Caring for Our Children: Chapter 3 - Health Promotion and Protection in Child Care Chapter 3: Health Promotion and Protection in Child Care 3.1 HEALTH PROMOTION IN CHILD CARE DAILY HEALTH CHECK STANDARD 3.001 Conduct of Daily Health Check Every day, a trained staff member shall conduct a health check of each child. This health check shall be conducted as soon as possible after the child enters the child care facility and whenever a change occurs while that child is in care. The health check shall address: a) Changes in behavior (such as lethargy or drowsiness) or appearance from behaviors observed during the previous day's attendance; b) Skin rashes, itchy skin, itchy scalp, or (during a lice outbreak) nits; c) If there is a change in the child's behavior or appearance, elevated body temperature, determined by taking the child's temperature; d) Complaints of pain or of not feeling well; e) Other signs or symptoms of illness (such as drainage from eyes, vomiting, diarrhea, and so on); f) Reported illness or injury in child or family members since last date of attendance. The facility shall gain information necessary to complete the daily health check by direct observation of the child, by querying the parent or legal guardian, and, where applicable, by conversation with the child. RATIONALE: Daily intake procedures to appraise each child's health and to ascertain recent illness or injury in the child and family reduce the transmission of communicable diseases in child care settings and enable the caregivers to plan for necessary care while the child is in care at the facility. COMMENTS: This assessment should be performed in a relaxed and comfortable manner that respects the family's culture as well as the child's body and feelings. The health consultant (see Health Consultants, STANDARD 1.040 through STANDARD 1.043) should train the caregiver(s) in conducting a health check, using a checklist. See Appendix F, for a sample symptom record. See Appendix G, for American Academy of Pediatrics' Recommended Childhood Immunization Schedule . Contact information is located in Appendix BB. Assessment by querying the parent should be at the time of transfer of care from the parent to the facility. If this happens outside the facility (when the child is put on a bus or in a car pool, for example), the facility should use some means of communication, such as written notes, checklists, conversations between bus drivers and parents, and daily log books. See STANDARD 3.068, regarding exclusion from child care. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.002 Documentation of the Daily Health Check The facility shall keep, for at least 3 months, a written record of concerns it identifies for each child during the daily health checks. RATIONALE: Although the vast majority of communicable diseases of concern in child care have incubation periods of less than 21 days, lags in reporting, non-apparent infections, and the slow-to-develop nature of some outbreaks suggest keeping data for 3 months. COMMENTS: For additional information on daily health assessment, see also Incidence Logs of Illness, Injury, and Other Problems, STANDARD 8.061 through STANDARD 8.064 and Child Records, STANDARD 8.046 through STANDARD 8.052. TYPE OF FACILITY: Center; Large Family Child Care Home PREVENTIVE HEALTH SERVICES STANDARD 3.003 Routine Health Supervision The facility shall require that the children have routine health supervision by the child's health provider, according to the standards of the American Academy of Pediatrics (AAP). Such health supervision includes routine screening tests, immunizations, and documentation and plotting on standard growth (if younger than 24 months of age) graphs of height and weight assessment and head circumference. School health services are acceptable to meet this standard if they meet the AAP's standards for school-age children and if the results of such examinations are shared with the child care provider as well as with the school health system. With parental consent, pertinent health information shall 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 helps detect disease when it is most treatable and through immunization, to prevent diseases for which effective vaccines are available. When children are receiving care that involves the school health system, such care should be coordinated by exchange of information with parental permission among the school health system, the child's usual source of health care, and the child care provider so 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 by health care providers 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). Growth charts are based on data from national probability samples representative of children in the general population. Their use by health care providers will direct the child care provider's attention to unusual body size, which may be a result of disease or poor nutrition that requires modification of feeding practices in the child care setting (2). COMMENTS: Some infants and toddlers identified as showing signs of neglect and failure to thrive because of lack of food or inconsistent feeding practices are enrolled in facilities for both promotional and preventive health services. Periodic and accurate height and weight measurements that are plotted and interpreted by a person who is competent in performing these tasks provide an easily obtainable indicator of health status. If such measurements are made in the child care facility, the data from the measurements should be shared by the facility with everyone involved in the child's care, including parents, caregivers, and the child's health care provider. The health consultant can provide staff training on growth assessment. See Health Consultants, STANDARD 1.040 through STANDARD 1.043. See Appendix H, for Recommendations for Preventive Pediatric Health Care . See STANDARD 3.004, on follow-up for nutrition and growth problems and nutrition assessment data; and STANDARD 8.047 through STANDARD 8.052, on files to be kept for each child in care. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.004 Assessment and Planning of Nutrition for Individual Children Nutrition assessment data (such as growth and anemia screening) shall be an integral part of the routine health supervision documented in the health record. Communication shall occur with a health care provider on how to meet the nutritional needs of children found to be at risk for nutritional problems. RATIONALE: Children who need special nutrition intervention or dietary modification of child care feeding routines because of growth problems must be identified so that preventive health/nutrition care can be provided at a critical time during growth and development. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home IMMUNIZATIONS STANDARD 3.005 Immunization Documentation The facility shall require that all children enrolling in child care provide written documentation of immunizations appropriate for the child's age. Infants, toddlers, older children, and adolescents shall be immunized as specified in the Recommended Childhood Immunization Schedule developed by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practice of the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Practice (AAFP) (AA). See Appendix G. Children whose immunizations are late or not given according to the schedule shall be immunized as recommended by the American Academy of Pediatrics (3) Because of frequent changes, an updated schedule is published by the AAP every January and shall be consulted for current information (4). RATIONALE: Routine immunization at the appropriate age is the best means of preventing vaccine-preventable diseases. Laws requiring the age-appropriate immunization of children attending licensed facilities exist in almost all states. Parents of children who attend unlicensed child care should be encouraged to comply with the Recommended Childhood Immunization Schedule for infants and children. See Appendix G. Immunization is particularly important for children in child care because preschool-aged children currently have the highest age-specific incidence of many vaccine-preventable diseases (specifically, measles, pertussis, rubella, varicella, and Haemophilus influenzae type b disease). COMMENTS: In addition to publication in print, as shown in Appendix G, the current Recommended Childhood Immunization Schedule is posted on the web site of the American Academy of Pediatrics: www.aap.org/ ; and the web site of the Centers for Disease Control and Prevention: www.cdc.gov/ . TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.006 Under-immunized Children If immunizations are not to be administered because of a medical condition, a statement from the child's health care provider documenting the reason why the child is exempt from the immunization requirement shall be on file. If immunizations are not given because of parents' religious beliefs, a waiver signed by the parent shall be on file. If a child who is not immunized is in care, the parents must be notified of the risk of the spread of preventable diseases. Children who have not received their age-appropriate immunizations prior to enrollment and do not have documented religious or medical exemptions from routine childhood immunizations shall show evidence of an appointment for immunizations. The immunization series shall be initiated within one month and completed according to the Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP). See Appendix G. If a vaccine-preventable disease to which children are susceptible occurs in the facility, unimmunized children shall be excluded for the duration of possible exposure or until the age-appropriate immunizations have been completed (whichever comes first). RATIONALE: Routine immunization at the appropriate age is the best means of preventing vaccine-preventable diseases. Laws requiring the age-appropriate immunization of children attending licensed facilities exist in all states (73). Parents of children who attend unlicensed child care should be encouraged to comply with the Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) for infants and children. See Appendix G. The exclusion of an unimmunized child from the facility in the event of an outbreak of a vaccine-preventable disease protects the health of that unimmunized child. 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]. [SIGNED], [PHYSICIAN] [DATE]" See Appendix G, for the Recommended Childhood Immunization Schedule from the AAP. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.007 Immunization of Child Care Providers Child care providers shall be current for all immunizations routinely recommended for adults by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). All child care providers shall have: a) Completed a primary series for tetanus and diphtheria, and shall receive boosters every 10 years; b) Been immunized or certified immune by a health care provider against measles, mumps, rubella, poliomyelitis, varicella (chickenpox), and hepatitis B following guidelines of the ACIP (2, 4). Additionally, influenza immunization is recommended for people 50 years of age and older and pneumococcal polysaccharide vaccine is recommended for people 65 years of age or older. If a staff member is not appropriately immunized for medical or religious reasons, the child care facility shall require documentation of the reason, in writing. RATIONALE: Vaccine-preventable infections of adults represent a continuing cause of morbidity and mortality and 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 (4, 5) COMMENTS: For additional information on adult immunization, contact the Centers for Disease Control and Prevention (CDC) or visit the CDC website at www.cdc.gov/. Contact information is located in Appendix BB. For additional information on vaccine-preventable diseases, see Health Plan for Child Health Services, STANDARD 8.013 through STANDARD 8.017; for additional immunization standards, Pre-employment Staff Health Appraisal, STANDARD 1.045. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home SLEEP STANDARD 3.008 Scheduled Rest Periods and Sleep Arrangements The facility shall provide an opportunity for, but shall not require, sleep and rest. The facility shall make available a regular rest period for school-aged children, if the child desires. For children who are unable to sleep, the facility shall provide time and space for quiet play. Unless the child has a note from a physician specifying otherwise, infants shall be placed in a supine (back) position for sleeping to lower the risks of Sudden Infant Death Syndrome (SIDS). Soft surfaces and gas-trapping objects such as pillows, quilts, sheepskins, soft bumpers or waterbeds shall not be placed under or with an infant for sleeping. When infants can easily turn over from the supine to the prone position, they shall be put down to sleep on their back, but allowed to adopt whatever position they prefer for sleep. Unless a doctor specifies the need for a positioning device that restricts movement within the child's bed, such devices shall not be used. RATIONALE: Conditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, and a regular time for rest (6). Most preschool children in all-day care benefit from scheduled periods of rest. This rest may take the form of actual napping, a quiet time, or a change of pace between activities. The times of naps will affect behavior at home (8). The supine (back) position presents the least risk of SIDS (7, 8). Once infants develop the motor skills to move from their back to their side or stomach it is safe to put them to sleep on their backs and allow them to adapt to whatever position makes them comfortable. Repositioning sleeping infants onto their backs is not recommended once the child has learned to turn over easily from supine (back) to prone (front). If a child has an illness or a disability that predisposes the child to airway obstruction in the back sleeping position, parents should give the child care provider a physician's note specifying the need for prone sleeping and any other special arrangements required for that child. COMMENTS: In the young infant, favorable conditions for sleep and rest include being dry, well-fed, and comfortable. A school-age child care facility should make available board games and other forms of quiet play. The 1996 update to the statement prepared by the AAP Task Force on Infant Positioning and SIDS details the rationale for preferential back-positioning when caregivers put children down to sleep. Infants who are back-sleepers at home, but are put to sleep in the prone position in child care settings, have a higher risk of SIDS (7). A certain amount of "tummy time" while the child is awake and observed helps muscle development and reduces the tendency for back positioning to flatten the back of the head (8). Additional resources are available from the National SIDS Resource Center and the Back to Sleep Campaign or from the local or state health department. Contact information is located in Appendix BB. See STANDARD 5.146, for additional information on appropriate bedding to reduce the risk of SIDS. See STANDARD 1.023 and STANDARD 1.038, regarding child care provider training on SIDS. See also STANDARD 3.089, regarding dealing with SIDS deaths. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.009 Unscheduled Access to Rest Areas All children shall have access to rest or nap areas whenever the child desires to rest. These rest or nap areas shall be set up to reduce distraction or disturbance from other activities. All facilities shall provide for rest areas for children who need to rest off schedule, including children who become ill, at least until the child leaves the facility for care elsewhere. RATIONALE: Any child, especially children who are ill, may need more opportunity for rest or quiet activities. COMMENTS: See also STANDARD 3.008, on additional sleep requirements. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home ORAL HEALTH STANDARD 3.010 Routine Oral Hygiene activities Caregivers shall promote the habit of regular tooth brushing. All children with teeth shall brush or have their teeth brushed at least once during the hours the child is in child care. Using a size-appropriate brush and a small amount of fluoride toothpaste, the caregiver shall either brush the child's teeth or supervise as the child brushes his/her own teeth. The younger the child the more the caregiver needs to be involved. After feeding, an infant's teeth and gums shall be wiped with a moist cloth to remove any remaining liquid that coats the teeth and gums and which turns to plaque causing tooth decay. Very few preschool-age children have the hand-eye coordination or the fine motor skills necessary to complete the complex process of tooth brushing. The caregiver shall be able to evaluate each child's motor activity and to teach the child the correct method of tooth brushing when the child is capable of doing this activity. The caregiver shall monitor the tooth brushing activity and thoroughly brush the child's teeth after the child has finished brushing. The cavity-causing effect of frequent exposure to food shall be reduced by offering the children rinsing water after snacks when brushing is not possible. RATIONALE: Regular tooth brushing with fluoride toothpaste and flossing is encouraged to reinforce oral health habits and prevent gingivitis and tooth decay. 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. Tooth brushing at least once a day reduces build-up of decay-causing plaque. The development of tooth decay-producing plaque begins when an infant's first tooth appears in his/her mouth. Tooth decay cannot form without this plaque or 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. Tooth brushing and flossing activities at home may not suffice to learn 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 should use a layer of fluoride toothpaste (about children under three years of age and a pea-sized amount for children over three years of age) and rinse well. Fluoride is the single most effective way to prevent tooth decay. Brushing of teeth with fluoridated toothpaste is the most efficient way to apply fluoride to the teeth. Children under 3 years of age may swallow toothpaste that contains fluoride. If children swallow more than recommended amounts of fluoride toothpaste, they are at risk for fluorosis, a condition caused by excessive levels of fluoride intake. The children can also rinse and spit out after a snack if their teeth have already been brushed after a meal. Rinsing with water helps to remove food particles from teeth and may prevent cavities. 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, take a rinsing drink, and then spit into the cup. For information on toothbrush storage, see STANDARD 5.095 and STANDARD 5.151. For additional information on oral health, see also STANDARD 3.011; and STANDARD 8.046 through STANDARD 8.052, on child records. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.011 Oral Health Education All children with teeth shall have oral hygiene as a part of their daily activity. Those two years and older shall have developmentally appropriate oral health education that includes information on what plaque is, the process of dental caries development, and the importance of good oral hygiene behaviors. School-age children shall receive additional information including the preventive use of fluoride, dental sealants, mouth guards, and the importance of healthy eating behaviors and regularly scheduled dental visits. Older children shall be informed about the effect of tobacco products on their oral health and additional reasons for avoidance. RATIONALE: Studies have reported that the oral health of participants improved as a result of educational programs (9, 10). COMMENTS: Child care providers are encouraged to advise parents that the following ages for preventive and early intervention dental services and education are suggested: Dental visits, evaluation for systemic fluoride therapy at six months of age, and professionally applied topical fluoride treatments for high risk children; First dental visit whenever there is a question of an oral health problem, but no later than 3 years of age; Dental sealants generally at 6 or 7 years of age for first permanent molars, and for primary molars if deep pits and grooves or other high risk factors are present. When possible, child care providers should provide education for parents on good oral hygiene practices and avoidance of behaviors that increase the risk of early childhood caries, such as inappropriate use of a bottle and frequent consumption of carbohydrate-rich foods. 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. See Health Education, STANDARD 2.060 through STANDARD 2.064. TYPE OF FACILITY: Center 3.2 HYGIENE TOILETING AND DIAPERING STANDARD 3.012 Type of Diapers Diapers worn by children shall be able to contain urine and stool and minimize fecal contamination of the children, caregivers, environmental surfaces, and objects in the child care setting. Only disposable diapers with absorbent gelling material or carboxymethyl cellulose may be used unless the child has a medical reason that does not permit the use of disposable diapers (such as allergic reactions). When children cannot use disposable diapers for a medical reason, the reason shall be documented by the child's health care provider. When cloth diapers are used, the diaper shall have an absorbent inner lining completely contained within an outer covering made of waterproof material that prevents the escape of feces and urine. The outer covering and inner lining shall be changed together at the same time as a unit and shall not be reused unless both are cleaned and disinfected, washed, and either chemically disinfected or heat dried at 165 degrees F or more. No rinsing or dumping of the contents of the diaper shall be performed at the child care facility. RATIONALE: Gastrointestinal tract disease caused by bacteria, viruses, parasites, and hepatitis A virus infection of the liver are spread from infected persons through fecal contamination of objects in the environment and hands of caregivers and children. Procedures that reduce fecal contamination, such as minimal handling of soiled diapers and clothing, handwashing, proper personal hygiene, and fecal containment in diapered children control the spread of these diseases. Diapering practices that require increased manipulation of the diaper and waterproof covering, particularly reuse of the covering before it is cleaned and disinfected, present increased opportunities for fecal contamination of the caregivers' hands, the child, and consequently, objects and surfaces in the environment. Environmental contamination has been associated with increased diarrheal rates in child care facilities (11). Fecal contamination in the center environment may be less when paper diapers are used than when cloth diapers worn with pull-on waterproof pants are used (14). When clothes are worn over either paper or cloth diapers with pull-on waterproof pants, there is a reduction in contamination (11, 14). Diaper dermatitis occurs frequently in diapered children. Diapering practices that reduce the frequency and severity of diaper dermatitis will require less application of skin creams, ointments, and drug treatments, thereby decreasing the likelihood for fecal contamination of caregivers' hands. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (11). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (11, 12). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (11). Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the diaper used (11). The use of modern disposable diapers with absorbent gelling material or carboxymethyl cellulose has been associated with less frequent and severe diaper dermatitis in some children than with the use of cloth diapers and pull-on pants made of a waterproof material (14). COMMENTS: Several types of diapers or diapering systems are currently available: disposable paper diapers, reusable cloth diapers worn with pull-on waterproof pants, reusable cloth diapers worn with a modern front closure waterproof cover, and single unit reusable diaper systems with an inner cotton lining attached to an outer waterproof covering. Two types of diapers meet the physical requirements of the standard: modern disposable paper diapers, with absorbent gelling material or carboxymethyl cellulose, and single unit reusable diaper systems, with an inner cotton lining attached to an outer waterproof covering. A third type, reusable cloth diapers worn with a modern front closure waterproof cover, meet the standard only: If the cloth diaper and cover are removed simultaneously as a unit and are not removed as two separate pieces, and; If the cloth diaper and outer cover are not reused until both are cleaned and disinfected. Reusable cloth diapers worn either without a covering or with pull-on pants made of waterproof material do not meet the physical requirements of the standard and are not recommended in facilities. Whichever diapering system is used in the facility, clothes should be worn over diapers while the child is in the facility. Rigorous protocols should be implemented for diaper handling and changing, personal hygiene, and environmental decontamination. While single unit reusable diaper systems, with an inner cloth lining attached to an outer waterproof covering, and reusable cloth diapers, worn with a modern front closure waterproof cover, meet the physical criteria of this standard (if used as described), they have not been evaluated for their ability to reduce fecal contamination, or for their association with diaper dermatitis. Moreover, it has not been demonstrated that the waterproof covering materials remain waterproof with repeated cleaning and disinfecting. If these reusable diaper products are used in child care, the user should determine the waterproof characteristics of the covering material at frequent intervals. For additional information on decreasing contamination when diapering, see also STANDARD 3.014; Handwashing, STANDARD 3.020 through STANDARD 3.024; and Sanitation, Disinfection, and Maintenance of Handwashing Sinks, STANDARD 3.029. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.013 Checking For The Need To Change Diapers Diapers shall be checked for wetness and feces at least hourly, visually inspected at least every two hours, and whenever the child indicates discomfort or exhibits behavior that suggests a soiled or wet diaper. Diapers shall be changed when they are found to be wet or soiled. RATIONALE: Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the type of diaper used (11). Diaper dermatitis occurs frequently in diapered children. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (12). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (11, 12). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (12). Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents can be assessed by smell. Nonetheless, since these methods of checking may be inaccurate, the diaper should be opened and checked visually at least every two hours. Even though modern disposable diapers can continue to absorb moisture for an extended period of time when they are wet, they should be changed after two hours of wearing if they are found to be wet. This prevents rubbing of wet surfaces against the skin, a major cause of diaper dermatitis. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.014 Diaper Change Procedure The following diaper changing procedure shall be posted in the changing area, shall be followed for all diaper changes, and shall be used as part of staff evaluation of caregivers who do diaper changing. Child caregivers shall never leave a child alone on a table or countertop, even for an instant. A safety strap or harness shall not be used on the diaper changing table. If an emergency arises, caregivers shall put the child on the floor or take the child with them. Step 1: Get organized. Before you bring the child to the diaper changing area, wash your hands, gather and bring what you need to the diaper changing table: · Non-absorbent paper liner large enough to cover the changing surface from the child's shoulders to beyond the child's feet; · Fresh diaper, clean clothes (if you need them); · Wipes for cleaning the child's genitalia and buttocks removed from the container or dispensed so the container will not be touched during diaper changing; · A plastic bag for any soiled clothes; · Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers); · A thick application of any diaper cream (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. · Always keep a hand on the child; · 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; · Put soiled clothes in a plastic bag and securely tie the plastic bag to send the soiled clothes home. Step 3: Clean the child's diaper area. · Place the child on the diaper change surface and unfasten the diaper but leave the soiled diaper under the child. · 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. · Lift the child's legs as needed to use disposable wipes to clean the skin on the child's genitalia and buttocks. Remove stool and urine from front to back and use a fresh wipe each time. Put the soiled wipes into the soiled diaper or directly into a plastic-lined, hands-free covered can. Step 4: Remove the soiled diaper without contaminating any surface not already in contact with stool or urine. · Fold the soiled surface of the diaper inward. · 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 or laundry service. · If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can. · Whether or not gloves were used, use a disposable wipe to clean the surfaces of the caregiver's hands and another to clean the child's hands, and put the wipes into the plastic-lined, hands-free covered can. · Check for spills under the child. If there are any, use the paper that extends under the child's feet to fold over the disposable paper so a fresh, unsoiled paper surface is now under the child's buttocks. Step 5: Put on a clean diaper and dress the child. · Slide a fresh diaper under the child. · Use a facial or toilet tissue to apply any necessary diaper creams, discarding the tissue in a covered, plastic-lined, hands-free covered can. · Note and plan to report any skin problems such as redness, skin cracks, or bleeding. · 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. · Use soap and water, no less than 60 degrees F and no more than 120 degrees F, at a sink to wash the child's hands, if you can. · If a child is too heavy to hold for handwashing or cannot stand at the sink, use commercial disposable diaper wipes or follow this procedure: · Wipe the child's hands with a damp paper towel moistened with a drop of liquid soap. · Wipe the child's hands with a paper towel wet with clear water. · Dry the child's hands with a paper towel. Step 7: Clean and sanitize the diaper-changing surface. · Dispose of the disposable paper liner used on the diaper changing surface in a plastic-lined, hands-free covered can. · Clean any visible soil from the changing surface with detergent and water; rinse with water. · Wet the entire changing surface with the sanitizing solution (e.g. spray a sanitizing bleach solution of 1/4 cup of household liquid chlorine bleach in one gallon of tap water, mixed fresh daily)(3). · Put away the spray bottle of sanitizer. If the recommended bleach dilution is sprayed as a sanitizer on the surface, leave it in contact with the surface for at least 2 minutes. The surface can be left to air dry or can be wiped dry after 2 minutes of contact with the bleach solution. Step 8: Wash your hands according to the procedure in STANDARD 3.021 and record the diaper change in the child's daily log. · 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). Report as necessary (16). 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. Posting the multi-step procedure may help caregivers maintain the routine. Assembling all necessary supplies before bringing the child to the changing area will ensure the child's safety and make the change more efficient. 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 and subsequently spread disease. Commonly, caregivers 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. 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 or 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 should use a commercial diaper 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. Although handwashing is much more effective than using wipes for either the child's or the caregiver's hands there is a significant risk of injury from losing control of the child on the diaper table if handwashing is attempted at this point. Therefore using a wipe for the child's and caregiver's hands while the caregiver is holding the child is a reasonable compromise. Although gloves are not necessary for diaper changing, they may reduce contamination of the caregiver's hands and reduce the presence of infectious disease agents under the fingernails and from the hand surfaces. Even if gloves are used, caregivers must wash their hands after each child's diaper changing to prevent the spread of disease-causing agents. Gloves can provide a protective barrier, but they offer little protection beyond that achieved by good handwashing. To achieve maximum benefit from use of the gloves, the caregiver must remove the gloves properly after cleaning the child's genitalia and buttocks and removing the soiled diaper. Otherwise, the contaminated gloves will spread infectious disease agents to the clean surfaces as the child is dressed with a clean diaper and clothing. Note that sensitivity to latex is a growing problem. If caregivers or children who are sensitive to latex are present in the facility, gloves must be made of vinyl or some other substance that does not contain or cross-react with latex. See Appendix D, for proper technique for removing gloves. Prior to using a bleach solution to sanitize, clean any visible soil from the surface with a detergent and rinse well with water. By itself, bleach is not a good cleaning agent. Two minutes of contact with a solution of cup household liquid chlorine bleach in one gallon of tap water prepared fresh daily is an effective method of surface-sanitizing of environmental surfaces and other inanimate objects that have first been thoroughly cleaned of organic soil (19, 20, 34). Domestic bleach is sold in the conventional strength of 5.25% hypochlorite and a more recently marketed "ultra" bleach product that contains 6% hypochlorite solution. The recommended 1:64 dilution of 1/4 cup of domestic bleach to 1 gallon of water (or 1 tablespoon to 1 quart of water) produces a solution that contains 500-800 parts per million of available chlorine. Unpublished tests by Chlorox shows 2 minutes of contact on a visibly clean surface that has been coated with a spray of a 1:64 dilution of household bleach, kills most disease-causing organisms on that surface. Air-drying is fine, since chlorine evaporates when the solution dries. If the surface is to be wiped dry, wait for the 2 minute contact time to elapse first. Industrially prepared detergent-sanitizer solutions or detergent cleaning, rinsing and application of a non-bleach sanitizer is acceptable as long as these products are non-toxic for children and are used according to the manufacturer's instructions. Always assume that the outside of the spray bottle of sanitizing solution is contaminated. Therefore, the spray bottle should be put away before handwashing (the last and essential part of every diaper change). COMMENTS: The procedure outlined here is an updated version of that found in Keeping Healthy:Parents, Teachers, and Children available from the National Association for the Education of Young Children (NAEYC). The recommended procedure is based on extensive experience observing and teaching diaper changing technique to caregivers. This procedure is demonstrated step-by-step in the video series, Caring for Our Children , also available from the NAEYC and the American Academy of Pediatrics (AAP). Contact information is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.015 Use of A Diaper Changing Area Children shall be diapered or have soiled underwear changed in the diaper changing area. RATIONALE: The use of a separate area for diaper changing or changing of soiled underwear reduces contamination of other parts of the child care environment (15). COMMENTS: See also Diaper Changing Areas, STANDARD 5.132. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.016 Access to Diaper Changing Area Children shall be discouraged from remaining in or entering the diaper changing area. The contaminated surfaces of waste containers shall not be accessible to children. RATIONALE: Children cannot be expected to avoid contact with contaminated surfaces in the diaper changing area. They should be in this area only for diaper changing and be protected as much as possible from contact with contaminated surfaces. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.017 Use of Diaper Changing Surface Diaper changing shall not be conducted on surfaces used for other purposes, especially not on any counter that is used during food preparation or mealtimes. RATIONALE: Using diaper changing surfaces for any other use increases the likelihood of contamination and spreading of infectious disease agents. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.018 Handling cloth Diapers If cloth diapers are used, soiled cloth diapers and/or soiled training pants shall never be rinsed or carried through the child care area to place the fecal contents in a toilet. Reusable diapers shall be laundered by a commercial diaper service approved by the health department or, if laundered by the caregiver, in a manner that meets the approval of the health department. Soiled cloth diapers shall be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child's family. The sealed plastic bag shall be sent home with the child at the end of the day. The containers or sealed diaper bags of soiled cloth diapers shall not be accessible to any child. RATIONALE: Containing and minimizing the handling of soiled diapers so they do not contaminate other surfaces is essential to prevent the spread of infectious disease. Putting stool into a toilet in the child care facility increases the likelihood that other surfaces will be contaminated during the disposal. There is no reason to use the toilet for stool if disposable diapers are being used. If laundered diapers are involved, the stool can be dumped at the time the diapers are laundered. Commercial diaper laundries use a procedure that separates solid components from the diapers and does not require prior dumping of feces into the toilet. COMMENTS: For more information on cloth diapers, see STANDARD 3.012. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.019 Maintenance of Changing Tables Changing tables shall be nonporous, kept in good repair, and cleaned and sanitized after each use to remove visible soil, followed by wetting with an approved sanitizing solution. RATIONALE: Many communicable diseases can be prevented through appropriate hygiene, sanitation, and disinfection procedures. It is difficult, if not impossible to sanitize porous surfaces, broken edges, and surfaces that cannot be completely cleaned. Bacterial cultures of environmental surfaces in child care facilities have shown fecal contamination, which has been used to gauge the adequacy of sanitation and hygiene measures practiced at the facility (17). COMMENTS: Caregivers should be reminded that many sanitizers leave residues that can cause skin irritation or other symptoms. Users of all sanitizers except bleach should rinse the surface with clear water, after proper contact time. Rinsing after using bleach is unnecessary, as the chlorine in the solution evaporates, leaving only a residue of water. A sprayed solution of rine bleach to 1 gallon of water requires 2 minutes of contact time to kill the usual load of common infectious agents found in feces (3, 19). Prior to using a bleach solution to sanitize, clean any visible soil from the surface with a detergent and rinse well with water. By itself, bleach is not a good cleaning agent. Two minutes of contact with a solution of household liquid chlorine bleach in one gallon of tap water prepared fresh daily is an effective method of surface-sanitizing of environmental surfaces and other inanimate objects that have first been thoroughly cleaned of organic soil (19, 20, 34). Domestic bleach is sold in the conventional strength of 5.25% hypochlorite and a more recently marketed "ultra" bleach product that contains 6% hypochlorite solution. The recommended 1:64 dilution of 1/4 cup of domestic bleach to 1 gallon of water (or 1 tablespoon to 1 quart of water) produces a solution that contains 500-800 parts per million of available chlorine. Unpublished tests by Chlorox shows 2 minutes of contact on a visibly clean surface that has been coated with a spray of a 1:64 dilution of household bleach, kills most disease-causing organisms on that surface. Air-drying is fine, since chlorine evaporates when the solution dries. If the surface is to be wiped dry, wait for the 2 minute contact time to elapse first. Industrially prepared detergent-sanitizer solutions or detergent cleaning, rinsing and application of a non-bleach sanitizer is acceptable as long as these products are non-toxic for children and are used according to the manufacturer's instructions. Select a sanitizer that will kill vegetative bacteria, fungi, and viruses. The product must be registered by the U.S. Environmental Protection Agency (EPA) for use as a sanitizer. Prepare and use all products according to label directions for sanitizing, except bleach used in a spray application. The spray application of bleach solution has been tested but has not been reviewed by EPA for commercial labeling. See Appendix I, for Selecting an Appropriate Sanitizer (18). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home HANDWASHING STANDARD 3.020 Situations That Require Handwashing All staff, volunteers, and children shall follow the procedure in STANDARD 3.021 for handwashing at the following times: a) Upon arrival for the day or when moving from one child care group to another; b) Before and after: · Eating, handling food, or feeding a child; · Giving medication; · Playing in water that is used by more than one person. c) After: · Diapering; · Using the toilet or helping a child use a toilet; · Handling bodily fluid (mucus, blood, vomit), from sneezing, wiping and blowing noses, from mouths, or from sores; · Handling uncooked food, especially raw meat and poultry; · Handling pets and other animals; · Playing in sandboxes; · Cleaning or handling the garbage. RATIONALE: Handwashing is the most important way to reduce the spread of infection. Many studies have shown that unwashed or improperly washed hands are the primary carriers of infections. Deficiencies in handwashing have contributed to many outbreaks of diarrhea among children and caregivers in child care centers (21). In child care centers that have implemented a hand-washing training program, the incidence of diarrheal illness has decreased by 50% (22). One study found that handwashing helped to reduce colds when frequent and proper handwashing practices were incorporated into a child care center's curriculum (22, 23, 24). Good handwashing after playing in sandboxes will help prevent ingesting zoonotic parasites that could be present in contaminated sand and soil (26). Thorough handwashing with soap for at least 10 seconds using comfortably warm, running water, (no less than 60 degrees F and no more than 120 degrees F) removes organisms from the skin and allows them to be rinsed away (25). Handwashing is effective in preventing transmission of disease. Washing hands after eating is especially important for children who eat with their hands, to decrease the amount of saliva (which may contain organisms) on their hands. Illnesses may be spread in a variety of ways: In human waste (urine, stool); In body fluids (saliva, nasal discharge, secretions from open injuries; eye discharge, blood); Cuts or skin sores; By direct skin-to-skin contact; By touching an object that has germs on it; In drops of water, such as those produced by sneezing and coughing, that travel through the air. Since many infected people carry communicable 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 carrying out hygienic procedures on a routine basis (24). Animals, including pets, are a source of infection for people, and people may be a source of infection for animals (27). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.021 Handwashing PROCEDURE Children and staff members shall wash their hands using the following method: a) Check to be sure a clean, disposable paper (or single-use cloth) towel is available. b) Turn on warm water, no less than 60 degrees F and no more than 120 degrees F, to a comfortable temperature. c) Moisten hands with water and apply liquid soap to hands. d) Rub hands together vigorously until a soapy lather appears, and continue for at least 10 seconds. Rub areas between fingers, around nailbeds, under fingernails, jewelry, and back of hands. e) Rinse hands under running water, no less than 60 degrees F and no more than 120 degrees F, until they are free of soap and dirt. Leave the water running while drying hands. f) Dry hands with the clean, disposable paper or single use cloth towel. g) If taps do not shut off automatically, turn taps off with a disposable paper or single use cloth towel. h) 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. RATIONALE: Running water over the hands removes soil, including infection-causing organisms. 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. Warm water, no less than 60 degrees F and no more than 120 degrees F, is more comfortable than cold water; using warm water promotes adequate rinsing during handwashing (25). Children and staff members should use liquid soap. Although adequately drained bar soap has not been incriminated in transmission of bacteria; bar soaps sitting in water have been shown to be heavily contaminated with Pseudomonas and other bacteria. Many children do not have the dexterity to handle a bar of soap. Many adults and children do not take the time to rinse the soil they have applied to the soap bar before putting down the soap bar. By using a paper towel to turn off the water faucet, people who have just completed handwashing prevent recontamination of their hands. COMMENTS: Premoistened cleansing towlettes 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, such as during an outing, towlettes may be used as a temporary measure until hands can be washed under running water. Antibacterial soaps may be used but are not required. Water basins should not be used as an alternative to running water. If running water from an approved central plumbing source is unavailable, the staff should use a large container fitted with a spigot and fill it daily with a supply of safe water to run water over the hands, which are held above a water basin as a temporary measure. 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. Outbreaks of disease have been linked to shared wash water and wash basins. Single-use towels can be used. Shared cloth towels can transmit infectious disease. Even though a child may use a cloth towel that is solely for that child's use, preventing shared use of towels is difficult. Disposable towels prevent this problem, but once used, must be discarded. Many communicable diseases can be prevented through appropriate hygiene and sanitation. Taps that turn off automatically or those that can be turned off without using hands avoid the recontamination problem. The use of cloth roller towels is not recommended for the following reasons: Children often use cloth roll dispensers improperly, resulting in more than one child using the same section of towel. Incidents of accidental strangulation have been reported (oral communication, U.S. Consumer Product Safety Commission Data Office, September 2000). For additional information, see Keeping Healthy , available from the National Association for the Education of Young Children (NAEYC) and The ABC's of Safe and Healthy Child Care available from the Centers for Disease Control and Prevention (CDC). Contact information located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.022 Assisting Children with Handwashing Caregivers shall 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 shall either use a child-size 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 shall wash his or her own hands. If a child is unable to stand and is too heavy to hold safely to wash the hands at the sink, caregivers shall use the following method: · Wipe the child's hands with a damp paper towel moistened with a drop of liquid soap. Then discard the towel. · Wipe the child's hands with a clean, wet, paper towel until the hands are free of soap. Then discard the towel. · Dry the child's hands with a clean paper towel. RATIONALE: Encouraging and teaching children good handwashing practices must be done in a safe manner. Washing the hands of infants helps reduce the spread of infection, and washing under water is best. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.023 Training and Monitoring For Handwashing The facility shall ensure that staff members and children who are developmentally able to learn personal hygiene are instructed in, and monitored on, the use of running water, soap, and single-use or disposable towels in handwashing, as specified in STANDARD 3.021. RATIONALE: Education of the staff regarding handwashing and other cleaning procedures can reduce the occurrence of illness in the group of children in care (21, 23). Staff training and monitoring have been shown to reduce the spread of infections of the gastrointestinal tract (often with diarrhea) or liver (28-31). In a study of four centers, staff training in hygiene combined with close monitoring of staff compliance was associated with a significant decrease in infant-toddler diarrhea (28). In another study, periodic evaluation of caregivers trained in hygiene was associated with significant improvement in the practices under study. Training combined with evaluation was associated with additional significant improvement (29). In a study of 12 centers, continuous surveillance without training was associated with a significant decrease in diarrheal illness during the course of longitudinal study. One-time staff training without subsequent monitoring did not result in additional decreases (31). A similar decline in diarrhea rates during the course of surveillance without training was observed in a longitudinal study of 52 centers (30). These studies suggest that training combined with outside monitoring of child care practices can modify staff behavior as well as the occurrence of disease. Involving the children in similar education can be expected to improve the effectiveness of staff training in controlling the spread of infectious disease. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home NOSE-BLOWING STANDARD 3.024 Procedure For Nasal Secretions Staff members and children shall blow or wipe their noses with disposable, one-use tissues and then discard them in a plastic-lined, covered, hands-free trash container. After blowing the nose, they shall wash their hands, as specified in STANDARD 3.021 and STANDARD 3.022. RATIONALE: Handwashing is the most important way to reduce the spread of infection. Many studies have shown that unwashed or improperly washed hands are the primary carriers of infections. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home EXPOSURE TO BODY FLUIDS STANDARD 3.025 Cuts and Scrapes Cuts or sores that are leaking body fluids shall be covered with a dry dressing to avoid contamination of surfaces in child care. The caregiver shall wear gloves if there is to be any contact with a wound. If an individual has a cut or sore that is leaking a body fluid that cannot be contained or cannot be covered with a dry dressing, that person shall be excluded from the facility until the cut or sore is scabbed over or healed. RATIONALE: Touching a contaminated object or surface may spread infectious organisms. Body fluids may contain infectious organisms. Gloves can provide a protective barrier against infectious diseases that may be carried in body fluids. COMMENTS: Covering sores on lips and on eyes is difficult. Dry scabs are best left open to the air. See STANDARD 3.069, for information regarding staff herpes simplex (cold sores). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.026 Prevention of Exposure to Blood and Bodily Fluids Child care facilities shall adopt a modified version of Standard Precautions developed for use in hospitals by The Centers for Disease Control and Prevention as defined in this standard and as may be recommended by the Centers for Disease Control and Prevention for child care settings in the future. This modified version of Standard Precautions shall be used to handle potential exposure to blood, including the blood-containing body fluids and tissue discharges, and to handle other potentially infectious fluids. In child care settings, exceptions to Standard Precautions as defined by the Centers for Disease Control and Prevention for hospital settings shall include: a) Use of non-porous gloves is optional unless blood or blood containing body fluids may be involved. Gloves are not required for feeding human milk or cleaning up of spills of human milk. b) Gowns and masks are not required. c) Sufficient barriers include materials such as disposable diaper table paper that is moisture resistant, and non-porous gloves. The staff shall be educated regarding routine precautions to prevent transmission of bloodborne pathogens before beginning to work in the facility and at least annually thereafter. The staff training shall comply with requirements of the Occupational Safety and Health Administration (OSHA), where applicable. Procedures for Standard Precautions shall include: a) Surfaces that may come in contact with potentially infectious body fluids must be disposable or of a material that can be sanitized. Use of materials that can be sterilized is not required. b) The staff shall 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 sanitized before further contact occurs with them by other objects or individuals. c) When spills of body fluids, urine, feces, blood, saliva, nasal discharge, eye discharge, injury or tissue discharges, and human milk occur, these spills shall be cleaned up immediately, and further managed as follows: 1) For spills of vomit, urine, human milk, and feces, all floors, walls, bathrooms, tabletops, toys, kitchen counter tops, and diaper-changing tables in contact shall be cleaned and sanitized as for the procedure for diaper changing tables in STANDARD 3.014, Step 7.; 2) For spills of blood or other potentially infectious body fluids, including injury and tissue discharges, the area shall be cleaned and sanitized. Care shall be taken to avoid splashing any contaminated materials onto any mucus membrane (eyes, nose, mouth); 3) Blood-contaminated material and diapers shall be disposed of in a plastic bag with a secure tie. 4) Floors, rugs and carpeting that have been contaminated by body fluids shall be cleaned by blotting to remove the fluid as quickly as possible, then sanitized by spot-cleaning with a detergent-disinfectant, and shampooing, or steam-cleaning the contaminated surface. 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 (19, 28). 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 (11). Blood and body fluids containing blood (such as watery discharges from injuries) pose the highest potential risk, because bloody body fluids contain the highest concentration of viruses. In addition, hepatitis B virus can survive in 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 with these bloodborne diseases unless they are visibly contaminated with blood, although these fluids do pose a risk with other infectious diseases. 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 (breast milk) can be contaminated with blood from a cracked nipple, the risk of transmission of infection to caregivers who are feeding expressed human milk is very low. Wearing of gloves to feed or clean up spills of expressed human milk is unnecessary, but caregivers with open cuts on their hands should avoid getting expressed human milk on their hands, especially if they have any open skin or sores on their hands. During the preparation of the 2 nd edition of Caring for Our Children, the Steering Committee consulted several experts on the issue of precautions required for handling of human milk. Published policies confirm a clear consensus that gloves are not required for feeding human milk. Although the issue of use of gloves for clean up of human milk spills has not been addressed in previously published policies or in peer-reviewed literature, the Steering Committee could find no persuasive evidence that the risk involved in cleaning up spills is sufficient to require the use of gloves for human milk spills in child care settings. 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). Because many infected people carry communicable 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 carrying out sanitation procedures on a routine basis. Education of the staff regarding cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (19, 28). Prior to using a bleach solution to sanitize, clean any visible soil from the surface with a detergent and rinse well with water. By itself, bleach is not a good cleaning agent. Two minutes of contact with a solution of cup household liquid chlorine bleach in one gallon of tap water prepared fresh daily is an effective method of surface-sanitizing of environmental surfaces and other inanimate objects that have first been thoroughly cleaned of organic soil (19, 20, 34). Domestic bleach is sold in the conventional strength of 5.25% hypochlorite and a more recently marketed "ultra" bleach product that contains 6% hypochlorite solution. The recommended 1:64 dilution of 1/4 cup of domestic bleach to 1 gallon of water (or 1 tablespoon to 1 quart of water) produces a solution that contains 500-800 parts per million of available chlorine. Unpublished tests by Chlorox shows 2 minutes of contact on a visibly clean surface that has been coated with a spray of a 1:64 dilution of household bleach, kills most disease-causing organisms on that surface. Air-drying is fine, since chlorine evaporates when the solution dries. If the surface is to be wiped dry, wait for the 2 minute contact time to elapse first. Industrially prepared detergent-sanitizer solutions or detergent cleaning, rinsing and application of a non-bleach sanitizer is acceptable as long as these products are non-toxic for children and are used according to the manufacturer's instructions. Cleaning and sanitizing 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 sanitizing the surface without damaging it requires use of special cleaning agents designed for use on rugs, or steam cleaning. Requirements of the OSHA for a facility plan and annual training of staff members who may be exposed to blood as a condition of their employment apply to child care workers who are employees. COMMENTS: The Region III office of OSHA developed a model plan for child care facilities. Filling in the blanks in this model plan is easier than starting from scratch to write a conforming plan. The sanctions for failing to comply with OSHA requirements can be costly, both in fines and in health consequences. Child care providers should take the necessary steps to meet OSHA requirements. Regional offices of OSHA are listed with other federal agencies in the telephone directory. Either single-use disposable gloves or utility gloves should be used. 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 bleach solution up to the wrist. The gloves should then be taken off and hung to dry. The utility gloves should be worn, not handled, during this cleaning and sanitizing procedure. Staff who wear gloves must be mindful that the wearing of gloves does not prevent contamination of their hands or of surfaces touched with contaminated gloved hands. Handwashing and sanitizing of contaminated surfaces is still required even when gloves are used. For the proper technique for removing gloves, see Appendix D. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.027 Feeding Of Human Milk To Another Mother's Child If a child has been fed another child's bottle of expressed human milk, this shall be treated as an accidental exposure to a potential HIV-containing body fluid. Providers shall: a) Inform the parents of the child who was given the wrong bottle that: 1) Their child was given another child's bottle of expressed human milk; 2) The risk of transmission of HIV is very small; 3) They should notify the child's physician of the exposure; 4) The child should have a baseline test for HIV and a follow-up test six months later. 5) The mother of the child should have an HIV test immediately and a follow-up test six months later. b) Inform the mother who expressed the human milk of the bottle switch and ask: 1) If she has ever had an HIV test and, if so, if she would be willing to share the results with the parents of the exposed child; 2) If she does not know if she has ever had an HIV test, if she would be willing to contact her obstetrician and find out, and if she has, share the results with the parents; 3) If she has never had an HIV test, if she would be willing to have one immediately and a follow-up test six months later and share results with the parents; 4) If the mother has had a previous test more than six months prior to the incident, if she would be willing to have a test immediately and a follow-up test six months later and share results with the parents; 5) When the human milk was expressed and how it was handled before being brought to the facility. RATIONALE: Baseline HIV testing on all parties concerned is necessary to rule out the current existence of the HIV virus. A repeat test at six months after exposure is necessary to ensure that sero-conversion (a previously negative blood test becomes positive), to the HIV virus has not occurred. The mother of the baby who drank the wrong bottle is asked to be tested at baseline and six months to ensure any potential positive tests are not the result of a mother-child exposure. The mother who's expressed breast milk was fed to the baby is encouraged to have a baseline HIV test and then repeated in six months, as a recent exposure to the HIV virus may not be evident on the baseline test. Instances in which one child is mistakenly fed another child's bottle should be rare if proper procedures are used; more common occurrence is for one child to feed from a bottle that another child has dropped or that was put down. Risk of HIV transmission from expressed human milk that another child has drunk is believed to be low because: In the United States, women who are HIV-positive and aware of that fact are advised not to breastfeed their infants; Compounds present in human milk act, together with time and cold temperatures, to destroy the HIV present in expressed human milk (34, 35). COMMENTS: While the risk of HIV transmission through human milk is low, it is still a concern. There is probably an even greater risk of transmitting hepatitis B, hepatitis C, or CMV (cytomegalovirus). HIV testing may not account for a potential exposure to the virus from the time in between the previous test and the exposure. An infant should be tested up to 9 months after the exposure if the status of the donor mother is unknown. If an infant is exposed to expressed human milk from the wrong mother, that infant should complete the hepatitis B vaccination series, if he/she has not already. For additional information on human milk, see STANDARD 4.017. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 3.3 SANITATION, DISINFECTION, AND MAINTENANCE STANDARD 3.028 Routine Frequency of Cleaning and Sanitation The routine frequency of cleaning and sanitation in the facility shall be as indicated in the table below. This frequency shall be increased from baseline routine frequencies whenever there are outbreaks of illness, there is known contamination, visible soil, or when recommended by the health department to control certain infectious diseases. All surfaces, furnishings, and equipment that are not in good repair or that have been contaminated by body fluids shall be taken out of service until they are repaired, cleaned, and, if contaminated, sanitized effectively. RATIONALE: Since children will touch any surface they can reach (including floors), all surfaces in a child care facility may be contaminated and can spread infectious disease agents. Therefore, all surfaces must be properly sanitized. 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) that contaminate environmental surfaces remain infectious for variable periods of time, and infection has been acquired by touching articles and surfaces contaminated with infectious respiratory secretions (33). Regular and thorough cleaning of rooms prevents the transmission of diseases (17). Many communicable diseases can be prevented through appropriate hygiene and sanitation procedures. Bacterial cultures of environmental surfaces in child care facilities have shown fecal contamination, which has been used to gauge the adequacy of facilities' sanitation and hygiene measures. Therefore, a reasonable effort should be made to clean respiratory secretions from environmental surfaces. However, to continuously maintain tabletops and toys free of contamination from respiratory tract secretions is an unrealistic goal. Meals and snacks are often served on the same tables used for play. Children frequently remove food from their plates and eat directly from the surface of the table. This behavior should be discouraged, and cleaning and sanitizing prior to eating may reduce the risk of transmitting disease. Mops should be assumed to be contaminated since they are used to remove contamination from other surfaces. COMMENTS: Levels of fecal coliforms in the environment have been shown to increase during outbreaks of diarrheal illnesses. Increasing the frequency of cleaning and sanitizing may reduce environmental contamination. Doubling the frequency is somewhat arbitrary, and health officials may recommend a more frequent cleaning schedule in certain areas, depending on the nature of the problem.Head gear can be placed in the dryer. Another way to prevent transmission of lice nits is to have children wear disposable shower caps before playing with hats. See Pediculosis capitis (head lice), STANDARD 6.038. The bleach solution used for sanitizing the child care environment is also appropriate for sanitizing mops and rags. Detachable mop heads and reusable rags may be cleaned in a washing machine and dried in a mechanical dryer or hung to dry. Compliance with these procedures is measured by staff interviews and by observation of practices when contamination occurs. See also STANDARD 3.026, for information regarding exposure to blood and bodily fluids. For more information on frequency of cleaning and sanitizing, see page 106 for a frequency chart adapted from Keeping Healthy, 1999 from the National Association for the Education of Young Children. Contact information is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home SANITATION, DISINFECTION, AND MAINTENANCE OF TOILET LEARNING/TRAINING EQUIPMENT, TOILETS, AND BATHROOMS STANDARD 3.029 Potty Chairs Use of potty chairs shall be discouraged. If potty chairs are used, they shall be emptied into a toilet, cleaned in a utility sink, sanitized after each use, and stored in the bathroom. After the potty is sanitized, the utility sink shall also be sanitized. RATIONALE: Sanitary handling of potty chairs is difficult and, therefore, their use in child care facilities is not recommended. Potty chairs should not be washed in a sink used for washing hands. COMMENTS: If potty chairs are used, they should be constructed of plastic or similar nonporous synthetic products. Wooden potty chairs should not be used, even if the surface is coated with a finish. The finished surface of wooden potty chairs is not durable and, therefore, may become difficult to wash and sanitize effectively. For more information on potty chairs, see STANDARD 5.124. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.030 Equipment Used for Cleaning and Sanitizing Utility gloves and equipment designated for cleaning and sanitizing toilet learning/training equipment and flush toilets shall be used for each cleaning and shall not be used for other cleaning purposes. Utility gloves shall be washed with soapy water and dried after each use. RATIONALE: Contamination of hands and equipment in a child care room has played a role in the transmission of disease (17). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home AREA CLEAN SANITIZE FREQUENCY Classrooms/Child Care/Food Areas Countertops/tabletops, Floors, Door and cabinet handles X X Daily and when soiled. Food preparation & service surfaces X X Before and after contact with food activity; between preparation of raw and cooked foods. Carpets and large area rugs X . Vacuum daily when children are not present. Clean with a carpet cleaning method approved by the local health authority. Clean carpets only when children will not be present until the carpet is dry. Clean carpets at least monthly in infant areas, at least every 3 months in other areas and when soiled. Small rugs X . Shake outdoors or vacuum daily. Launder weekly. Utensils, surfaces and toys that go into the mouth or have been in contact with saliva or other body fluids X X After each child's use, or use disposable, one-time utensils or toys. Toys that are not contaminated with body fluids. Dress-up clothes not worn on the head. Sheets and pillowcases, individual cloth towels (if used), combs and hairbrushes, wash cloth and machine-washable cloth toys. (None of these items should be shared among children.) X . Weekly and when visibly soiled. Blankets, sleeping bags, Cubbies X . Monthly and when soiled. Hats X . After each child's use or use disposable hats that only one child wears. Cribs and crib mattresses X . Weekly, before use by a different child, and whenever soiled or wet. Phone receivers X X Weekly. Toilet and Diapering Areas . . . Handwashing sinks, faucets, surrounding counters, soap dispensers, door knobs X X Daily and when soiled. Toilet seats, toilet handles, door knobs or cubicle handles, floors X X Daily, or immediately if visibly soiled. Toilet bowls X X Daily. Changing tables, potty chairs (Use of potty chairs in child care is discouraged because of high risk of contamination). X X After each child's use. General Facility . . . Mops and cleaning rags X X Before and after a day of use, wash mops and rags in detergent and water, rinse in water, immerse in sanitizing solution, and wring as dry as possible. After cleaning and sanitizing, hang mops and rags to dry. Waste and diaper containers X . Daily. Any surface contaminated with body fluids: saliva, mucus, vomit, urine, stool, or blood X X Immediately, as specified in STANDARD 3.026. Adapted from Keeping Healthy, National Association for the Education of Young Children. 1999. STANDARD 3.031 Rags and Disposable Towels Used for Cleaning Disposable towels shall be preferred for cleaning. If clean reusable rags are used, they shall be laundered separately between uses for cleaning. Disposable towels shall be sealed in a plastic bag and removed to outside garbage. Cloth rags shall be placed in a closed, foot-operated receptacle until laundering. RATIONALE: Materials used for cleaning become contaminated in the process and must be handled so they do not spread potentially infectious material. COMMENTS: Sponges generally are contaminated with bacteria and are difficult to clean. Therefore, use of sponges in child care facilities for cleaning purposes is not recommended. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.032 Odors Odors in toilets, bathrooms, diaper changing and other inhabited areas of the facility shall be controlled by ventilation and sanitation. Toilets and bathrooms, janitorial closets, and rooms with utility sinks or where wet mops and chemicals are stored shall be mechanically ventilated to the outdoors with local exhaust mechanical ventilation to control and remove odors. Chemical air fresheners shall not be used. RATIONALE: Chemical air fresheners may cause nausea or an allergic response in some children. Ventilation and sanitation help control and prevent the spread of disease and contamination. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.033 Waste Receptacles Waste receptacles in toilet rooms shall be kept clean and in good repair, and emptied daily. RATIONALE: This practice prevents the spread of disease and filth. COMMENTS: For additional information on sanitation and maintenance of toilet learning/training equipment, toilets, and bathrooms, see also Toilets and Toilet Training Equipment, STANDARD 5.116 through STANDARD 5.125; and for Diaper Changing Areas, see STANDARD 5.132. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home SELECTION AND MAINTENANCE OF SURFACES STANDARD 3.034 Selection of Surfaces and Materials Walls, ceilings, floors, furnishings, equipment, and other surfaces shall be suitable to the location and the users. They shall be maintained in good repair, free from visible soil and in a clean condition. Carpets, porous fabrics, and other surfaces that trap soil and potentially contaminated materials shall not be used in toilet rooms, diaper change areas, and areas where food handling occurs. Areas used by staff or children who have allergies to dust mites or components of furnishings or supplies shall be maintained according to the recommendations of health professionals. RATIONALE: Carpets and porous fabrics are not appropriate for some areas because they are difficult to clean and sanitize. Disease-causing microorganisms have been isolated from carpets. Caregivers must remove illness-causing materials. Many allergic children have allergies to dust mites, which are microscopic insects that ingest the tiny particles of skin that people shed normally every day. Dust mites live in carpeting and fabric but can be killed by frequent washing and use of a mechanical, heated dryer. Restricting the use of carpeting and furnishings to types that can be laundered regularly helps. Other children may have allergies to animal products such as those with feathers, fur, or wool. Some may be allergic to latex. COMMENTS: One way to measure compliance with the standard for cleanliness is to wipe the surface with a clean mop or clean rag, and then insert the mop or rag in cold rinse water. If the surface is clean, no residue will appear in the rinse water. Disposable gloves are commonly made of latex or vinyl. If latex-sensitive individuals are present in the facility, only vinyl disposable gloves should be used. Other common supplies that contain latex, such as rubber bands, should also be removed from the environment. As long as their feet are clean, children and adults may be barefoot in the play area. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.035 Shoes in Infant Play Areas Before walking on surfaces that infants use specifically for play, adults and children shall remove or cover shoes they have worn outside the play area used by that group of infants. These individuals may wear shoes and shoe covers that are used only in the play area for that group of infants. RATIONALE: When infants play, they touch the surfaces on which they play with their hands, then put their hands in their mouths. Shoes may be conduits of infectious material when people walk on surfaces that are contaminated with disease-causing organisms, then walk in the infant play area. COMMENTS: Facilities can meet this standard in several ways. The facility can designate contained play surfaces for infant play on which no one walks with shoes. Individuals can wear shoes or slippers that are worn only to walk in the infant play area or they can wear clean cloth or disposable shoe covers over shoes that have been used to walk outside the infant play area. This standard applies to shoes that have been worn in toilet and diaper changing areas, in the play areas of other groups of children, as well as outdoors. All of these locations are potential sources of contamination for the area where infants are crawling and playing. TYPE OF FACILITY: Center; Large Family Child Care Home SELECTION, SANITATION, DISINFECTION, AND MAINTENANCE OF TOYS AND OBJECTS STANDARD 3.036 use of toys that can be washed and sanitized Toys that cannot be washed and sanitized shall not be used. Toys that children have placed in their mouths or that are otherwise contaminated by body secretion or excretion shall be set aside where children cannot access them. They must be set aside until they are washed with water and detergent, rinsed, sanitized, and air-dried by hand or in a mechanical dishwasher that meets the requirements of STANDARD 4.063 through STANDARD 4.065. Play with plastic or play foods shall be closely supervised to prevent shared mouthing of these toys. Machine washable cloth toys shall be for use by one individual only until these toys are laundered. Indoor toys shall not be shared between groups of infants or toddlers unless they are washed and sanitized before being moved from one group to the other. RATIONALE: Contamination of hands, toys and other objects in child care areas has played a role in the transmission of diseases in child care settings (17). All toys can spread disease when children put the toys in their mouths, touch the toys after putting their hands in their mouths during play or eating, or after toileting with inadequate handwashing. Using a mechanical dishwasher is an acceptable labor-saving approach for plastic toys as long as the dishwasher can wash and sanitize the surfaces. COMMENTS: Small toys with hard surfaces can be set aside for cleaning by putting them into a dish pan labeled "soiled toys." This dish pan can contain soapy water to begin removal of soil, or it can be a dry container used to bring the soiled toys to a toy cleaning area later in the day. Having enough toys to rotate through cleaning makes this method of deferred cleaning possible. See STANDARD 3.028, for frequency of routine cleaning and sanitizing. For more information regarding appropriate play materials for young children, see STANDARD 2.012. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.037 Objects Intended For the Mouth Thermometers, pacifiers, teething toys, and similar objects shall be cleaned and reusable parts shall be sanitized between uses. Pacifiers shall not be shared. RATIONALE: Contamination of hands, toys and other objects in child care areas has played a role in the transmission of diseases in child care settings (17). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.038 Routine Checks of Play Equipment A staff member shall be assigned to check all play equipment at least monthly to ensure that it is safe for children. In addition, the staff shall observe equipment while children are playing on it to ensure that it is safe for children. RATIONALE: A monthly safety check of all the equipment in the facility as a focused task provides an opportunity to notice wear and tear that requires maintenance. Observations should be made while the children are playing, too, to spot any maintenance problems and correct them as soon as possible. COMMENTS: Site safety checklists have been developed for this type of periodic audit. The following is an example of an adaptation of such a checklist (71): Toys and play equipment have no sharp edges or points, small parts, pinch points, chipped paint, splinters, or loose nuts or bolts. All painted toys are free of lead. Toys are put away when not in use. Toys that are mouthed are washed and sanitized after each use. Children are not permitted to play with any type of plastic bag, latex balloon or latex/vinyl gloves. Children under 4 years of age are not permitted to have band aids that they can detach and thereby create a potential choking hazard. Gauze and tape should be used for bandaging instead. Unlike band aids, gauze and porous tape rarely form complete airway plugs. Toys are too large to fit completely into a child's mouth and have no small, detachable parts to cause choking. No coins, safety pins, or marbles for children under 4 years of age. Infants and toddlers are not permitted to eat small objects and foods that may easily cause choking, such as hot dogs, hard candy, seeds, nuts, popcorn, and uncut round foods such as whole grapes and olives. Toy chests have air holes and a lid support or have no lid. A lid that slams shut can cause pinching, head injuries, or suffocation. Shooting or projectile toys are not present. Commercial art materials are stored in their original containers out of children's reach. The manufacturer's label includes a reference to meeting ASTM Standards. Rugs, curtains, pillows, blankets, and cloth toys are flame-resistant. Sleeping surfaces are firm. Waterbeds and soft bedding materials such as sheepskin, quilts, comforters, pillows, and granular materials (plastic foam beds or pellets) used in beanbags are not accessible to infants. Hinges and joints are covered to prevent small fingers from being pinched or caught. Protrusions such as nails or bolts are not present. Cribs, playpens, and highchairs are away from drapery cords and electrical cords. Cribs, playpens, and highchairs are used properly and according to the manufacturer's recommendations for age and weight. Cribs have no corner posts. Cribs have slats placed 2-3/8 inches apart or less and have snug-fitting mattresses. Mattresses are set at their lowest settings and sides are locked at their highest settings. Toys are not hung across the cribs of infants who can sit up. Rattles, pacifiers, or other objects are never hung around an infant's neck. Five-gallon buckets are not accessible to infants and toddlers (See STANDARD 3.045). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home SELECTION, SANITATION, DISINFECTION, AND MAINTENANCE OF BEDDING STANDARD 3.039 Individual Bedding Bedding (sheets, pillows, blankets, sleeping bags) shall be of a type that can be washed. Each child's bedding shall be kept separate from other children's bedding, on the bed or stored in individually labeled bins, cubbies, or bags. Bedding shall be cleaned according to STANDARD 3.028. RATIONALE: Lice infestation, scabies, and ringworm are among the most common infectious diseases in child care. Toddlers often nap or sleep on mats or cots and the mats or cots are taken out of storage during nap time, then placed back in storage. Lice, infestations, scabies, ringworm and other diseases can be spread if bedding material that various children use are stored together. Providing bedding for each child and storing each set in individually labeled bins, cubbies, or bags in a manner that separates the personal articles of one individual from those of another will prevent the spread of disease. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.040 Crib Surfaces Cribs and crib mattresses shall have a nonporous, easy-to-wipe surface. All surfaces shall be cleaned as specified in STANDARD 3.028. RATIONALE: Contamination of hands, toys and other objects in child care areas has played a role in the transmission of diseases in child care settings (17). COMMENTS: For additional information on sanitation, disinfection, and maintenance of bedding, see also Laundry, STANDARD 5.140 and STANDARD 5.141. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home 3.4 HEALTH PROTECTION IN CHILD CARE STANDARD 3.041 Tobacco Use and Prohibited Substances Tobacco use, alcohol, and illegal drugs shall be prohibited on the premises of the facility at all times. 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 developing bronchitis, pneumonia, and middle ear infections when they experience common respiratory infections (36-39). Separation of smokers and nonsmokers within the same air space does not eliminate or minimize exposure of nonsmokers to secondhand smoke. Cigarettes used by adults are the leading cause of ignition of fatal house fires (40-42). COMMENTS: The age, defenselessness, and lack of discretion of the children under care make this prohibition an absolute requirement. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home ANIMALS STANDARD 3.042 Pets That Might Have Contact with Children Any pet or animal present at the facility, indoors or outdoors, shall be in good health, show no evidence of carrying any disease, be fully immunized, and be maintained on a flea, tick, and worm control program. A current (time-specified) certificate from a veterinarian shall be on file in the facility, stating that the specific pet meets these conditions. All contact between animals and children shall be supervised by a caregiver who is close enough to remove the child immediately if the animal shows signs of distress or the child shows signs of treating the animal inappropriately. The caregiver shall instruct children on safe procedures to follow when in close proximity to these animals (for example, not to provoke or startle animals or touch them when they are near their food). Potentially aggressive animals (such as pit bulls) shall not be in the same physical space with the children. RATIONALE: The risk of injury, infection, and aggravation of allergy from contact between children and animals is significant. The staff must plan carefully when having an animal in the facility and when visiting a zoo or local pet store. Children should be brought into direct contact only with animals known to be friendly and comfortable in the company of children. Dog bites to children under 4 years of age usually occur at home, and the most common injury sites are the head, face, and neck. Dog bites cause an estimated 600,000 injuries and 10-20 deaths a year (45). Many human illnesses can be acquired from pets (43, 52-53). Many allergic children have symptoms when they are around animals. About 6% of the U.S. population is allergic to animals, and 25% of people being treated for allergies are sensitive to dogs and cats (47). COMMENTS: Bringing animals and children together has both risks and benefits. Pets teach children about how to be gentle and responsible, about life and death, and about unconditional love. Nevertheless, animals can pose serious health risks. Facilities must be sure an animal is healthy and a suitable pet to bring into contact with children, as determined by a recent check-up by a veterinarian. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.043 Prohibited Pets The facility shall not keep or bring in ferrets, turtles, iguanas, lizards or other reptiles, psittacine birds (birds of the parrot family), or any wild or dangerous animals. The facility may consider an exception for reptiles if: a) The animals are kept behind a glass wall in a tank or container where a child cannot touch the animals or the inside of the tank; b) The health department grants authority for possession of such animals. RATIONALE: Animals, including pets, are a source of illness for people, and people may be a source of illness for animals (27, 45). Reptiles may carry salmonella and pose a risk to children who are likely to put unwashed hands in their mouths. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.044 Care For Pets The facility shall care for all pets as recommended by the health department. When pets are kept on the premises, the facility shall write and adhere to procedures for their care and maintenance. Proof of current compliance with required pet immunizations shall be signed by a veterinarian and shall be kept on file at the facility. When animals are kept in the child care facility, the following conditions shall be met: a) The living quarters of animals shall be enclosed and kept clean of waste to reduce the risk of human contact with this waste; b) Animal cages shall be of an approved type with removable bottoms and shall be kept clean and sanitary; c) Animal litter boxes shall not be located in areas accessible to children; d) All animal litter shall be removed immediately from children's areas and discarded as required by local health authorities; e) Animal food supplies shall be kept out of reach of children; f) Live animals and fowl shall be prohibited from food preparation, food storage, and eating areas; g) Caregivers and children shall wash their hands after handling animals, animal food, or animal wastes, as specified in Handwashing, STANDARD 3.021 through STANDARD 3.024. RATIONALE: Animals, including pets, are a source of illness for people; likewise, people may be a source of illness for animals (27, 45). Handwashing is the most important way to reduce the spread of infection. Unwashed or improperly washed hands are primary carriers of infections. Just as food intended for human consumption may become contaminated, a pet's food can become contaminated by standing at room temperature, or by being exposed to animals, insects, or people. TYPE OF FACILITY : Center; Large Family Child Care Home; Small Family Child Care Home WATER SAFETY STANDARD 3.045 Supervision Near Bodies of Water Children shall not be permitted to play without constant supervision in areas where there is any body of water, including swimming pools, built-in wading pools, tubs, pails, sinks, or toilets, ponds and irrigation ditches. Children who need assistance with toileting shall not be allowed in toilet or bathroom facilities without direct visual supervision. Children less than 5 years of age shall not be left unattended in a bathtub or shower. RATIONALE: Small children can drown within 30 seconds, in as little as 2 inches of liquid (44). In a comprehensive study of drowning and submersion incidents involving children under 5 years of age in Arizona, California, and Florida, the U.S. Consumer Product Safety Commission found that: Submersion incidents involving children usually happen in familiar surroundings; Pool submersions involving children happen quickly. Seventy-seven percent of the victims had been missing from sight for 5 minutes or less; Child drowning is a silent death. Splashing may not occur to alert someone that the child is in trouble. Each year, approximately 1,500 children under age 20 drown. A national study that examines where drowning most commonly take 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). Researchers from the National Institute of Child Health and Human Development, Johns Hopkins University School of Public Health, the U.S. Consumer Product Safety Commission and the Maternal and Child Health Bureau reviewed more that 1,400 death certificates from 1995. All of the death certificates were for children under 20 years of age who drowned. While swimming pools pose the greatest risk for toddlers, about one-quarter of drowning among toddlers are in other freshwater sites, such as ponds or lakes. Researchers found that after the age of 10, the risk of drowning in a swimming pool was up to 15 times greater among black males as compared with white males. The reason for this increased risk is unknown. One explanation offered by the study's authors was that the public pools in which black teens swim might be less safe, with fewer lifeguards and more crowded conditions. Or the increased risk could be attributed to a difference in swimming ability, resulting from fewer opportunities for black males to participate in swimming lessons. The study authors conclude that there is a need for multifaceted approach to drowning prevention. The American Academy of Pediatrics recommends: Swimming lessons for all children over the age of 5; Constant supervision of infants and young children when they are in the bathtub or around other bodies of water; Installation of fencing that separates homes from residential pools; Use of personal flotation devices when riding on a boat or playing near a river, lake or ocean; Teaching children never to swim alone or without adult supervision; Teaching children the dangers of drug and alcohol consumption during aquatic activities; Stressing the need for parents and teens to learn cardiopulmonary resuscitation (74). Deaths and nonfatal injuries have been associated with baby bathtub "supporting ring" devices that are supposed to keep a baby 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 baby to tip over. A baby also may slip between the legs of the bath ring and become trapped under it. Caregivers must not rely on these devices to keep a baby safe in the bath and must never leave a baby alone in these bath support rings (50, 56). An estimated 50 infants and toddlers drown each year in buckets containing liquid used for mopping floors and other household chores. Of all buckets, the 5-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 5-gallon bucket head first (48). 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 (49). COMMENTS: 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 mental retardation. See STANDARD 1.005, for information regarding supervision and child:staff ratios during wading and swimming activities. See also Safety Rules for Swimming/Wading Pools, STANDARD 5.215. For fencing water hazards, see STANDARD 5.198. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.046 Behavior Around a Pool Caregivers shall prohibit dangerous behavior in or around the pool. Children shall not be permitted to push each other, hold each other under water, or run at poolside. Children shall be instructed to call for help only in a genuine emergency. RATIONALE: Such behavior is dangerous and will distract caregivers from supervising other children, thereby placing the other children at risk. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.047 Pool Toys Tricycles, wagons, and other non-water toys shall not be permitted on the pool deck. Use of flotation devices shall be prohibited. RATIONALE: Playing with non-water toys, such as tricycles or wagons, on the pool deck may result in unintentional falls into the water. Reliance on flotation devices may give children false confidence in their ability to protect themselves in deep water. Flotation devices also may promote complacency in caregivers who believe the child is safe. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home EMERGENCY PROCEDURES STANDARD 3.048 Emergency Procedures When an immediate response is required, the following emergency procedures shall be utilized: a) First aid shall be employed, and the emergency medical response team shall be called, as indicated; b) The facility shall implement a plan for emergency transportation to a local hospital or health care facility; c) The parent or parent's emergency contact person shall be called as soon as practical; d) A staff member shall accompany the child to the hospital and will stay with the child until the parent or emergency contact person arrives. RATIONALE: The staff must know the plan for dealing with emergency situations when a child requires immediate care and a parent is not available. COMMENTS: First aid instructions are provided by the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.049 Written Plan For Medical Emergency Facilities shall have a written plan for immediate management and rapid access to medical care as appropriate to the situation. This plan shall: a) Describe for each child any special emergency procedures that will be used, if required, by the caregiver or by a physician or registered nurse available to the caregiver; b) Note any special medical procedures, if required by the child's condition, that will be used or might be required for the child while he/she is in the facility's care, including the possibility of a need for cardiac resuscitation; c) Include in a separate format, any information to be given to an emergency responder in the event that one must be called to the facility for the child. This information shall include: 1) Any special information needed by the emergency responder to respond appropriately to the child's condition; 2) A listing of the child's health care providers in the event of an emergency. RATIONALE: The medical aspect of caring for children is likely to be the facet of care that caregivers are most poorly equipped to carry out, as their training is usually in early childhood education. The preparation of a written plan (a brief one would suffice) provides and opportunity for caregivers to work out how to deal with routine, urgent, and emergency medical needs. Children with special needs may need an emergency responder whether it is for an asthma emergency, a cardiac emergency, or any of a number of conditions that put children at risk for emergency response and transport. An individual child's written plan for the first responders will save time and may be critical in the provision of appropriate care of a child in crisis. COMMENTS: Training and other technical assistance for developing emergency plans can be obtained from the following: American Academy of Pediatrics (AAP); American Nurses' Association (ANA); State and community nursing associations; National therapy associations; Local resource and referral agencies; Federally funded, University Centers for Excellence in Developmental Disabilities Education, Research, and Service, programs for individuals with developmental disabilities; Other colleges and universities with expertise in training others to work with children who have special needs; Community-based organizations serving people with disabilities (Easter Seals, American Diabetes Association, American Lung Association, etc.). Community sources of training in infant/child CPR (American Heart Association, American Red Cross, Emergency Medical Services for Children National Resource Center). The State-designated lead agency responsible for implementing IDEA may provide additional help. For additional information regarding emergency plans, see STANDARD 8.022 and STANDARD 8.023. For additional discussion about first aid and CPR, see STANDARD 1.026. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.050 Syrup of Ipecac Syrup of ipecac shall be available for administration as a vomiting agent, but shall be used only under the direction of the poison control center, a physician, or a nurse practitioner. RATIONALE: An emetic (vomiting agent), such as syrup of ipecac, limits the absorption of certain toxins. Emetics, however, should not be used without the direction of a physician or a poison control center, because certain toxic substances (petroleum distillates, for example) can damage breathing passages when vomited and aspirated (55). TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.051 Use of Fire Extinguishers The staff shall demonstrate the ability to locate and operate the Fire extinguishers. RATIONALE: A fire extinguisher may be used to put out a small fire or to clear an escape path. (57). COMMENTS: Staff should be trained that the first priority is to remove the children from the facility safely and quickly. Fighting a fire is secondary to the safe exit of the children and staff. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.052 Response to Fire and Burns Children shall be instructed to STOP, DROP, and ROLL when garments catch fire. Children shall be instructed to crawl on the floor under the smoke. Cool water shall be applied to burns immediately. The injury shall be covered with a loose bandage or clean cloth. 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 (57). COMMENTS: For additional information on emergency procedures, see Emergency Plan, STANDARD 8.022 and STANDARD 8.023; and Evacuation Plan and Drills, STANDARD 8.024 through STANDARD 8.027. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home CHILD ABUSE AND NEGLECT STANDARD 3.053 Reporting Suspected Child Abuse, Neglect, Exploitation The facility shall report to the 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, neglect, or exploitation may have occurred. RATIONALE: All states in the United States 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. Failure to report abuse is a crime in all states and may lead to legal penalties. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.054 Consultants on Child Abuse and Neglect Caregivers and health professionals shall establish linkages with physicians, child psychiatrists, nurses, nurse practitioners, physician's assistants, and child protective services who are knowledgeable about child abuse and neglect and are willing to provide them with consultation about suspicious injuries or other circumstances that may indicate abuse or neglect. The names of these consultants shall be available for inspection. Child care workers are mandated to report suspected child abuse and neglect. RATIONALE: Many mistakes in reporting can be avoided by working with an experienced consultant before a decision is made about what to do. When the child care worker's level of suspicion is high, a consultation with an outside expert may not be needed, and could delay the initiation of an effective investigation and adequate protection of the child. COMMENTS: Many health departments will be willing to provide this service. The American Academy of Pediatrics (AAP) can also assist in recruiting and identifying physicians who are skilled in this work. Contact information for the AAP is located in Appendix BB. See also Health Consultation, STANDARD 8.020; and Health Consultants, STANDARD 1.040 through STANDARD 1.044. TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.055 Immunity of Reporters of Child Abuse From Sanction Caregivers who report abuse in the settings where they work shall be immune from discharge, retaliation, or other disciplinary action for that reason alone, unless it is proven that the report was malicious. RATIONALE: Reports of child abuse in child care settings are made infrequently by workers. Reported cases suggest that sometimes workers are intimidated by superiors in the centers where they work, and for that reason, fail to report abuse (58). TYPE OF FACILITY: Center STANDARD 3.056 Instruction and Forms for Staff To Recognize and Report Child Abuse Caregivers shall know methods for reducing the risks of child abuse and neglect. They shall know how to recognize common symptoms and signs of child abuse and neglect. Employees and volunteers in centers shall receive an instruction sheet about child abuse reporting that contains a summary of the state child abuse reporting statute and a statement that they will not be discharged solely because they have made a child abuse report. Some states have specific forms that are required to be completed when abuse is reported or which, though not required, assist mandated reporters in documenting accurate and thorough reports. In those states, facilities shall have such forms on hand and all staff shall be trained in the appropriate use of those forms. RATIONALE: While caregivers are not expected to be able to definitively diagnose or investigate child abuse, it is important that they be aware of common signs and symptoms of child maltreatment, such as extensive, unexplained bruises and recurrent serious injuries. Reports of child abuse in child care settings are made infrequently by workers. Reported cases suggest that sometimes workers are intimidated by superiors in the centers where they work, and for that reason, fail to report abuse (58). COMMENTS: For information on common factors that lead to abuse, see Appendix K, Clues to Child Abuse and Neglect , and Appendix L, Risk Factors for Abuse and/or Neglect . TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home STANDARD 3.057 Care for Children Who Have Been Abused Child care providers in facilities where children with behavioral abnormalities related to abuse or neglect are enrolled, shall have access to specialized training and expert advice. The capacity of the child care setting to meet the needs of an abused child shall be assessed, with consultation from experts in the area. RATIONALE: Abused children are likely to be more needy and to require more individual staff time and attention than children who are not abused. COMMENTS: A quantitative standard for this case is difficult to establish at present. Centers serving children with a history of abuse-related behavior problems may require more staff.