities about any additional regulations that apply.

RATIONALE
The presence of children in the kitchen increases the risk of contamination of food and the risk of injury to children from burns. Use of kitchen appliances and cooking techniques may require more skill than can be expected for children’s developmental level. The most common burn in young children is scalding from hot liquids tipped over in the kitchen (1).

The kitchen should be used only by authorized individuals who have met the requirements of the local health authority and who know and follow the food safety rules of the facility so they do not contaminate food and food surfaces for food-related activities. Under adult supervision, school-age children may be encouraged to help with developmentally appropriate food preparation, which increases the likelihood that they will eat new foods.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
REFERENCES
  1. Ring, L. M. 2007. Kids and hot liquids–A burning reality. J Pediatric Health Care 21:192-94.

Standard 4.8.0.3: Maintenance of Food Service Surfaces and Equipment

All surfaces that come into contact with food, including tables and countertops, as well as floors and shelving in the food preparation area should be in good repair, free of cracks or crevices, and should be made of smooth, nonporous material that is kept clean and sanitized. All kitchen equipment should be clean and should be maintained in operable condition according to the manufacturer’s guidelines for maintenance and operation. The facility should maintain an inventory of food service equipment that includes the date of purchase, the warranty date, and a history of repairs.

RATIONALE
Cracked or porous materials should be replaced because they trap food and other organic materials in which microorganisms can grow (1). Harsh scrubbing of these areas tends to create even more areas where organic material can lodge and increase the risk of contamination. Repairs with duct tape, package tapes, and other commonly used materials add surfaces that trap organic materials.

Food service equipment is designed by the manufacturer for specific types of use. The equipment must be maintained to meet those performance standards or food will become contaminated and spoil (1). An accurate and ongoing inventory of food service equipment tracks maintenance requirements and can provide important information when a breakdown occurs.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. National Restaurant Association. 2008. ServSafe essentials. 5th ed. Upper Saddle River, NJ: Prentice Hall.

Standard 4.9.0.2: Staff Restricted from Food Preparation and Handling

Anyone who has signs or symptoms of illness, including vomiting, diarrhea, and infectious skin sores that cannot be covered, or who potentially or actually is infected with bacteria, viruses or parasites that can be carried in food, should be excluded from food preparation and handling. Staff members may not contact exposed, ready-to-eat food with their bare hands and should use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. No one with open or infected skin eruptions should work in the food preparation area unless the injuries are covered with nonporous (such as latex or vinyl), single use gloves.

In centers and large family child care homes, staff members who are involved in the process of preparing or handling food should not change diapers. Staff members who work with diapered children should not prepare or serve food for older groups of children. When staff members who are caring for infants and toddlers are responsible for changing diapers, they should handle food only for the infants and toddlers in their groups and only after thoroughly washing their hands. Caregivers/teachers who prepare food should wash their hands carefully before handling any food, regardless of whether they change diapers. When caregivers/teachers must handle food, staffing assignments should be made to foster completion of the food handling activities by caregivers/teachers of older children, or by caregivers/teachers of infants and toddlers before the caregiver/teacher assumes other caregiving duties for that day. Aprons worn in the food service area must be clean and should be removed when diaper changing or when using the toilet.

RATIONALE
Food handlers who are ill can easily transmit their illness to others by contaminating the food they prepare with the infectious agents they are carrying. Frequent and proper handwashing before and after using plastic gloves reduces food contamination (1,2,4).

Caregivers/teachers who work with infants and toddlers are frequently exposed to feces and to children with infections of the intestines (often with diarrhea) or of the liver. Education of child care staff regarding handwashing and other cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (1,2,4).

The possibility of involving a larger number of people in a foodborne outbreak is greater in child care than in most households. Cooking larger volumes of food requires special caution to avoid contamination of the food with even small amounts of infectious materials. With larger volumes of food, staff must exercise greater diligence to avoid contamination because larger quantities of food take longer to heat or to cool to safe temperatures. Larger volumes of food spend more time in the danger zone of temperatures (between 41°F and 135°F) where more rapid multiplication of microorganisms occurs (3).

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
REFERENCES
  1. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
  2. U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.
  3. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
  4. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

Standard 4.9.0.3: Precautions for a Safe Food Supply

All foods stored, prepared, or served should be safe for human consumption by observation and smell (1-2). The following precautions should be observed for a safe food supply:

  1. Home-canned food; food from dented, rusted, bulging, or leaking cans, and food from cans without labels should not be used;
  2. Foods should be inspected daily for spoilage or signs of mold, and foods that are spoiled or moldy should be promptly and appropriately discarded;
  3. Meat should be from government-inspected sources or otherwise approved by the governing health authority (3);
  4. All dairy products should be pasteurized and Grade A where applicable;
  5. Raw, unpasteurized milk, milk products; unpasteurized fruit juices; and raw or undercooked eggs should not be used. Freshly squeezed fruit or vegetable juice prepared just prior to serving in the child care facility is permissible;
  6. Unless a child’s health care professional documents a different milk product, children from twelve months to two years of age should be served only human milk, formula, whole milk or 2% milk (6). Note: For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older should be served skim or 1% milk. If cost-saving is required to accommodate a tight budget, dry milk and milk products may be reconstituted in the facility for cooking purposes only, provided that they are prepared, refrigerated, and stored in a sanitary manner, labeled with the date of preparation, and used or discarded within twenty-four hours of preparation;
  7. Meat, fish, poultry, milk, and egg products should be refrigerated or frozen until immediately before use (5);
  8. Frozen foods should be defrosted in one of four ways: In the refrigerator; under cold running water; as part of the cooking process, or by removing food from packaging and using the defrost setting of a microwave oven (5). Note: Frozen human milk should not be defrosted in the microwave;
  9. Frozen foods should never be defrosted by leaving them at room temperature or standing in water that is not kept at refrigerator temperature (5);
  10. All fruits and vegetables should be washed thoroughly with water prior to use (5);
  11. Food should be served promptly after preparation or cooking or should be maintained at temperatures of not less than 135°F for hot foods and not more than 41°F for cold foods (12);
  12. All opened moist foods that have not been served should be covered, dated, and maintained at a temperature of 41°F or lower in the refrigerator or frozen in the freezer, verified by a working thermometer kept in the refrigerator or freezer (12);
  13. Fully cooked and ready-to-serve hot foods should be held for no longer than thirty minutes before being served, or promptly covered and refrigerated;
  14. Pasteurized eggs or egg products should be substituted for raw eggs in the preparation of foods such as Caesar salad, mayonnaise, meringue, eggnog, and ice cream. Pasteurized eggs or egg products should be substituted for recipes in which more than one egg is broken and the eggs are combined, unless the eggs are cooked for an individual child at a single meal and served immediately, such as in omelets or scrambled eggs; or the raw eggs are combined as an ingredient immediately before baking and the eggs are fully cooked to a ready-to-eat form, such as a cake, muffin or bread;
  15. Raw animal foods should be fully cooked to heat all parts of the food to a temperature and for a time of; 145°F or above for fifteen seconds for fish and meat; 160°F for fifteen seconds for chopped or ground fish, chopped or ground meat or raw eggs; or 165°F or above for fifteen seconds for poultry or stuffed fish, stuffed meat, stuffed pasta, stuffed poultry or stuffing containing fish, meat or poultry.

RATIONALE
Safe handling of all food is a basic principle to prevent and reduce foodborne illnesses (14). For children, a small dose of infectious or toxic material can lead to serious illness (13). Some molds produce toxins that may cause illness or even death (such as aflatoxin or ergot).

Keeping cold food below 41°F and hot food above 135°F prevents bacterial growth (1,6,12). Food intended for human consumption can become contaminated if left at room temperature.

Foodborne illnesses from Salmonella and E. coli 0157:H7 have been associated with consumption of contaminated, raw, or undercooked egg products, meat, poultry, and seafood. Children tend to be more susceptible to E. coli 0157:H7 infections from consumption of undercooked meats, and such infections can lead to kidney failure and death.

Home-canned food, food from dented, rusted, bulging or leaking cans, or leaking packages/bags of frozen foods, have an increased risk of containing microorganisms or toxins. Users of unlabeled food cans cannot be sure what is in the can and how long the can has been stored.

Excessive heating of foods results in loss of nutritional content and causes foods to lose appeal by altering color, consistency, texture, and taste. Positive learning activities for children, using their senses of seeing and smelling, help them to learn about the food they eat. These sensory experiences are counterproductive when food is overcooked. Children are not only shortchanged of nutrients, but are denied the chance to use their senses fully to learn about foods.

Caregivers/teachers should discourage parents/guardians from bringing home-baked items for the children to share as it is difficult to determine the quality of the ingredients used and the cleanliness of the environment in which the items are baked and transported. Parents/guardians should be informed why home baked items like birthday cake and cupcakes are not the healthiest choice and the facility should provide ideas for healthier alternatives such as fruit cups or fruit salad to celebrate birthdays and other festive events.

Several states allow the sale of raw milk or milk products. These products have been implicated in outbreaks of salmonellosis, listeriosis, toxoplasmosis, and campylobacteriosis and should never be served in child care facilities (7,8). Only pasteurized milk and fruit juices should be served. Foods made with uncooked eggs have been involved in a number of outbreaks of Salmonella infections. Eggs should be well-cooked before being eaten, and only pasteurized eggs or egg substitutes should be used in foods requiring raw eggs.

The American Academy of Pediatrics (AAP) recommends that children from twelve months to two years of age receive human milk, formula, whole milk, or 2% milk. For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older can drink skim, or 1%, milk (6,9-11).

Soil particles and contaminants that adhere to fruits and vegetables can cause illness. Therefore, all fruits or vegetables to be eaten and used to make fresh juice at the facility should be thoroughly washed first.

Thawing frozen foods under conditions that expose any of the food’s surfaces to temperatures between 41°F and 135°F promotes the growth of bacteria that may cause illness if ingested. Storing perishable foods at safe temperatures in the refrigerator or freezer reduces the rate at which microorganisms in these foods multiply (12).

COMMENTS
The use of dairy products fortified with vitamins A and D is recommended (4).

The FDA provides the following Website for caregivers/teachers to check status of foods and food products that have been recalled, see http://www.fda.gov.

Temperatures come from the FDA 2009 Food Code (12). Local or state regulations may differ. Caregivers/teachers should consult with the health department concerning questions on proper cooking temperatures for specific foods.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.7 Feeding Cow’s Milk
4.8.0.6 Maintaining Safe Food Temperatures
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures
REFERENCES
  1. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
  2. Food Marketing Institute (FMI), U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Facts about food and floods: A consumer guide to food quality and safe handling after a flood or power outage. Washington, DC: FMI.
  3. Potter, M. E. 1984. Unpasteurized milk: The hazards of a health fetish. JAMA 252:2048-52.
  4. Sacks, J. J. 1982. Toxoplasmosis infection associated with raw goat’s milk. JAMA 246:1728-32.
  5. Chicago Dietetic Association. 1996. Manual of clinical dietetics. 5th ed. Chicago, IL: American Dietetic Association.
  6. Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.
  7. Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
  8. U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
  9. Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  10. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
  11. Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.
  12. U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.
  13. Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
  14. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

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

Standard 5.1.1.2: Inspection of Buildings

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

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

  2. Centers for Disease Control and Prevention (CDC). 2012. Announcement: Response to the advisory committee on childhood lead poisoning prevention report, low level lead exposure harms children: A renewed call for primary prevention. MMWR. Atlanta, GA: CDC.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6120a6.htm?s_cid=mm6120a6_e.

Standard 5.1.1.3: Compliance with Fire Prevention Code

Every twelve months, the child care facility should obtain written documentation to submit to the regulatory licensing authority that the facility complies with a state-approved or nationally recognized Fire Prevention Code. If available, this documentation should be obtained from a fire prevention official with jurisdiction where the facility is located. Where fire safety inspections or a Fire Prevention Code applicable to child care centers is not available from local authorities, the facility should arrange for a fire safety inspection by an inspector who is qualified to conduct such inspections using the National Fire Protection Association’s NFPA 101: Life Safety Code.

RATIONALE
Regular fire safety checks by trained officials will ensure that a child care facility continues to meet all applicable fire safety codes. NFPA 101: Life Safety Code addresses child care facilities in two chapters devoted exclusively to this occupancy – chapter 16, “New Day-Care Occupancies” and chapter 17, “Existing Day-Care Occupancies” (1).
TYPE OF FACILITY
Center

Standard 5.1.1.5: Environmental Audit of Site Location

Frequently Asked Questions/CFOC3 Clarifications

Reference: 5.1.1.5

Date: 10/13/2011

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

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

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

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

 

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

The environmental audit should include assessments of:

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

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

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

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

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

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

 

Standard 5.1.3.2: Possibility of Exit from Windows

All windows in areas used by children under five years of age should be constructed, adapted, or adjusted to limit the exit opening accessible to children to less than four inches, or be otherwise protected with guards that prevent exit by a child, but that do not block outdoor light. Where such windows are required by building or fire codes to provide for emergency rescue and evacuation, the windows and guards, if provided, should be equipped to enable staff to release the guard and open the window fully when evacuation or rescue is required. Opportunities should be provided for staff to practice opening these windows, and such release should not require the use of tools or keys. Children should be given information about these windows, relevant safety rules, as well as what will happen if the windows need to be opened for an evacuation.

RATIONALE
To prevent children from falling out of windows, standards from the U.S. Consumer Product Safety Commission (CPSC) and the ASTM International (ASTM) require the opening size to be four inches to prevent the child from getting through or the head from being entrapped (1,2). Some children may be able to pass their body through a slightly larger opening but then get stuck and hang from the window opening with their head trapped inside. Caregivers/teachers must not depend on screens to keep children from falling out of windows. Windows to be used as fire exits must be immediately accessible. Staff should supervise children when they are near these windows, and incorporate safety information and relevant emergency procedures and drills into their day-to-day curriculum so that children will better understand the safety issues and what will happen if they need to leave the building through the windows.
COMMENTS
“Screens” are intended to prevent flying insects from coming into the facility whereas window “guards” are the type of devices commonly used to provide building security and prevent intruders.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. ASTM International. ASTM F2090-08 Standard specification for window fall prevention devices with emergency escape (egress) release mechanisms. West Conshohocken, PA: ASTM.
  2. U.S. Consumer Product Safety Commission (CPSC). New standards for window guards to help protect children from fails. Release #00-126. Washington, DC: CPSC.  http://www.cpsc.gov/en/Newsroom/News-Releases/2000/New-Standards-for-Window-Guards-To-Help-Protect-Children-From-Falls-/.

Standard 5.1.4.1: Alternate Exits and Emergency Shelter

Each building or structure, new or old, should be provided with a minimum of two exits, at different sides of the building or home, leading to an open space at ground level. If the basement in a small family child care home is being used, one exit must lead directly to the outside. Exits should be unobstructed, allowing occupants to escape to an outside door or exit stair enclosure in case of fire or other emergency. Each floor above or below ground level used for child care should have at least two unobstructed exits that lead to an open area at ground level and thereafter to an area that meets safety requirements for a child care indoor or outdoor area. Children should remain there until their parents/guardians can pick them up, if reentry into the facility is not possible.

Entrance and exit routes should be reviewed and approved by the applicable fire inspector. Exiting should meet all the requirements of the current edition of the NFPA 101: Life Safety Code from the National Fire Protection Association (NFPA).

RATIONALE
Unobstructed exit routes are essential for prompt evacuation. The purpose of having two ways to exit when child care is provided on a floor above or below ground level is to ensure an alternative exit if fire blocks one exit (1).
COMMENTS
Using an outdoor playground as a safe place to exit to may not always be possible. Where the playground is fully surrounded by fencing, it is important that a gate that staff is trained, authorized, and equipped to open, be provided to permit travel away from the building should fire expose children and staff to radiant heat and smoke. Some authorities will permit a fenced area with sufficient accumulation space at least fifty feet from the building to serve in lieu of a gated opening. Some child care facilities do not have a playground located adjacent to the child care building and use local parks as the playground site. Access to these parks may require crossing a street at an intersection with a crosswalk. This would normally be considered safe, especially in areas of low traffic; however, when sirens go off, a route that otherwise may be considered safe becomes chaotic and dangerous. During evacuation or an emergency, children, as well as staff, become excited and may run into the street when the playground is not fenced or immediately adjacent to the center (1).

In the event of a fire, staff members and children should be able to get at least fifty feet away from the building or structure. If the children cannot return to their usual building, a suitable shelter containing all items necessary for child care must be available where the children can safely remain until their parents/guardians come for them. An evacuation plan should take into consideration all available open areas to which staff and children can safely retreat in an emergency (1).

For information about the NFPA 101: Life Safety Code, contact the NFPA.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.4.6 Labeled Emergency Exits
5.1.4.7 Access to Exits
REFERENCES
  1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.1.5.4: Guards at Stairway Access Openings

Securely installed, effective guards (such as gates) should be provided at the top and bottom of each open stairway in facilities where infants and toddlers are in care. Gates should have latching devices that adults (but not children) can open easily in an emergency. “Pressure gates” or accordion gates should not be used. Gate design should not aid in climbing. Gates at the top of stairways should be hardware mounted (e.g., to the wall) for stability. Basement stairways should be shut off from the main floor level by a full door. This door should be self-closing and should be kept locked to entry when the basement is not in use. No door should be locked to prohibit exit at any time.

RATIONALE
Falls down stairs and escape upstairs can injure infants and toddlers. A gate with a difficult opening device can cause entrapment in an emergency (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.1.6.6 Guardrails and Protective Barriers
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). Old accordion style baby gates are dangerous. http://www.cpsc.gov/CPSCPUB/PUBS/5085.pdf.

Standard 5.1.6.6: Guardrails and Protective Barriers

Guardrails, a minimum of thirty-six inches in height, should be provided at open sides of stairs, ramps, and other walking surfaces (e.g., landings, balconies, porches) from which there is more than a thirty-inch vertical distance to fall. Spaces below the thirty-six inches height guardrail should be further divided with intermediate rails or balusters as detailed in the next paragraph.

For preschoolers, bottom guardrails greater than nine inches but less or equal to twenty-three inches above the floor should be provided for all porches, landings, balconies, and similar structures. For school age children, bottom guardrails should be greater than nine inches but less or equal to twenty inches above the floor, as specified above.

For infants and toddlers, protective barriers should be less than three and one-half inches above the floor, as specified above. All spaces in guardrails should be less than three and a half inches. All spaces in protective barriers should be less than three and one-half inches. If spaces do not meet the specifications as listed above, a protective material sufficient to prevent the passing of a three and one-half inch diameter sphere should be provided.

Where practical or otherwise required by applicable codes, guardrails should be a minimum of forty-two inches in height to help prevent falls over the open side by staff and other adults in the child care facility.

RATIONALE
Structures such as porches, landings, balconies, and other similar structures that are raised more than thirty inches above an adjacent ground or floor, pose increased risk for fall injuries. Spaces between three and one-half inches and nine inches are a head entrapment hazard (1).

Guardrails are designed to protect against falls from elevated surfaces, but do not discourage climbing or protect against climbing through or under. Protective barriers protect against all three and provide greater protection. Guardrails are not recommended to use for infants and toddlers; protective barriers should be used instead.

A top guardrail with a minimum height of forty-two inches serves the needs of all occupants – children as well as adults (2). The minimum thirty-six-inch guardrail height detailed in this standard is based solely on the needs of children.

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
  2. National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.2.1.1: Ensuring Access to Fresh Air Indoors

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

 

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


RATIONALE

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

 

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

 

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

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

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

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

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

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

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

 

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

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

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

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

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

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

Standard 5.2.1.11: Portable Electric Space Heaters

Portable electric space heaters should:

  1. Be attended while in use and be off when unattended;
  2. Be inaccessible to children;
  3. Have protective covering to keep hands and objects away from the electric heating element;
  4. Bear the safety certification mark of a nationally recognized testing laboratory;
  5. Be placed on the floor only and at least three feet from curtains, papers, furniture, and any flammable object;
  6. Be properly vented, as required for proper functioning;
  7. Be used in accordance with the manufacturer’s instructions;
  8. Not be used with an extension cord.

The heater cord should be inaccessible to children as well.

RATIONALE
Portable electric space heaters are a common cause of fires and burns resulting from very hot heating elements being too close to flammable objects and people (1).
COMMENTS
To prevent burns and potential fires, space heaters must not be accessible to children. Children can start fires by inserting flammable material near electric heating elements. Curtains, papers, and furniture must be kept away from electric space heaters to avoid potential fires. Some electric space heaters function by heating oil contained in a heat-radiating portion of the appliance. Even though the electrical heating element is inaccessible in this type of heater, the hot surfaces of the appliance can cause burns. Cords to electric space heaters should be inaccessible to the children. Heaters should not be placed on a table or desk. Children and adults can pull an active unit off or trip on the cord.

To prevent burns or potential fires, consideration must be given to the ages and activity levels of children in care and the amount of space in a room. Alternative methods of heating may be safer for children. Baseboard electric heaters are cooler than radiant portable heaters, but still hot enough to burn a child if touched.

If portable electric space heaters are used, electrical circuits must not be overloaded. Portable electric space heaters are usually plugged into a regular 120-volt electric outlet connected to a fifteen-ampere circuit breaker. A circuit breaker is an overload switch that prevents the current in a given electric circuit from exceeding the capacity of a line. Fuses perform the same function in older systems. If too many appliances are plugged into a circuit, calling for more power than the capacity of the circuit, the breaker reacts by switching off the circuit. Constantly overloaded electrical circuits can cause electrical fires. If a circuit breaker is continuously switching the electric power off, reduce the load to the circuit before manually resetting the circuit breaker (more than one outlet may be connected to a single circuit breaker). If the problem persists, stop using the circuit and consult an electrical inspector or electrical contractor.

The Occupational Safety and Health Administration (OSHA) has a program that recognizes Nationally Recognized Testing Laboratories. Private sector organizations are listed on their Website at http://www.osha.gov/dts/otpca/nrtl/index
.html#nrtls.

Manufacturer’s instructions should be kept on file.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.1.13 Barriers/Guards for Heating Equipment and Units
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 2001. What you should know about space heaters. Washington, DC: CPSC. http://www.nnins.com/documents/WHATYOUSHOULDKNOWABOUTSPACEHEATERS.pdf.

Standard 5.2.4.2: Safety Covers and Shock Protection Devices for Electrical Outlets

All electrical outlets accessible to children who are not yet developmentally at a kindergarten grade level of learning should be a type called “tamper-resistant electrical outlets.” These types of outlets look like standard wall outlets but contain an internal shutter mechanism that prevents children from sticking objects like hairpins, keys, and paperclips into the receptacle (2). This spring-loaded shutter mechanism only opens when equal pressure is applied to both shutters such as when an electrical plug is inserted (2,3).

In existing child care facilities that do not have “tamper-resistant electrical outlets,” outlets should have “safety covers” that are attached to the electrical outlet by a screw or other means to prevent easy removal by a child. “Safety plugs” should not be used since they can be removed from an electrical outlet by children (2,3).

All newly installed or replaced electrical outlets that are accessible to children should use “tamper-resistant electrical outlets.”

In areas where electrical products might come into contact with water, a special type of outlet called Ground Fault Circuit Interrupters (GFCIs) should be installed (2). A GFCI is designed to trip before a deadly electrical shock can occur (1). To ensure that GFCIs are functioning correctly, they should be tested at least monthly (2). GFCIs are also available in a tamper-resistant design.

RATIONALE
Tamper-resistant electrical outlets or securely attached safety covers prevent children from placing fingers or sticking objects into exposed electrical outlets and reduce the risk of electrical shock, electrical burns, and potential fires (2). GFCIs provide protection from electrocution when an electric outlet or electric product may come into contact with water (1).

Approximately 2,400 children are injured annually by inserting objects into the slots of electrical outlets (2,3). The majority of these injuries involve children under the age of six (2,3).

Plastic safety plugs inserted into electric outlets are not the safest option since they can easily be removed by children and, depending on their size, present a potential choking hazard if placed in a child’s mouth (3).

COMMENTS
One type of outlet cover replaces the outlet face plate with a plate that has a spring-loaded outlet cover, which will stay in place when the receptacle is not in use. For receptacles where the facility does not intend to unplug the appliance, a more permanent cap-type cover that screws into the outlet receptacle is available. Several effective outlet safety devices are available in home hardware and infant/children stores (4).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.4.3 Ground-Fault Circuit-Interrupter for Outlets Near Water
REFERENCES
  1. National Electrical Manufacturers Association. Real safety with tamper-resistant receptacles.http://www.childoutletsafety.org.
  2. National Fire Protection Association. National electrical code fact sheet: Tamper-resistant electrical receptacles. http://www.nfpa.org/public-education/by-topic/top-causes-of-fire/electrical/tamper-resistant-electrical-receptacles.
  3. Electrical Safety Foundation International (ESFI). 2008. Know the dangers in your older home Rosslyn, VA: ESFI. http://files.esfi.org/file/Know-The-Dangers-of-Your-Older-Home.pdf
  4. National Fire Protection Association (NFPA). 2010. NFPA 70: National electrical code. 2011 ed. Quincy, MA: NFPA.

Standard 5.2.4.4: Location of Electrical Devices Near Water

No electrical device or apparatus accessible to children should be located so it could be plugged into an electrical outlet while a person is in contact with a water source, such as a sink, tub, shower area, water table, or swimming pool.

RATIONALE
Contact with a water source while using an electrical device provides a path for electricity through the person who is using the device (1,2). This can lead to electrical injury.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). CPSC safety alert: Install Ground-Fault Circuit-Interrupter Protection for Pools, Spas and Hot Tubs. http://www.cpsc.gov//PageFiles/118868/5039.pdf.
  2. National Fire Protection Association (NFPA). 2011. NFPA 70: National electrical code. 2011 ed. Quincy, MA: NFPA.

Standard 5.2.5.1: Smoke Detection Systems and Smoke Alarms

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 5.2.7.6: Storage and Disposal of Infectious and Toxic Wastes

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

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

Standard 5.2.8.1: Integrated Pest Management

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 5.2.9.1: Use and Storage of Toxic Substances

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

 

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

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

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

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

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

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

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

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

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

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

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

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

 

Standard 5.2.9.2: Use of a Poison Center

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

The caregiver/teacher should not induce vomiting unless instructed by the poison center.

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

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

Standard 5.2.9.3: Informing Staff Regarding Presence of Toxic Substances

Employers should provide staff with hazard information, including access to and review of the Safety Data Sheets (SDS) as required by the Occupational Safety and Health Administration (OSHA), about the presence of toxic substances such as formaldehyde, cleaning and sanitizing supplies, insecticides, herbicides, and other hazardous chemicals in use in the facility. Staff should always read the label prior to use to determine safety in use. For example, toxic products regulated by the Environmental Protection Agency (EPA) will have an EPA signal word of CAUTION, WARNING, or DANGER. Where nontoxic substitutes are available, these nontoxic substitutes should be used instead of toxic chemicals. If a nontoxic product is not available, caregivers/teachers should use the least toxic product for the job. A CAUTION label is safer than a WARNING label, which is safer than a DANGER label.

RATIONALE
These precautions are essential to the health and well-being of the staff and the children alike. Many cleaning products and art materials contain ingredients that may be toxic. Regulations require employers to make the complete identity of these materials known to users. Because nontoxic substitutes are available for virtually all necessary products, exchanging them for toxic products is required.
COMMENTS
The U.S. Department of Labor, which oversees OSHA, is responsible for protection of workers and is listed in the phone books of all large cities. Because standards change frequently, the facility should seek the latest standards from the EPA. Information on toxic substances in the environment is available from the EPA. For information on consumer products contact the U.S. Consumer Product Safety Commission (CPSC). For information on art and craft materials, contact the Art and Creative Materials Institute (ACMI). The local health jurisdiction can also be a resource for information on hazardous chemicals in child care.

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

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.8.1 Integrated Pest Management
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.7 Proper Use of Art and Craft Materials
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks
REFERENCES
  1. Wargo, J. 2004. The physical school environment: An essential component of a health-promoting school. WHO Information series on School Health, document 2. Geneva: WHO. http://www.who.int/school_youth_health/media/en/physical_sch_environment.pdf.
  2. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 5.2.9.4: Radon Concentrations

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

 

Radon concentrations inside a home or building used for child care must be less than four picocuries (pCi) per liter of air. All facilities must be tested for the presence of radon, according to U.S. Environmental Protection Agency (EPA) testing protocols for long-term testing (i.e., greater than ninety days in duration using alpha-track or electret test devices). Radon testing should be conducted after a major renovation to the building or HVAC system (1,2). 

RATIONALE
Radon is a colorless, odorless, radioactive gas that comes from the natural breakdown of uranium in soil, rock and water, and gets into the air you breath. It can be found in soil, water, building materials, and natural gas. Radon from the soil is the main cause of radon problems. Radon typically moves up through the ground to the air above and into a home or building through cracks and other holes in the foundation. Radon can get trapped inside the home or building where it can build up. In a small number of homes, the building materials can give off radon, but the materials themselves rarely cause problems. If radon is present in the water supply, most of the risk is related to radon released into the air when water is used for showering or other household purposes (1). When radon gas is inhaled, it can cause lung cancer. Radon levels can be easily measured to determine if acceptable levels have been exceeded. The risk can be reduced by lowering the levels of radon in the home or building. Fixing buildings to reduce radon exposure may entail sealing cracks in the foundation or ventilating the area under the foundation.
COMMENTS
The average indoor radon level is estimated to be about 1.3 pCi per liter of air, and about 0.4 pCi per liter is normally found in the outside air. Most homes today can be reduced to two picocuries per liter or below (1).

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


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

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

 

Standard 5.2.9.5: Carbon Monoxide Detectors

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

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

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

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

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

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

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

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

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

For other questions on CO poisoning call the poison center.

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

Standard 5.2.9.13: Testing for Lead

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

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

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

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

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

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

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

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

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

The danger from lead paint depends on:

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

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

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

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

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

Standard 5.3.1.1: Safety of Equipment, Materials, and Furnishings

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

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

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

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

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

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

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

Standard 5.3.1.12: Availability and Use of a Telephone or Wireless Communication Device

The facility should provide at all times at least one working non-pay telephone or wireless communication device for general and emergency use:

  1. On the premises of the child care facility;
  2. In each vehicle used when transporting children;
  3. On field trips.

Drivers, while transporting children should not operate a motor vehicle while using a mobile telephone or wireless communications device when the vehicle is in motion or a part of traffic, with the exception of use of a navigational system or global positioning system device.

RATIONALE
A telephone must be available to all caregivers/teachers in an emergency (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.5.1.1 Competence and Training of Transportation Staff
6.5.2.5 Distractions While Driving
REFERENCES
  1. Walsh, E. 2004. Health and safety notes: Field trip safety tips. Berkeley, CA: California Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/fieldtripsen070604_adr.pdf.

Standard 5.4.5.2: Cribs

Facilities should check each crib before its purchase and use to ensure that it is in compliance with the current U.S. Consumer Product Safety Commission (CPSC) and ASTM safety standards.

Recalled or “second-hand” cribs should not be used or stored in the facility. When it is determined that a crib is no longer safe for use in the facility, it should be dismantled and disposed of appropriately.

Staff should only use cribs for sleep purposes and should ensure that each crib is a safe sleep environment. No child of any age should be placed in a crib for a time-out or for disciplinary reasons. When an infant becomes large enough or mobile enough to reach crib latches or potentially climb out of a crib, they should be transitioned to a different sleeping environment (such as a cot or sleeping mat).

Each crib should be identified by brand, type, and/or product number and relevant product information should be kept on file (with the same identification information) as long as the crib is used or stored in the facility.

Staff should inspect each crib before each use to ensure that hardware is tightened and that there are not any safety hazards. If a screw or bolt cannot be tightened securely, or there are missing or broken screws, bolts, or mattress support hangers, the crib should not be used.

Safety standards document that cribs used in facilities should be made of wood, metal, or plastic. Crib slats should be spaced no more than two and three-eighths inches apart, with a firm mattress that is fitted so that no more than two fingers can fit between the mattress and the crib side in the lowest position. The minimum height from the top of the mattress to the top of the crib rail should be twenty inches in the highest position. Cribs with drop sides should not be used. The crib should not have corner post extensions (over one-sixteenth inch). The crib should have no cutout openings in the head board or footboard structure in which a child’s head could become entrapped. The mattress support system should not be easily dislodged from any point of the crib by an upward force from underneath the crib. All cribs should meet the ASTM F1169-10a Standard Consumer Safety Specification for Full-Size Baby Cribs, F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards, or the CPSC 16 CFR 1219, 1220, and 1500 – Safety Standards for Full-Size Baby Cribs and Non-Full-Size Baby Cribs; Final Rule.

Cribs should be placed away from window blinds or draperies.

As soon as a child can stand up, the mattress should be adjusted to its lowest position. Once a child can climb out of his/her crib, the child should be moved to a bed. Children should never be kept in their crib by placing, tying, or wedging various fabric, mesh, or other strong coverings over the top of the crib.

Cribs intended for evacuation purpose should be of a design and have wheels that are suitable for carrying up to five non-ambulatory children less than two years of age to a designated evacuation area. This crib should be used for evacuation in the event of fire or other emergency. The crib should be easily moveable and should be able to fit through the designated fire exit.

RATIONALE
Standards have been developed to define crib safety, and staff should make sure that cribs used in the facility meet these standards to protect children and prevent injuries or death (1-3). Significant changes to the ATSM and CPSC standards for cribs were published in December 2010. As of June 28, 2011 all cribs being manufactured, sold or leased must meet the new stringent requirements. Effective December 28, 2012 all cribs being used in early care and education facilities including family child care homes must also meet these standards. For the most current information about these new standards please go to http://www.cpsc.gov/info/cribs/index.html.

More infants die every year in incidents involving cribs than with any other nursery product (4). Children have become trapped or have strangled because their head or neck became caught in a gap between slats that was too wide or between the mattress and crib side.

An infant can suffocate if its head or body becomes wedged between the mattress and the crib sides (6).

Corner posts present a potential for clothing entanglement and strangulation (5). Asphyxial crib deaths from wedging the head or neck in parts of the crib and hanging by a necklace or clothing over a corner post have been well-documented (6).

Children who are thirty-five inches or taller in height have outgrown a crib and should not use a crib for sleeping (4). Turning a crib into a cage (covering over the crib) is not a safe solution for the problems caused by children climbing out. Children have died trying to escape their modified cribs by getting caught in the covering in various ways and firefighters trying to rescue children from burning homes have been slowed down by the crib covering (6).

CPSC has received numerous reports of strangulation deaths on window blind cords over the years (7).

COMMENTS
 For more information on articles in cribs, see Standard 5.4.5.1: Sleeping Equipment and Supplies and Standard 6.4.1.3: Crib Toys.

A “safety-approved crib” is one that has been certified by the Juvenile Product Manufacturers Association (JPMA).

If portable cribs and those that are not full-size are substituted for regular full-sized cribs, they must be maintained in the condition that meets the ASTM F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards. Portable cribs are designed so they may be folded or collapsed, with or without disassembly. Although portable cribs are not designed to withstand the wear and tear of normal full-sized cribs, they may provide more flexibility for programs that vary the number of infants in care from time to time.

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

To keep window blind cords out of the reach of children, staff can use tie-down devices or take the cord loop and cut it in half to make two separate cords. Consumers can call 1-800-506-4636 begin_of_the_skype_highlighting 1-800-506-4636 end_of_the_skype_highlighting or visit the Window Covering Safety Council Website at http://windowcoverings.org to receive a free repair kit for each set of blinds.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.3 Stackable Cribs
6.4.1.3 Crib Toys
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe?http://www.cpsc.gov/cpscpub/pubs/5009a.pdf.
  2. Juvenile Products Manufacturers Association. 2007. Safe and sound for baby: A guide to juvenile product safety, use, and selection. 9th ed. Moorestown, NJ: JPMA. http://www.jpma.org/content/retailers/safe-and-sound/.
  3. U.S. Consumer Product Safety Commission (CPSC). 1996. CPSC warns parents about infant strangulations caused by failure of crib hardware. http://www.ridgevfd.org/content/prevent/sleepwear.pdf
  4. U.S. Consumer Product Safety Commission (CPSC). 1997. The safe nursery. Washington, DC: CPSC.http://www.cpsc.gov/cpscpub/pubs/202.pdf.
  5. U.S. Consumer Product Safety Commission (CPSC). 2010. Safety standards for full-size baby cribs and non-full-size baby cribs; final rule. 16 CFR 1219, 1220, and 1500.http://www.cpsc.gov/businfo/frnotices/fr11/cribfinal.pdf.
  6. ASTM International. 2010. ASTM F406-10b: Standard consumer safety specification for non-full-size baby cribs/play yards. West Conshohocken, PA: ASTM.
  7. ASTM International. 2010. ASTM F1169-10a: Standard consumer safety specification for full-size baby cribs. West Conshohocken, PA: ASTM.

Standard 5.5.0.6: Inaccessibility to Matches, Candles, and Lighters

Matches, candles, and lighters should not be accessible to children.

RATIONALE
The U.S. Consumer Product Safety Commission (CPSC) estimates that 150 deaths occur each year from fires started by children playing with lighters. Children under five-years-old account for most of these fatalities (1). A child playing with candles or near candles is one of the biggest contributors to candle fires (2). Matches have also been the source of some fire-related deaths. Children may hide in a closet or under a bed when faced with fire, leading to fatalities (2).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Miller, D., R. Chowdhury, M. Greene. 2009. 2004-2006 residential fire loss estimates. Washington, DC: U.S. Consumer Product Safety Commission (CPSC). http://www.cpsc.gov/LIBRARY/fire06.pdf.
  2. U.S. Consumer Product Safety Commission (CPSC). Child-resistant lighters protect young children. Document #5021. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/
    5021.html.

Standard 5.5.0.7: Storage of Plastic Bags

Plastic bags, whether intended for storage, trash, diaper disposal, or any other purpose, should be stored out of reach of children.

RATIONALE
Plastic bags have been recognized for many years as a cause of suffocation. Warnings regarding this risk are printed on diaper-pail bags, dry-cleaning bags, and so forth. The U.S. Consumer Product Safety Commission (CPSC) has received average annual reports of twenty-five deaths per year to children due to suffocation from plastic bags. Nearly 90% of the reported deaths were to children under the age of one (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. U.S. Consumer Safety Commission (CPSC). Children still suffocating with plastic bags. Document #5604. Bethesda, MD: CPSC. http://nurse.png.woodcrest.schoolfusion.us/modules/locker/files/get_group_file.phtml?fid=2333676&gid=572924&sessionid=e71cb1192f18078f5dbd2fbf4f1f63bb

Standard 5.5.0.8: Firearms

Centers should not have any firearms, pellet or BB guns (loaded or unloaded), darts, bows and arrows, cap pistols, stun guns, paint ball guns, or objects manufactured for play as toy guns within the premises at any time. If present in a small or large family child care home, these items must be unloaded, equipped with child protective devices, and kept under lock and key with the ammunition locked separately in areas inaccessible to the children. Parents/guardians should be informed about this policy.

RATIONALE
The potential for injury to and death of young children due to firearms is apparent (1-5). These items should not be accessible to children in a facility (2,3).
COMMENTS
Compliance is monitored via inspection.
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Hemenway, D., D. Weil. 1990. Phasers on stun: The case for less lethal weapons. J Policy Analysis Management 9:94-98.
  2. Katcher, M. L., A. N. Meister., C. A. Sorkness, A. G. Staresinic, S. E. Pierce, B. M. Goodman, N. M. Peterson, P. M. Hatfield, J. A. Schirmer. 2006. Use of the modified Delphi technique to identify and rate home injury hazard risks and prevention methods for young children. Injury Prev 12:189-94.
  3. Grossman, D. C., B. A. Mueller, C. Riedy, et al. 2005. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA 296:707-14.
  4. DiScala, C., R. Sege. 2004. Outcomes in children and young adults who are hospitalized for firearms-related injuries. Pediatrics 113:1306-12.
  5. American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2004. Policy statement: Firearm-related injuries affecting the pediatric population. Pediatrics 114:1126.

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 5.7.0.4: Inaccessibility of Hazardous Equipment

Any hazardous equipment should be made inaccessible to children by barriers, or removed until rendered safe or replaced. The barriers should not pose any hazard.

RATIONALE
Limiting access to hazardous equipment can prevent injuries to children and staff in child care.
COMMENTS
Examples of barriers to equipment that pose a safety hazard are structures (including fences) that children can climb, prickly bushes, and standing bodies of water. Barriers such as plastic orange construction site fencing could be used to block access. While not child proof, it is conspicuous and sends a message that it is there to prevent access to the equipment it surrounds.
TYPE OF FACILITY
Center, Large Family Child Care Home

Chapter 6 - Play Areas/Playgrounds and Transportation

Standard 6.1.0.6: Location of Play Areas Near Bodies of Water

Outside play areas should be free from the following bodies of water:

  1. Unfenced swimming and wading pools;
  2. Ditches;
  3. Quarries;
  4. Canals;
  5. Excavations;
  6. Fish ponds;
  7. Water retention or detention basins;
  8. Other bodies of water.

RATIONALE
Drowning is one of the leading causes of unintentional death in children one to fourteen years of age (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Centers for Disease Control and Prevention. 2008. Water-related injuries. http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/.

Standard 6.1.0.8: Enclosures for Outdoor Play Areas

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.9.12 Treatment of CCA Pressure-Treated Wood
REFERENCES
  1. ASTM International (ASTM). 2009. Standard guide for fences/barriers for public, commercial, and multi-family residential use outdoor play areas. ASTM F2049-09b. West Conshohocken, PA: ASTM.
  2. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
  3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 6.2.1.9: Entrapment Hazards of Play Equipment

All openings in pieces of play equipment should be designed too large for a child’s head to get stuck in or too small for a child’s body to fit into, in order to prevent entrapment and strangulation. Openings in exercise rings (overhead hanging rings such as those used in a ring trek or ring ladder) should be smaller than three and one-half inches or larger than nine inches in diameter. Rings on long chains are prohibited. A play structure should have no openings with a dimension between three and one-half inches and nine inches. In particular, side railings, stairs, and other locations where a child might slip or try to climb through should be checked for appropriate dimensions.

Protrusions such as pipes, wood ends, or long bolts that may catch a child’s clothing are prohibited. Distances between two vertical objects that are positioned near each other should be less than three and one-half inches to prevent entrapment of a child’s head. No opening should have a vertical angle of less than fifty-five degrees. To prevent entrapment of fingers, openings should not be larger than three-eighths inch or smaller than one inch. A Certified Playground Safety Inspector (CPSI) is specially trained to find and measure various play equipment hazards.

RATIONALE
Any equipment opening between three and one-half inches and nine inches in diameter presents the potential for head entrapment. Similarly, openings between three-eighths inch and one inch can cause entrapment of the child’s fingers (1-2).
COMMENTS
To locate a CPSI, check the National Park and Recreation Association (NPRA) registry at https://ipv
.nrpa.org/CPSI_registry/.
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. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.2.3.1: Prohibited Surfaces for Placing Climbing Equipment

Equipment used for climbing should not be placed over, or immediately next to, hard surfaces such as asphalt, concrete, dirt, grass, or flooring covered by carpet or gym mats not intended for use as surfacing for climbing equipment.

All pieces of playground equipment should be placed over and surrounded by a shock-absorbing surface. This material may be either the unitary or the loose-fill type, as defined by the U.S. Consumer Product Safety Commission (CPSC) guidelines and ASTM International (ASTM) standards, extending at least six feet beyond the perimeter of the stationary equipment (1,2). These shock-absorbing surfaces must conform to the standard stating that the impact of falling from the height of the structure will be less than or equal to peak deceleration of 200G and a Head Injury Criterion (HIC) of 1000 and should be maintained at all times (3). Organic materials that support colonization of molds and bacteria should not be used. All loose fill materials must be raked to retain their proper distribution, shock-absorbing properties and to remove foreign material. This standard applies whether the equipment is installed outdoors or indoors.

RATIONALE
Head-impact injuries present a significant danger to children. Falls into a shock-absorbing surface are less likely to cause serious injury because the surface is yielding, so peak deceleration and force are reduced (1). The critical issue of surfaces, both under equipment and in general, should receive the most careful attention (1).
COMMENTS
Children should not dig in sand used under swings. It is not safe and the sand could be contaminated. If sand is provided in a play area for the purpose of digging, it should be in a covered box. Sand used as surfacing does not need to be covered. Staff should realize that sand used as surfacing may be used as a litter box for animals. Also, sand compacts and becomes less shock-absorbing when wet and it can become very hard when temperatures drop below freezing. Two scales are used for measuring the potential severity of falls. One is known as the G-max, and the other is known as the HIC. G-max measures the peak force at the time of impact; HIC measures total force during impact. Levels of 200 G-max or 1000 HIC have been accepted as thresholds for risk of life-threatening injuries. G-max and HIC levels of playground surfaces can be tested in various ways. The easiest one to use is the instrumented hemispherical triaxial headform. The individual conducting the test should use a process that conforms to the ASTM standard “F1292-09: Standard Specification for Impact Attenuation of Surfacing Materials within the Use Zone of Playground Equipment” (2).

For guidelines on play equipment and surfacing, contact the CPSC or a Certified Playground Safety Inspector (CPSI).

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.2.4.1 Sandboxes
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment
REFERENCES
  1. Sushinsky, G. F. 2005. Surfacing materials for indoor play areas: Impact attenuation test report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/FOIA/foia06/os/surfacing.pdf.
  2. ASTM International (ASTM). 2009. Standard specification for impact attenuation of surfacing materials within the use zone of playground equipment. ASTM F1292-09. West Conshohocken, PA: ASTM.
  3. U.S. Consumer Product Safety Commission (CPSC). 2010. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/PageFiles/122149/325.pdf.

Standard 6.2.4.4: Trampolines

Trampolines, both full and mini-size, should be prohibited from being used as part of the child care program activities both on-site and during field trips.

RATIONALE
Both the American Academy of Pediatrics (AAP) and American Academy of Orthopedic Surgeons (AAOS) Policy Statements recommend the prohibition of trampolines for children younger than six years of age (1,2). The U.S. Consumer Product Safety Commission (CPSC) also supports this position (3). The numbers of injuries incurred on trampolines is large and growing (4-8). Even if one accepts that the rates of injury are uncertain due to increasing sales as well as injuries, the severity of injury incurred (number of injuries requiring admission for surgery, small but documented number of deaths) all have supported those recommendations. Given the risk reflected in the recommendations of national health and safety groups, there are documented cases where insurance companies have refused to issue or to continue insurance to the home or child care center in which a trampoline was found.
COMMENTS
The AAP recommends: “Despite all currently available measures to prevent injury, the potential for serious injury while using a trampoline remains. The need for supervision and trained personnel at all times makes home use extremely unwise” (1). The trampoline should not be used at home, inside or outside. During anticipatory guidance, health care professionals should advise parents/guardians never to purchase a home trampoline or allow children to use home trampolines (2). The trampoline should not be part of routine physical education classes in schools (3). The trampoline has no place in outdoor playgrounds and should never be regarded as play equipment (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. Bond, A. 2008. Trampolines unsafe for children at any age. AAP News 29:29.
  2. Smith, G. A. 1998. Injuries to children in the United States related to trampolines, 1990-1995: A national epidemic. Pediatrics 101:406-12.
  3. Levine, D. 2006. All-terrain vehicle, trampoline, and scooter injuries and their prevention in children. Current Ops Pediatrics 18:260-65.
  4. Linakis, J. G., M. J. Mello, J. Machan, S. Amanullah, L. M. Palmisciano. 2007. Emergency department visits for pediatric trampoline-related injuries: An update. Academic Emergency Med 14:539-44.
  5. Shields, B. J., S. A. Fernandez, G. A. Smith. 2005. Comparison of mini-trampoline and full-sized trampoline injuries in the United States. Pediatrics 116:96-103.
  6. U.S. Consumer Product Safety Commission (CPSC). Consumer product safety alert: Trampoline safety alert. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/085.pdf.
  7. American Academy of Orthopedic Surgeons (AAOS). 2005. Trampolines and trampoline safety. Position Statement no. 1135. Rosemont, IL: AAOS.
  8. American Academy of Pediatrics, Committee on Injury and Poison Prevention, and Committee on Sports Medicine and Fitness. 2006. Policy statement: Trampolines at home, school, and recreational centers. Pediatrics 117:1846-47.

Standard 6.2.5.1: Inspection of Indoor and Outdoor Play Areas and Equipment

The indoor and outdoor play areas and equipment should be inspected daily for the following:

  1. Missing or broken parts;
  2. Protrusion of nuts and bolts;
  3. Rust and chipping or peeling paint;
  4. Sharp edges, splinters, and rough surfaces;
  5. Stability of handholds;
  6. Visible cracks;
  7. Stability of non-anchored large play equipment (e.g., playhouses);
  8. Wear and deterioration.

Observations should be documented and filed, and the problems corrected.

Facilities should conduct a monthly inspection as outlined in Appendix EE, America’s Playgrounds Safety Report Card.

RATIONALE
Regular outdoor inspections are critical to prevent deterioration of equipment and accumulation of hazardous materials within the play site, and to ensure that appropriate repairs are made as soon as possible (1,2). Pools of water may cause children to slip and fall.

A monthly safety check of all the equipment within the facility as a focused task provides an opportunity to notice wear and tear that requires maintenance.

COMMENTS
Regularity of inspections can be assured by assigning a staff member to check all play equipment to make certain that it is safe for children. Observations should be made while the children are playing, too, to spot any maintenance problems and correct them as soon as possible.

If an off-site play area is used, a safety check for hazardous materials within the play area should be done upon arrival to the off-site playground. Hazardous materials may have been left in the play area by other people before the arrival of children from the child care facility.

If the playground is not safe, then alternate gross motor activities should be offered rather than allowing children to use equipment that is not safe for them because of hazards.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
5.2.8.1 Integrated Pest Management
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
9.2.6.1 Policy on Use and Maintenance of Play Areas
9.2.6.2 Reports of Annual Audits/Monthly Maintenance Checks of Play Areas and Equipment
9.2.6.3 Records of Proper Installation and Maintenance of Facility Equipment
Appendix EE: America’s Playgrounds Safety Report Card
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
  2. U.S. Consumer Product Safety Commission (CPSC). For kids’ sake: Think toy safety. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/281.pdf.

Standard 6.3.1.1: Enclosure of Bodies of Water

All water hazards, such as pools, swimming pools, stationary wading pools, ditches, fish ponds, and water retention or detention basins should be enclosed with a fence that is four to six feet high or higher and comes within three and one-half inches of the ground. Openings in the fence should be no greater than three and one-half inches. The fence should be constructed to discourage climbing and kept in good repair.

If the fence is made of horizontal and vertical members (like a typical wooden fence) and the distance between the tops of the horizontal parts of the fence is less than forty-five inches, the horizontal parts should be on the swimming pool side of the fence. The spacing of the vertical members should not exceed one and three-quarters inches.

For a chain link fence, the mesh size should not exceed one and one-quarter square inches.

Exit and entrance points should have self-closing, positive latching gates with locking devices a minimum of fifty-five inches from the ground.

A wall of the child care facility should not constitute one side of the fence unless the wall has no openings capable of providing direct access to the pool (such as doors, windows, or other openings).

If the facility has a water play area, the following requirements should be met:

  1. Water play areas should conform to all state and local health regulations;
  2. Water play areas should not include hidden or enclosed spaces;
  3. Spray areas and water-collecting areas should have a non-slip surface, such as asphalt;
  4. Water play areas, particularly those that have standing water, should not have sudden changes in depth of water;
  5. Drains, streams, water spouts, and hydrants should not create strong suction effects or water-jet forces;
  6. All toys and other equipment used in and around the water play area should be made of sturdy plastic or metal (no glass should be permitted);
  7. Water play areas in which standing water is maintained for more than twenty-four hours should be treated according to Standard 6.3.4.1, and inspected for glass, trash, animal excrement, and other foreign material.

RATIONALE
Most drownings happen in fresh water, often in home swimming pools (1). Most children drown within a few feet of safety and in the presence of a supervising adult (1). Small fence openings (three and one-half inches or smaller) prevent children from passing through the fence (4). All areas must be visible to allow adequate supervision.

An effective fence is one that prevents a child from getting over, under, or through it and keeps the child from gaining access to the pool or body of water except when supervising adults are present. Fences are not childproof, but they provide a layer of protection for a child who strays from supervision.

Fence heights are a matter of local ordinance but it is recommended that it should be at least five feet. A house exterior wall can constitute one side of a fence if the wall has no openings providing direct access to the pool.

With fences made up of horizontal and vertical members, children should not be allowed to use the horizontal members as a form of ladder to climb into a swimming pool area. If the distance between horizontal members is less than forty-five inches, placing the horizontal members on the pool side of the fence will prevent children using this to climb over and into the pool area. However, if the horizontal members are greater than forty-five inches apart, it is more difficult for a child to climb and therefore the horizontal members could be placed on the side of the fence facing away from the pool (2).

COMMENTS
See the American National Standards Institute (ANSI) and ASTM International standards for pool safety (2,3).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
6.2.5.2 Inspection of Play Area Surfacing
6.3.1.2 Accessibility to Above-Ground Pools
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.
  2. ASTM International (ASTM). 2008. Standard guide for fences for residential outdoor swimming pools, hot tubs, and spas. ASTM F1908-08. West Conshohocken, PA: ASTM.
  3. American National Standards Institute (ANSI). 2005. Model barrier code for residential swimming pools, spas, and hot tubs. ANSI/IAF-8. New York: ANSI.
  4. U.S. Consumer Product Safety Commission (CPSC). How to plan for the unexpected: Preventing child drownings. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/PUBS/359.pdf.

Standard 6.3.1.4: Safety Covers for Swimming Pools

When not in use, in-ground and above-ground swimming pools should be covered with a safety cover that meets or exceeds the ASTM International (ASTM) standard “F1346-03: Standard performance specification for safety covers and labeling requirements for all covers for swimming pools, spas, and hot tubs” (2).

RATIONALE
Fatal injuries have occurred when water has collected on top of a secured pool cover. The depression caused by the water, coupled with the smoothness of the cover material, has proved to be a deadly trap for some children (1). The ASTM standard now defines a safety cover “as a barrier (intended to be completely removed before water use) for swimming pools, spas, hot tubs, or wading pools, attendant appurtenances and/or anchoring mechanisms which reduces--when properly labeled, installed, used and maintained in accordance with the manufacturer’s published instructions--the risk of drowning of children under five years of age, by inhibiting their access to the contained body of water, and by providing for the removal of any substantially hazardous level of collected surface water” (2).

Safety covers reduce the possibility of contamination by animals, birds, and insects.

COMMENTS
Facilities should check whether the manufacturers warrant their pool covers as meeting ASTM standards. See ASTM standard “F1346-03.” Some jurisdictions require four-sided fencing around swimming pools; the facility should follow the requirements of their jurisdiction. Best practice is four-sided fencing.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.3.1.1 Enclosure of Bodies of Water
REFERENCES
  1. ASTM International (ASTM). 2003. Standard performance specification for safety covers and labeling requirements for all covers for swimming pools, spas, and hot tubs. ASTM F1346-03. West Conshohocken, PA: ASTM.
  2. U.S. Consumer Product Safety Commission (CPSC). 2005. Guidelines for entrapment hazards: Making pools and spas safer. Washington, DC: CPSC. http://www.cdph.ca.gov/HealthInfo/injviosaf/Documents/DrowningEntrapmentHazards.pdf.

Standard 6.3.1.6: Pool Drain Covers

All covers for the main drain and other suction ports of swimming and wading pools should be listed by a nationally recognized testing laboratory in accordance with ASME/ANSI standard “A112.19.8: Standard for Suction Fittings for Use in Swimming Pools, Wading Pools, Spas and Hot Tubs,” and should be used under conditions that do not exceed the approved maximum flow rate, be securely anchored using manufacturer-supplied parts installed per manufacturer’s specifications, be in good repair, and be replaced at intervals specified by manufacturer. Facilities with one outlet per pump, or multiple outlets per pump with less than thirty-six inches center-to-center distance for two outlets, must be equipped with a Safety Vacuum Release System (SVRS) meeting the ASME/ANSI standard “A112.19.17: Manufactured Safety Vacuum Release Systems for Residential and Commercial Swimming Pool, Spas, Hot Tub and Wading Pool Suction Systems” or ASTM International (ASTM) standard “F2387-04: Standard Specification for Manufactured SVRS for Swimming Pools, Spas, and Hot Tubs” standards, as required by the Virginia Graeme Baker Pool and Spa Safety Act, Section 1404(c)(1)(A)(I) (1,2).

RATIONALE
In some instances, children have drowned as a result of their body or hair being entrapped or seriously injured by sitting on drain grates (3). Drain covers mitigate the five types of entrapment: hair, body, limb, evisceration, and mechanical (jewelry). Use of flat- or flush-mount covers/grates is prohibited. Use of drain covers under conditions that exceed the maximum flow rate can pose a hazard for entrapment. When drain covers are broken or missing, the body can be entrapped. When a child is playing with an open drain (one with the cover missing), a child can be entrapped by inserting a hand or foot into the pipe and being trapped by the resulting suction. Hair entrapment typically involves females with long, fine hair who are underwater with the head near the suction inlet; they become entrapped when their hair sweeps into and around the cover, and not because of the strong suction forces. Use of a SVRS will not mitigate hair, limb, and mechanical entrapment.
REFERENCES
  1. U.S. Consumer Product Safety Commission (CPSC). 2005. Guidelines for entrapment hazards: Making pools and spas safer. Washington, DC: CPSC. http://www.cdph.ca.gov/HealthInfo/injviosaf/Documents/DrowningEntrapmentHazards.pdf.
  2. U.S. Congress. 2007. Virginia Graeme Baker Pool and Spa Safety Act. 15 USC 8001. http://www.cpsc.gov/businfo/vgb/
    pssa.pdf.
  3. American National Standards Institute (ANSI), American Society of Mechanical Engineers (ASME). 2007. Standard for suction fittings for use in swimming pools, wading pools, spas and hot tubs. ANSI/ASME A112.19.8. Washington, DC: ANSI.

Standard 6.3.2.1: Lifesaving Equipment

Each swimming pool more than six feet in width, length, or diameter should be provided with a ring buoy and rope, a rescue tube, or a throwing line and a shepherd’s hook that will not conduct electricity. This equipment should be long enough to reach the center of the pool from the edge of the pool, should be kept in good repair, and should be stored safely and conveniently for immediate access. Caregivers/teachers should be trained on the proper use of this equipment so that in emergencies, caregivers/teachers will use equipment appropriately. Children should be familiarized with the use of the equipment based on their developmental level.

RATIONALE
Drowning accounts for the highest rate of unintentional injury-related death in children one to four years of age; this lifesaving equipment is essential (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
1.4.3.3 CPR Training for Swimming and Water Play
REFERENCES
  1. Safe Kids Worldwide. 2016. Keeping kids safe in and around water: Exploring misconceptions that lead to drowning. Washington, DC: Safe Kids Worldwide. https://www.safekids.org/research-report/keeping-kids-safe-and-around-water-exploring-misconceptions-lead-drowning

Standard 6.3.5.1: Hot Tubs, Spas, and Saunas

Children should not be permitted in hot tubs, spas, or saunas in child care. Areas should be secured to prevent any access by children.

RATIONALE
Any body of water, including hot tubs, pails, and toilets, presents a drowning risk to young children (1-3). Toddlers and infants are particularly susceptible to overheating.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.3.1.1 Enclosure of Bodies of Water
6.3.1.4 Safety Covers for Swimming Pools
6.3.1.6 Pool Drain Covers
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.
  2. U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
  3. Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Atlanta: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.

Standard 6.3.5.2: Water in Containers

Bathtubs, buckets, diaper pails, and other open containers of water should be emptied immediately after use.

RATIONALE
In addition to home swimming and wading pools, young children drown in bathtubs and pails (4). Bathtub drownings are equally distributed in both sexes. Any body of water, including hot tubs, pails, and toilets, presents a drowning risk to young children (1,2,4,5).

From 2003-2005, eleven children under the age of five died from drowning in buckets or containers that were being used for cleaning (4). Of all buckets, the five-gallon size presents the greatest hazard to young children because of its tall straight sides and its weight with even just a small amount of liquid. It is nearly impossible for top-heavy infants and toddlers to free themselves when they fall into a five-gallon bucket head first (3).

TYPE OF FACILITY
Center, Large Family Child Care Home
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85. http://pediatrics.aappublications.org/content/early/2010/05/24/peds.2010-1264
  2. U.S. Consumer Products Safety Commission (CPSC). Submersions related to non-pool and non-spa products, 2009 report. 2010. https://www.cpsc.gov/s3fs-public/pdfs/nonpoolsub2009.pdf
  3. U.S. Consumer Products Safety Commission (CPSC). In home danger: CPSC warns of children drowning in bathtubs, bath seats and buckets more than 400 deaths estimated over a five-year. period. 2012. https://www.cpsc.gov/Newsroom/News-Releases/2012/In-Home-Danger-CPSC-Warns-of-Children-Drowning-in-Bathtubs-Bath-Seats-and-Buckets-More-than-400-deaths-estimated-over-a-five-year-period/
  4. U.S. Consumer Safety Commission (CPSC). How to plan for the unexpected: Preventing child drownings. Document #359. https://www.cpsc.gov/s3fs-public/359.pdf
  5. Rivera, F. P. 1999. Pediatric injury control in 1999: Where do we go from here? Pediatrics 103:883-88.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Standard 6.4.1.5: Balloons

Infants, toddlers, and preschool children should not be permitted to inflate balloons, suck on or put balloons in their mouths nor have access to uninflated or underinflated balloons. Children under eight should not have access to latex balloons or inflated latex objects that are treated as balloons and these objects should not be permitted in the child care facility.

RATIONALE
Balloons are an aspiration hazard (1). The U.S. Consumer Product Safety Commission (CPSC) reported eight deaths from balloon aspiration with choking between 2006 and 2008 (1). Aspiration injuries occur from latex balloons or other latex objects treated as balloons, such as inflated latex gloves. Latex gloves are commonly used in child care facilities for diaper changing, but they should not be inflated (2). When children bite inflated latex balloons or gloves, these objects may break suddenly and blow an obstructing piece of latex into the child’s airway. Exposure to latex balloons could trigger an allergic reaction in children with latex allergies.

Underinflated or uninflated balloons of all types could be chewed or sucked and pieces potentially aspirated.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
REFERENCES
  1. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
  2. Garland, S. 2009. Toy-related deaths and injuries, calendar year 2008. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/toymemo08.pdf.

Standard 6.4.2.2: Helmets

Content in the STANDARD was modified on 3/31/2017.

 

All children one year of age and over should wear properly fitted and approved helmets while riding toys with wheels (tricycles, bicycles, etc.) or using any wheeled equipment (rollerblades, skateboards, etc.). Helmets should be removed as soon as children stop riding the wheeled toys or using wheeled equipment. Approved helmets should meet the standards of the U.S. Consumer Product Safety Commission (CPSC) (1). The standards sticker should be located on the bike helmet. Bike helmets should be replaced if they have been involved in a crash, the helmet is cracked, when straps are broken, the helmet can no longer be worn properly, or according to recommendations by the manufacturer (usually after three years).
It is not recommended that infants (children under the age of one year) wear helmets or ride as a passenger on wheeled equipment (2).

RATIONALE
Injuries occur when riding tricycles, bicycles, and other riding toys or wheeled equipment. Helmet use is associated with a reduction in the risk of any head injury by 69%, brain injury by 65%, and severe brain injuries by 74%, and recommended for all children one year of age and over (2-4).

Helmets can be a potential strangulation hazard if they are worn for activities other than when using riding toys or wheeled equipment and/or when worn incorrectly.

Infants are just learning to sit unsupported at about nine months of age. Until this age, infants have not developed sufficient bone mass and muscle tone to enable them to sit unsupported with their backs straight. Pediatricians advise against having infants sitting in a slumped or curled position for prolonged periods due to the underdevelopment of their neck muscles (5). This situation may even be exacerbated by the added weight of a bicycle helmet on the infant’s head. 

COMMENTS
The CPSC helmet standard was published in March 1998 (6). Bike helmets manufactured or imported for sale in the U.S. after January 1999 must meet the CPSC standard. Helmets made before this date will not have a CPSC approval label. However, helmets made before this date should have an ASTM International (ASTM) approval label. The American National Standard Institute (ANSI) standard for helmet approval has been withdrawn, and ANSI approval labels will no longer appear on helmets. The Snell Memorial Foundation also no longer certifies bike helmets.

Concern regarding the spreading of head lice when sharing helmets should not override the practice of using helmets. The prevention of a potential brain injury heavily outweighs a possible case of head lice. While it is best practice for each child to have his/her own helmet, this may not be possible. If helmets need to be shared, it is recommended to clean the helmet between users. Helmets should be cleaned according to manufacturer's instructions. 

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
6.4.2.1 Riding Toys with Wheels and Wheeled Equipment
REFERENCES
  1. ADDITIONAL REFERENCE:

    Centers for Disease Control and Prevention. 2015. Head injuries and bicycle safety. http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/headinjuries.html.
  2. U.S. Consumer Product Safety Commission (CPSC). 2017. CPSC’s Bicycle Helmet Standard. http://www.helmets.org/cpscstd.htm.
  3. Bicycle Helmet Safety Institute. 2016. Should you take your baby along? http://www.helmets.org/little1s.htm.
  4. Head Start. An Office of the Administration of Children and Families Early Childhood Learning & Knowledge Center (ECLKC). 2014. Play it safe: Walking and biking safely. https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family/for-families/safety/safety-prevention/PlayitSafeWal.htm
  5. Thompson, D. C., F. P. Rivara, R. S. Thompson. 1996. Effectiveness of bicycle safety helmets in preventing head injuries: A case-control study. JAMA 276:1968-73.
  6. U.S. Consumer Product Safety Commission. 2016. CPSC guidelines for age-related activities. Bicycle Helmet Safety Institute. http://www.helmets.org/ageguide.htm.
  7. U.S. Consumer Product Safety Commission (CPSC). 1998. Safety standard for bicycle helmets. http://www.bhsi.org/cpscstd.pdf.
NOTES

Content in the STANDARD was modified on 3/31/2017.

 

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
1.1.1.4 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
2.2.0.4 Supervision Near Bodies of Water
5.3.1.12 Availability and Use of a Telephone or Wireless Communication Device
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 6.5.1.2: Qualifications for Drivers

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

 

Any driver who transports children for a child care program should be at least twenty-one years of age and should have:

  1. A valid commercial driver’s license that authorizes the driver to operate the vehicle being driven;
  2. Evidence of a safe driving record for more than five years, with no crashes where a citation was issued;
  3. No alcohol, prescription or over-the-counter medications, or other drugs associated with impaired ability to drive, within twelve hours prior to transporting children. Drivers should ensure that any prescription or over-the-counter drugs taken will not impair their ability to drive;
  4. No tobacco, electronic cigarettes (e-cigarettes), alcohol, or drug use while driving;
  5. No criminal record of crimes against or involving children, child neglect or abuse, substance abuse, or any crime of violence;
  6. No medical condition that would compromise driving, supervision, or evacuation capability including fatigue and sleep deprivation;
  7. Valid pediatric CPR and first aid certificate if transporting children alone.

The driver’s license number and date of expiration, vehicle insurance information, and verification of current state vehicle inspection should be on file in the facility.

The child care program should require drug testing when noncompliance with the restriction on the use of alcohol or other drugs is suspected.

RATIONALE
Driving children is a significant responsibility. Child care programs must assure that anyone who drives the children is competent to drive the vehicle being driven.

It is known that driving under the influence of drugs (such as marijuana) and alcohol may impair a person's ability to drive safely (1-4). 

COMMENTS
The driver should advise his/her primary care provider of his/her job and question whether it is safe to drive children while on prescribed medication(s). Compliance can be measured by testing blood or urine levels for drugs. Refusal to permit such testing should preclude continued employment.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
9.2.5.1 Transportation Policy for Centers and Large Family Homes
9.2.5.2 Transportation Policy for Small Family Child Care Homes
6.5.2.5 Distractions While Driving
REFERENCES
  1. ADDITIONAL REFERENCE:

    Campaign for Tobacco-Free Kids. Secondhand smoke, kids and cars. 2016. http://www.tobaccofreekids.org/research/factsheets/pdf/0334.pdf.
  2. U.S. Centers for Disease Control and Prevention. 2016. Impaired driving: Get the facts. http://www.cdc.gov/motorvehiclesafety/impaired_driving/impaired-drv_factsheet.html
  3. Hartman RL, Huestis MA. Cannabis effects on driving skills.Clin Chem. 2013;59(3):478-492. doi:10.1373/clinchem.2012.194381.
  4. Lenné MG, Dietze PM, Triggs TJ, Walmsley S, Murphy B, Redman JR. The effects of cannabis and alcohol on simulated arterial driving: Influences of driving experience and task demand. Accid Anal Prev. 2010;42(3):859-866. doi:10.1016/j.aap.2009.04.021.
  5. Volkow, N.D., Baler, R.D., Compton, W.M., R.B. Weiss, S.R.B. Adverse health effects of marijuana use. N Engl J Med 2014:370:2219-2227. DOI: 10.1056/NEJMra1402309. 
NOTES

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

 

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.

Standard 6.5.2.4: Interior Temperature of Vehicles

The interior of vehicles used to transport children should be maintained at a temperature comfortable to children. When the vehicle’s interior temperature exceeds 82°F and providing fresh air through open windows cannot reduce the temperature, the vehicle should be air-conditioned. When the interior temperature drops below 65°F and when children are feeling uncomfortably cold, the interior should be heated. To prevent hyperthermia, all vehicles should be locked when not in use, head counts of children should be taken after transporting to prevent a child from being left unintentionally in a vehicle, and children should never be intentionally left in a vehicle unattended.

RATIONALE
Some children have problems with temperature variations. Whenever possible, opening windows to provide fresh air to cool a hot interior is preferable before using air conditioning. Over-use of air conditioning can increase problems with respiratory infections and allergies. Excessively high temperatures in vehicles can cause neurological damage in children (1).

Children’s bodies overheat three to five times faster than
adults because the hypothalamus regions of their brains, which control body temperature, are not as developed (1).

About thirty-seven children die every year from hyperthermia when they’re left in cars and the cars quickly heat up. Even with comfortable temperatures outdoors, the temperature in an enclosed car climbs rapidly.

Temperature increase inside a car with an outside temperature of 80°F (elapsed time in minutes) (2):

  1. After ten minutes: 99°F inside car;
  2. After twenty minutes: 109°F;
  3. After thirty minutes 114°F;
  4. After forty minutes: 118°F;
  5. After fifty minutes: 120°F;
  6. After sixty minutes: 123°F.
COMMENTS
In geographical areas that are prone to very cold or very hot weather, a small thermometer should be kept inside the vehicle. In areas that are very cold, adults tend to wear very warm clothing and children tend to wear less clothing than might actually be required. Adults in a vehicle, then, may be comfortable while the children are not. When air conditioning is used, adults might find the cool air comfortable, but the children may find that the cool air is uncomfortably cold. To determine whether the interior of the vehicle is providing a comfortable temperature to children, a thermometer should be used and children in the vehicle should be asked if they are comfortable. Non-verbal children and infants should be assessed by an adult for signs of hypo- or hyperthermia. Signs of hypothermia include: cold skin, very low energy, and may be non-responsive. Young infants do not shiver when cold. Signs of hyperthermia include: dizziness, disorientation, agitation, confusion, sluggishness, seizure, hot dry skin that is flushed but not sweaty, loss of consciousness, rapid heartbeat, hallucinations (2).
TYPE OF FACILITY
Center, Large Family Child Care Home
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. McLaren, C., J. Null, J. Quinn. 2005. Heat stress from enclosed vehicles: Moderate ambient temperatures cause significant temperature rise in enclosed vehicles. Pediatrics 116: e109-12.

Standard 6.5.3.1: Passenger Vans

Child care facilities that provide transportation to children, parents/guardians, staff, and others should avoid the use of fifteen-passenger vans whenever possible. Other vehicles, such as vehicles meeting the definition of a “school bus,” should be used to fulfill transportation of child passengers in particular. Conventional twelve- to fifteen-passenger vans cannot be certified as school buses by the National Highway Traffic Safety Administration (NHTSA) standards (2,4), and thus cannot be sold or leased, as new vehicles, to carry students on a regular basis. Caregivers/teachers should be knowledgeable about the laws of the state(s) in which their vehicles, including passenger vans, will be registered and used.

RATIONALE
Fifteen-passenger vans are more likely to be involved in a single-vehicle rollover crash than any other type of vehicle (1). Fifteen-passenger vans typically have seating positions for a driver and fourteen passengers. The risk of a rollover crash is greatly increased when ten or more people ride in a fifteen-passenger van (1). This increased risk occurs because the passenger weight raises the vehicle’s center of gravity and causes it to shift rearward. As a result, the van has less resistance to rollover and handles differently from other commonly driven passenger vehicles, making it more difficult to control in an emergency situation (3). Occupant restraint use is especially critical because large numbers of people die in rollover crashes when they are partially or completely thrown from the vehicle. The National Highway Traffic Safety Administration (NHTSA) estimates that people who wear their seat belts are about 75% less likely to be killed in a rollover crash than people who do not.

The NHTSA has the authority to regulate the first sale or lease of a new vehicle by a dealer. The applicable statute requires any person selling or leasing a new vehicle to sell or lease a vehicle that meets all applicable standards (6). Under NHTSA’s regulations, a “bus” is any vehicle, including a van, which has a seating capacity of eleven persons or more. The statute defines a “school bus” as any bus which is likely to be “used significantly” to transport “pre-primary, primary, and secondary” students to or from school or related events (5). A twelve- to fifteen-passenger van that is likely to be used significantly to transport students is a “school bus” by this definition, but cannot be certified as such.

COMMENTS
State law may require school bus equipment not specified in NHTSA regulations. Each state regulates how school buses are to be used and which agencies are responsible for developing and enforcing school bus regulations. In some states, requirements for transporting public school children differ from requirements for transporting children attending private schools and non-school organizations (e.g., Head Start programs, child care agencies, etc.)

For further information about state school bus regulations, contact the applicable State Director of Pupil Transportation. A list of State Directors can be obtained at http://www
.nasdpts.org or by calling 1-800-585-0340 begin_of_the_skype_highlighting 1-800-585-0340 end_of_the_skype_highlighting.

Organizations that use fifteen-passenger vans to transport children, students, seniors, sports groups, or others, need to be informed about how to reduce rollover risks, avoid potential dangers, and better protect occupants in the event of a rollover crash. Drivers should be alert to these vehicles’ high center of gravity – particularly when fully loaded – and their increased chance of rollover. The following are the NHTSA’s official recommendations (1):

  1. Caregivers/teachers should keep passenger load light. NHTSA research has shown that fifteen-passenger vans have a rollover risk that increases dramatically as the number of occupants increases from fewer than five to more than ten. In fact, fifteen-passenger vans (with ten or more occupants) had a rollover rate in single vehicle crashes that is nearly three times the rate of those that were lightly loaded.
  2. The van’s tire pressure should be checked frequently — at least once a week. A just-released NHTSA study found that 74% of all fifteen-passenger vans had improperly inflated tires. By contrast, 39% of passenger cars had improperly inflated tires. Improperly inflated tires can change handling characteristics, increasing the prospect of a rollover crash in fifteen-passenger vans.
  3. Require all occupants to use their seat belts or the appropriate child restraint. Nearly 80% of those who have died nationwide in fifteen-passenger vans were not buckled up. Wearing seat belts dramatically increases the chances of survival during a rollover crash.
  4. If at all possible, seat passengers and place cargo forward of the rear axle — and avoid placing any loads on the roof. By following these guidelines, you’ll lower the vehicle’s center of gravity and lower the chance of a rollover crash.
  5. Be mindful of speed and road conditions. The analysis of fifteen-passenger van crashes also shows that the risk of rollover increases significantly at speeds over fifty miles per hour and on curved roads (1).
  6. Only qualified drivers should be behind the wheel. Special training and experience are required to properly operate a fifteen-passenger van. Drivers should only operate these vehicles when well rested and fully alert.

For more information on fifteen-passenger vans, see http://www.nhtsa.gov/CA/10-14-2010/ and http://www.nhtsa
.gov/people/injury/buses/choosing_schoolbus/pre-school-bus_01.html.

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
REFERENCES
  1. 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.
  2. Transportation. 1994. 49 U.S.C. §30112.  
  3. Transportation. 1994. 49 U.S.C. §30125.
  4. Aird, L. 2007. Moving kids safely in child care: A refresher course. Exchange (Jan/Feb): 25-28. http://www.childcareexchange.com/library/5017325.pdf.
  5. National Highway Traffic Safety Administration. School Buses. http://www.nhtsa.gov/School-Buses.
  6. National Highway Traffic Safety Administration. Reducing the risk of rollover crashes in 15-passenger vans. http://www.safercar.gov/staticfiles/DOT/safercar/Equipment and Safety/Vans/documents/NHTSA_FLYER.pdf.

Chapter 7 - Infectious Disease

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.

Standard 7.3.3.1: Influenza Immunizations for Children and Caregivers/Teachers

The parent/guardian of each child six months of age and older should provide written documentation of current annual vaccination against influenza unless there is a medical contraindication or philosophical or religious objection. Children who are too young to receive influenza vaccine before the start of influenza season should be immunized annually beginning when they reach six months of age.

Staff caring for all children should receive annual vaccination against influenza. Ideally people should be vaccinated before the start of the influenza season (as early as August or September) and immunization should continue through March or April.

RATIONALE
The American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) recommend that influenza vaccination of all children, begins at six months of age, and adolescents and adults begin before or during the influenza season. Children who are at high risk of influenza complications and respiratory tract infections such as influenza commonly are scattered in out-of-home child care settings. The risk of complications from influenza is greater among children less than two years of age. Infants less than six months of age represent a particularly vulnerable group because they are too young to receive the vaccine. Therefore, people responsible for caring for these children should be immunized (1,2).

Seasonal influenza vaccine should be offered to all children as soon as the vaccine is available, even as early as August or September; a protective response to immunization remains throughout the influenza season. Immunization efforts should continue throughout the entire influenza season, even after influenza activity has been documented in a community. Each influenza season often extends well into March and beyond, and there may be more than one peak of activity in the same season. Thus, immunization through at least May 1st can still protect recipients during that particular season and also provide ample opportunity to administer a second dose of vaccine to children requiring two doses in that season (1).

Children who are too young to receive the influenza vaccine before the start of influenza season should be immunized when they reach six months of age, if influenza vaccination is still recommended at that time. Child contacts who are vaccine-eligible should be vaccinated.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
7.3.3.2 Influenza Control
7.3.3.3 Influenza Prevention Education
REFERENCES
  1. Centers for Disease Control and Prevention. 2010. Update: Recommendations of the ACIP regarding use of CSL seasonal influenza vaccine (Afluria) in the United States during 2010-2011. MMWR 59 (31): 989-92. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5931a4.htm.
  2. American Academy of Pediatrics, Committee on Infectious Disease. 2010. Recommendations for prevention and control of influenza in children, 2010-2011. Pediatrics 126:816-28.

Standard 7.3.3.2: Influenza Control

When influenza is circulating in the community, facilities should encourage parents/guardians to keep children with symptoms of acute respiratory tract illness with fever at home until their fever has subsided for at least twenty-four hours without use of fever reducing medication.

Caregivers/teachers with symptoms of acute respiratory tract illness with fever also should remain at home until their fever subsides for at least twenty-four hours.

RATIONALE
The Centers for Disease Control and Prevention (CDC) recommends that caregivers/teachers encourage parents/guardians of sick children to keep the children home and away from their regular child care setting until the children have been without fever for twenty-four hours, to prevent spreading illness to others (1).
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
7.3.3.1 Influenza Immunizations for Children and Caregivers/Teachers
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
7.3.3.2 Influenza Control
REFERENCES
  1. Centers for Disease Control and Prevention. 2010. Update: Recommendations of the ACIP regarding use of CSL seasonal influenza vaccine (Afluria) in the United States during 2010-2011. MMWR 59 (31): 989-92. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5931a4.htm.

Standard 7.3.5.1: Recommended Control Measures for Invasive Meningococcal Infection in Child Care

Identification of an individual with invasive meningococcal infection in the child care setting should result in the following:

  1. Immediate notification of the local or state health department;
  2. Notification of parents/guardians about child care contacts to the person with invasive meningococcal infection;
  3. Assistance with provision of antibiotic prophylaxis and vaccine receipt, as advised by the local or state health department, to child care contacts;
  4. Frequent updates and communication with parents/guardians, health care professionals, and local health authorities.

RATIONALE
Due to the increased transmissibility of meningococcal infections following close personal contact with oral and respiratory tract secretions of a person with infection, institution of antibiotic prophylaxis within twenty-four hours of diagnosis of the index case is advised. Younger age and close contact with an infected person increases the attack rate of meningococcal disease among child care attendees to several hundred fold greater than the general population. As outbreaks may occur in child care settings, chemoprophylaxis with oral rifampin is the prophylaxis of choice for exposed child contacts. In some cases, intramuscular ceftriaxone may be used as an alternative if a contraindication to oral rifampin exists in the contact (1,2). In contacts over eighteen years of age, oral rifampin, ciprofloxacin, or intramuscular ceftriaxone, are effective (2,3). Rifampin is not recommended for pregnant women.

In addition to chemoprophylaxis with an oral antimicrobial agent, immunoprophylaxis with a meningococcal vaccination of age-eligible contacts in an outbreak setting, if the infection is due to a serogroup contained in the vaccine, may be recommended by the local or state health department (1,2).

COMMENTS
For facilities that care for older school-age children, meningococcal vaccine is recommended at eleven or twelve years of age with a second dose administered at sixteen years of age.

For additional information regarding meningococcal disease, consult the current edition of the Red Book from the American Academy of Pediatrics (AAP).

RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
REFERENCES
  1. American Academy of Pediatrics, Committee on Infectious Diseases. 2009. Prevention and control of meningococcal disease: Recommendations for use of meningococcal vaccines in pediatric patients. Pediatrics 123:1421-22.

  2. Centers for Disease Control and Prevention. 2007. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 years with meningococcal conjugate vaccine. MMWR 56:749-95. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5631a3.htm.

  3. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red book: 2015 report to the committee of infectious diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. 

Standard 7.4.0.1: Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections

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

Facilities should employ the following procedures, in addition to those stated in Child and Staff Inclusion/Exclusion/Dismissal, Standards 3.6.1.1-3.6.1.4, to prevent and control infections of the gastrointestinal tract (including diarrhea) or hepatitis A (1,2):
Exclusion:

a. Toilet trained children who develop diarrhea should be removed from the facility by their parent/guardian. Diarrhea is defined as stools that are more frequent or less formed than usual for that child and not associated with changes in diet.

b. Diapered children should be excluded if stool is not contained in the diaper, stool frequency exceeds two or more stools above normal for that child during the program day, blood or mucus in the stool, abnormal color of stool, no urine output in eight hours, jaundice (when skin and white parts of the eye are yellow, a symptom of hepatitis A), fever with behavior change, or looks or acts ill.

c. 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.
d. Caregivers/teachers with diarrhea as defined in Standard 3.6.1.2 should be excluded. Separation and exclusion of children or caregivers/teachers should not be deferred pending health assessment or laboratory testing to identify an enteric pathogen.
e. Exclusion for diarrhea should continue until  diapered children have their stool contained by the diaper (even if the stools remain loose), 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.
f.  Exclusion for hepatitis A virus (HAV) should continue for one week after onset of illness and after all contacts have received vaccine or immune globulin as recommended.
g. Alternate care for children with diarrhea or hepatitis A should be provided in facilities for children who are ill that can provide separate care for children with infections of the gastrointestinal tract (including diarrhea) or hepatitis A.

Informing parents/guardians and public health:

a. The local health department should be informed immediately of the occurrence of HAV infection or an increased frequency of diarrheal illness in children or staff in a child care facility.
b. If there has been an exposure to a person with hepatitis A or diarrhea in the child care facility, caregivers/teachers should inform parents/guardians, in cooperation with the health department, that their children may have been exposed to children with HAV infection or to another person with a diarrheal illness.
c. If a child or staff member is confirmed to have hepatitis A disease (HAV), all other children and staff in the group should be checked to be sure everyone who was exposed has received the hepatitis A vaccine or immune globulin within 2 weeks of exposure.  

Return to Care:

a. Children can be readmitted when they are able to fully participate in program activities without the caregivers/teachers having to compromise their ability to care for the health and safety of other children in the group.
b. Children and caregivers/teachers who excrete intestinal pathogens but no longer have diarrhea generally may be allowed to return to child care once the diarrhea resolves, except for the case of infections with Shigella, Shiga toxin-producing Escherichia. coli (STEC),or Salmonella enterica serotype Typhi. For Shigella and STEC, resolution of symptoms and two negative stool cultures are required for readmission, unless state requirements differ. For Salmonella serotype Typhi, resolution of symptoms and three negative stool cultures are required for return to child care. For Salmonella species other than serotype Typhi, documentation of negative stool cultures are not required from asymptomatic people for readmission to child care.

RATIONALE

Intestinal organisms, including HAV, cause disease in children, caregivers/teachers, and close family members (1,2). Disease has occurred in outbreaks within centers and as sporadic episodes. Although many intestinal agents can cause diarrhea in children in child care, rotavirus, other enteric viruses, Giardia intestinalisShigella, and Cryptosporidium have been the main organisms implicated in outbreaks
Caregivers/teachers should always observe children for signs of disease to permit early detection and implementation of control measures. Facilities should consult the local health department to determine whether the increased frequency of diarrheal illness requires public health intervention.
The most important characteristic of child care facilities associated with increased frequencies of diarrhea or hepatitis A is the presence of young children who are not toilet trained. Contamination of hands, communal toys, and other classroom objects is common and plays a role in transmission of enteric pathogens in child care facilities.
Studies frequently find that fecal contamination of the environment is common in centers and is highest in infant and toddler areas, where diarrhea or hepatitis A are known to occur most often. Studies indicate that the risk of diarrhea is significantly higher for children in centers than for age-matched children cared for at home or in small family child care homes. The spread of infection from children who are not toilet trained to other children in child care facilities, or to their household contacts is common, particularly when Shigella, rotavirus, Giardia intestinalis, Cryptosporidium, or HAV are the causal agents (1,2).
With recommendations for administration of rotavirus vaccine between two and six months of age and 2 doses of hepatitis A vaccine given at least 6 months apart between 12 and 23 months, rates of disease due to rotavirus and hepatitis A have decreased.
To decrease diarrheal disease in child care due to all pathogens, staff and parents/guardians must be educated about modes of transmission as well as practical methods of prevention and control. Staff training in hand hygiene, combined with close monitoring of compliance, is associated with a significant decrease in infant and toddler diarrhea (1,2). Staff training on a single occasion, without close monitoring, does not result in a decrease in diarrhea rates; this finding emphasizes the importance of monitoring as well as education. Therefore, appropriate hygienic practices, hygiene monitoring, and education are important in limiting diarrheal infections and hepatitis. Asymptomatic children can still easily transmit infection to susceptible adults who often develop signs and symptoms of disease and may become seriously ill.

COMMENTS
Sample letters of notification to parents/guardians that their child may have been exposed to an infectious disease are contained in the current publication of the American Academy of Pediatrics (AAP), Managing Infectious Diseases in Child Care and Schools. For additional information regarding enteric (diarrheal) and HAV infections, consult the current edition of the Red Book, also from the AAP.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
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
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.4 Infectious Disease Outbreak Control
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply
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
3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
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
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals
3.6.1.3 Thermometers for Taking Human Temperatures
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
4.9.0.1 Compliance with U.S. Food and Drug Administration Food Sanitation Standards, State and Local Rules
4.9.0.4 Leftovers
4.9.0.5 Preparation for and Storage of Food in the Refrigerator
4.9.0.6 Storage of Foods Not Requiring Refrigeration
4.9.0.7 Storage of Dry Bulk Foods
4.9.0.8 Supply of Food and Water for Disasters
4.9.0.9 Cleaning Food Areas and Equipment
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records
2.1.2.5 Toilet Learning/Training
Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule
REFERENCES
  1. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
NOTES

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

Standard 7.5.10.1: Staphylococcus Aureus Skin Infections Including MRSA

The following should be implemented when children or staff with lesions suspicious for Staphylococcus aureus infections are identified:

  1. Lesions should be covered with a dressing;
  2. Report the lesions to the parent/guardian with a recommendation for evaluation by a primary care provider; and
  3. Exclusion is not warranted unless the individual meets any of the following criteria:
    1. Care for other children would be compromised by care required for the person with the S. aureus infection;
    2. The individual with the S. aureus infection has fever or a change in behavior;
    3. The lesion(s) cannot be adequately covered by a bandage or the bandage needs frequent changing; and
    4. A health care professional or health department official recommends exclusion of the person with S. aureus infection (1).

Meticulous hand hygiene following contact with lesions should be practiced (1). Careful hand hygiene and sanitization of surfaces and objects potentially exposed to infectious material are the best ways to prevent spread. Children and staff in close contact with an infected person should be observed for symptoms of S. aureus infection and referred for evaluation, if indicated.

A child may return to group child care when staff members are able to care for the child without compromising their ability to care for others, the child is able to participate in activities, appropriate therapy is being given, and the lesions can be covered (1).

S. aureus skin infections initially may appear as red raised areas that may become pus-filled abscesses or “boils,” surrounded by areas of redness and tenderness. Fever and other symptoms including decreased activity, bone and joint pain, and difficulty breathing may occur when the infection occurs in other body systems. If any of these signs or
symptoms occur, the child should be evaluated by his/her primary care provider.

RATIONALE
S. aureus (also known as “Staph”) is a bacterium that commonly causes superficial skin infections (cellulitis and abscesses). It also may cause muscle, bone, lung, and blood (invasive) infections. One type of S. aureus, called methicillin-resistant S. aureus or “MRSA,” is resistant to one or more classes of antibiotics. S. aureus and MRSA have been the source of attention due to increasing rates of infections from these bacteria associated with health care associated (HCA) infections and in healthy children and adults in the community. Transmissibility and infectivity is comparable to infections with S. aureus without methicillin resistance. Therefore signs and symptoms, incubation and contagion periods, control of spread, and exclusion guidelines are identical for all S. aureus infections, including infections with methicillin resistance or MRSA (1,2).

Most people with skin infections due to S. aureus do not develop invasive infections; they may experience recurrent skin infections. Infants and children who are diapered and pre-adolescents and adolescents who participate in team sports may have an increased risk for developing S. aureus skin infections. This is likely due to frequent breaks of skin and the sharing of towels. The incubation period for S. aureus skin infections is unknown. Some people may carry MRSA without having symptoms of active infection. These people are considered to be “colonized” with S. aureus; however, they are not considered to be infectious when they do not have active infection.

S. aureus skin infections may occur at sites of skin trauma. Pus and other material draining from skin lesions should be considered to be infectious. Treatment of S. aureus skin infections may be accomplished with an oral or an intravenous antibiotic or a combination of both. In some cases, incision and drainage of the lesion(s) alone may be required. In other instances, incision and drainage of smaller lesions with the use of a topical antibiotic may result in a cure. Skin lesions are considered to be infectious until they have healed; therefore, they should be kept covered and dry. Frequent hand hygiene to prevent spread of S. aureus should be practiced at home and in child care (1). Evaluation by a primary care provider in people with severe or prolonged symptoms may be indicated.

COMMENTS
S. aureus skin infections are common, especially among infants wearing diapers and adolescent members of sports teams. Infections may be more common among children where other family members have or have had skin lesions and during the warmer months when skin exposure to trauma may be increased. Shedding of bacteria from skin lesions may occur until the lesion has healed. Occasionally S. aureus infections may occur in several children at the same time or within a few of days of each other. Consultation with a health care professional and the local health department may be sought when several people have these symptoms.

For additional information for parents/guardians and caregivers/teachers, refer to information posted by the Centers for Disease Control and Prevention (CDC) at https://www.cdc.gov/mrsa/index.html.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
3.6.1.1 Inclusion/Exclusion/Dismissal of Children
Appendix A: Signs and Symptoms Chart
REFERENCES
  1. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. 
  2. 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.

Chapter 9 - Policies

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
3.4.3.3 Response to Fire and Burns
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
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. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Book: 2015 Report to the Committee of Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. 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 9.2.3.12: Infant Feeding Policy

A policy about infant feeding should be developed with the input and approval from the nutritionist/registered dietitian and should include the following:

  1. Storage and handling of expressed human milk;
  2. Determination of the kind and amount of commercially prepared formula to be prepared for infants as appropriate;
  3. Preparation, storage, and handling of infant formula;
  4. Proper handwashing of the caregiver/teacher and the children;
  5. Use and proper sanitizing of feeding chairs and of mechanical food preparation and feeding devices, including blenders, feeding bottles, and food warmers;
  6. Whether expressed human milk, formula, or infant food should be provided from home, and if so, how much food preparation and use of feeding devices, including blenders, feeding bottles, and food warmers, should be the responsibility of the caregiver/teacher;
  7. Holding infants during bottle-feeding or feeding them sitting up;
  8. Prohibiting bottle propping during feeding or prolonging feeding;
  9. Responding to infants’ need for food in a flexible fashion to allow cue feedings in a manner that is consistent with the developmental abilities of the child (policy acknowledges that feeding infants on cue rather than on a schedule may help prevent obesity) (1,2);
  10. Introduction and feeding of age-appropriate solid foods (complementary foods);
  11. Specification of the number of children who can be fed by one adult at one time;
  12. Handling of food intolerance or allergies (e.g., cow’s milk, peanuts, orange juice, eggs, wheat).

Individual written infant feeding plans regarding feeding needs and feeding schedule should be developed for each infant in consultation with the infant’s primary care provider and parents/guardians.

RATIONALE
Growth and development during infancy require that nourishing, wholesome, and developmentally appropriate food be provided, using safe approaches to feeding. Because individual needs must be accommodated and improper practices can have dire consequences for the child’s health and safety, the policy for infant feeding should be developed with professional nutritionists/registered dietitians. The infant feeding plans should be developed with each infant’s parents/guardians and, when appropriate, in collaboration with the child’s primary care provider.
TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Feeding Infants on Cue by a Consistent Caregiver/Teacher
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.8.0.8 Microwave Ovens
Appendix JJ: Our Child Care Center Supports Breastfeeding
REFERENCES
  1. Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry, M. W. Gillman. 2006. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics 118:2341-48.
  2. Birch, L., W. Dietz. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating, 59-93. Elk Grove Village, IL: American Academy of Pediatrics.

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
1.5.0.1 Employment of Substitutes
1.5.0.2 Orientation of Substitutes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.4.5 Death
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 9.2.4.3: 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
3.4.3.3 Response to Fire and Burns
3.4.3.2 Use of Fire Extinguishers
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
5.4.5.2 Cribs
9.2.4.3 Disaster Planning, Training, and Communication
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 9.2.4.7: Sign-In/Sign-Out System

The facility should have a sign-in/sign-out system to track who enters and exits the facility. The system should include name, contact number, relationship to facility (e.g., parent/guardian, vendor, guest, etc.) and recorded time in and out.

RATIONALE
This system helps to maintain a secure environment for children and staff. It also provides a means to contact visitors if needed (such as a disease outbreak) or to ensure all individuals in the building are evacuated in case of an emergency.
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

Standard 9.2.4.8: Authorized Persons to Pick Up Child

Names, addresses, and telephone numbers of persons authorized to take a child under care out of the facility should be maintained during the enrollment process along with clarification/documentation of any custody issues/court orders. The legal guardian(s) of the child should be established and documented at this time.

If there is an extenuating circumstance (e.g., the parent/guardian or other authorized person is not able to pick up the child), another individual may pick up a child from child care if they are authorized to do so by the parent/guardian in authenticated communication such as a witnessed phone conversation in which the caller provides pre-specified identifying information or writing with pre-specified identifying information. The telephone authorization should be confirmed by a return call to the parents/guardians. The facility should establish a mechanism for identifying a person for whom the parents/guardians have given the facility prior written authorization to pick up their child, such as requiring photo ID or including a photo of each authorized person in the child’s file.

If a previously unauthorized individual drops off the child, he or she will not be authorized to pick up the child without first being added to the authorization record. Policies should address how the facility will handle the situation if a parent/guardian arrives who is intoxicated or otherwise incapable of bringing the child home safely, or if a non-custodial parent attempts to claim the child without the consent of the custodial parent.

Should an unauthorized individual arrive without the facility receiving prior communication with the parent/guardian, the parent/guardian should be contacted immediately, preferably privately. If the information provided by the parent/guardian does not match the information and identification of the unauthorized individual, the child will not be permitted to leave the child care facility. If it is determined that the parent/guardian is unaware of the individual’s attempt to pick-up the child, or if the parent/guardian has not or will not authorize the individual to take the child from the child care facility, information regarding the individual should be documented and the individual should be asked to leave. If the individual does not leave and his or her behavior is concerning to the child care staff or if the child is abducted by force, then the police should be contacted immediately with a detailed description of the individual and any other obtainable information such as a license plate number.

RATIONALE
Releasing a child into the care of an unauthorized person may put the child at risk. If the caregiver/teacher does not know the person, it is the caregiver’s/teacher’s responsibility to verify that the person picking up the child is authorized to do so. This requires checking the written authorization in the child’s file and verifying the identity of the person. Caregivers/teachers must not be unwitting accomplices in schemes to gain custody of children by accepting a telephone authorization provided falsely by a person claiming to be the child’s custodial parent or claiming to be authorized by the parent/guardian to pick up the child.
COMMENTS
The facility can use photo identification such as photographs supplied by the parents/guardians, photo taken with a camera by the facility, photo ID such as a driver’s license, as a mechanism for verifying the identification of a new person to whom the parents/guardians have given written authorization to pick up their child. Identification methods may include passwords.

Caregivers/teachers should consider having a child car seat policy stating all authorized persons that pick-up a child have an age-appropriate car seat to transport a child from the child care program. This policy is discussed with parents/guardians during the enrollment process. Repeated failure to comply with the policy may be grounds for dismissal. Many child care facilities have extra car seats on hand to lend in case a parent/guardian forgets one (1).

Caregivers/teachers should not attempt to handle on their own an unstable (e.g., intoxicated) parent/guardian who wants to be admitted but whose behavior poses a risk to the children. Caregivers/teachers should consult local police or the local child protection agency about their recommendations for how staff can obtain support from law enforcement authorities to avoid incurring increased liability by releasing a child into an unsafe situation or by improperly refusing to release a child.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
9.2.4.9 Policy on Actions to Be Followed When No Authorized Person Arrives to Pick Up a Child
REFERENCES
  1. Public Counsel Law Center in California. 1998. Guidelines for releasing children and custody issues. http://www.publiccounsel
    .org/publications/release.pdf.

Standard 9.4.1.10: Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program

The facility should document that a child’s parent/guardian was notified immediately in the event of a death of their child, of an injury or illness of their child that required professional medical attention, or if their child was lost/missing.

Documentation should also occur noting when law enforcement was notified (immediately) in the event of a death of a child or a lost/missing child.

The facility should document in accordance with state regulations, its response to any of the following events:

  1. Death;
  2. Serious injury or illness that required medical attention;
  3. Reportable infectious disease;
  4. Any other significant event relating to the health and safety of a child (such as a lost child, a fire or other structural damage, work stoppage, or closure of the facility).

The caregiver/teacher should call 9-1-1 to insure immediate emergency medical support for a death or serious injury or illness. They should follow state regulations with regard to when they should notify state agencies such as the licensing agency and the local or state health department about any of the above events.

RATIONALE
The licensing agency should be notified according to state regulations regarding any of the events listed above because each involves special action by the licensing agency to protect children, their families, and/or the community. If death, serious injury, or illness or any of the events in item d) occur due to negligence by the caregiver/teacher, immediate suspension of the license may be necessary. Public health staff can assist in stopping the spread of the infectious disease if they are notified quickly by the licensing agency or the facility (1,2). The action by the facility in response to an illness requiring medical attention is subject to licensing review.

A report form that records death, maltreatment, serious injury or illness is also necessary for providing information to the child’s parents/guardians and primary care provider, other appropriate health agencies, law enforcement agency, and the insurance companies covering the parents/guardians and the facility.

COMMENTS
Guidance on policies for parental notification of child maltreatment reports should be sought from child care health consultants or local child abuse prevention agencies. Surveillance for symptoms can be accomplished easily by using a combined attendance and symptom record. Any symptoms can be noted when the child is signed in, with added notations made during the day when additional symptoms appear. Simple forms, for a weekly or monthly period, that record data for the entire group help caregivers/teachers spot patterns of illness for an individual child or among the children in the group or center.

Multi-copy forms can be used to make copies of an injury report simultaneously for the child’s record, for the parent/guardian, for the folder that logs all injuries at the facility, and for the licensing agency. Facilities should secure the parent/guardian’s signature on the form at the time it is presented to the parent/guardian.

TYPE OF FACILITY
Center, Large Family Child Care Home
RELATED STANDARDS
7.3.5.1 Recommended Control Measures for Invasive Meningococcal Infection in Child Care
7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
9.2.4.1 Written Plan and Training for Handling Urgent Medical Care or Threatening Incidents
9.4.1.9 Records of Injury
9.4.1.11 Review and Accessibility of Injury and Illness Reports
7.3.5.2 Informing Public Health Authorities of Meningococcal Infections
7.3.7.1 Informing Public Health Authorities of Pertussis Cases
7.3.10.1 Measures for Detection, Control, and Reporting of Tuberculosis
7.4.0.3 Disease Surveillance of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.4.0.4 Maintenance of Records on Incidents of Diarrhea
7.6.1.4 Informing Public Health Authorities of Hepatitis B Virus (HBV) Cases
Appendix F: Enrollment/Attendance/Symptom Record
Appendix CC: Incident Report Form
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America’s Playgrounds Safety Report Card
REFERENCES
  1. Galil, K., B. Lee, T. Strine, C. Carraher, A. L. Baughman, M. Eaton, J. Montero, J. Seward. 2002. Outbreak of varicella at a day-care center despite vaccination. N Engl J Med 347:1909-15.
  2. Aguero, J., M. Ortega-Mendi, M. Eliecer Cano, A. Gonzalez de Aledo, J. Calvo, L. Viloria, P. Mellado, T. Pelayo, A. Fernandez-Rodriguez, L. Martinez-Martinez. 2008. Outbreak of invasive group A streptococcal disease among children attending a day-care center. Pediatr Infect Dis J 27:602-4.

Standard 9.4.1.12: Record of Valid License, Certificate, or Registration of Facility

Every facility should hold a valid license or certificate, or documentation of, registration prior to operation as required by the local and/or state statute.

RATIONALE
Licensing registration provides recognition that the facility meets regulatory requirements which are written to insure that children are cared for by qualified staff in a safe environment that supports the children’s development and protects them from maltreatment while they are in child care programs.
TYPE OF FACILITY
Center, Large Family Child Care Home

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
3.6.3.2 Labeling, Storage, and Disposal of Medications
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
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.

Chapter 10 - Licensing and Community Action

Standard 10.4.2.1: Frequency of Inspections for Child Care Centers, Large Family Child Care Homes, and Small Family Child Care Homes

The licensing inspector should make an onsite inspection to measure compliance with licensing rules prior to issuing an initial license and at least two inspections each year to each center and large and small family child care home thereafter. At least one of the inspections should be unannounced and more if needed for the facility to achieve satisfactory compliance or is closed at any time (1). Sufficient numbers of licensing inspectors should be hired to provide adequate time visiting and inspecting facilities to insure compliance with regulations

The number of inspections should not include those inspections conducted for the purpose of investigating complaints. Complaints should be investigated promptly, based on severity of the complaint. States are encouraged to post the results of licensing inspections, including complaints, on the Internet for parent and public review. Parents/guardians should be provided easy access to the licensing rules and made aware of how to report complaints to the licensing agency. 

RATIONALE
Licensing inspections are important to assist facilities to achieve and maintain full compliance with licensing rules. Supervision and monitoring of child care facilities are critical to facilitate continued compliance with the rules in order to prevent or correct problems before they become serious (2). Technical assistance and consultation provided by licensing inspectors on an on-going basis are essential to help programs achieve compliance with the rules and go beyond the basic level of quality. These positive strategies are most effective when they are coupled with the non-regulatory methods used by other parts of the early care and education community to promote quality (such as professional development, quality and improvement rating systems, accreditation, peer support, and consumer education) (3). All of these methods are most effective when they work together within a coordinated early care and education system. Research has demonstrated that posting of licensing information on the Internet has a positive effect on compliance with licensing rules (3).
REFERENCES
  1. Witte, A. D., M. Queralt. 2004. What happens when child care inspections and complaints are made available on the internet? Faculty Working Paper 10227, Wellesley College Department of Economics and National Bureau of Economic Research, Wellesley Child Care Research Partnership.
  2. National Association for Regulatory Administration (NARA). 1999. Licensing workload assessment. Technical assistance bulletin #99-01. Lexington, KY: NARA. 
  3. National Association for Regulatory Administration (NARA). 2010. Strong licensing: The foundation for a quality early care and education system: NARA’s call to action. http://www.naralicensing.org/associations/4734/files/NARA_Call_to_Action.pdf.