Chapter03

CHAPTER 3:
Health Promotion and Protection

3.1 Health Promotion in Child Care

3.1.1 Daily Health Check

STANDARD 3.1.1.1: Conduct of Daily Health Check

Every day, a trained staff member should conduct a health check of each child. This health check should be conducted as soon as possible after the child enters the child care facility and whenever a change in the child’s behavior or appearance is noted while that child is in care. The health check should address:

Reported or observed illness or injury affecting the child or family members since the last date of attendance;
Reported or observed changes in behavior of the child (such as lethargy or irritability) or in the appearance (e.g., sad) of the child from the previous day at home or the previous day’s attendance at child care;
Skin rashes, impetigo, itching or scratching of the skin, itching or scratching of the scalp, or the presence of one or more live crawling lice;
A temperature check if the child appears ill (a daily screening temperature check is not recommended);
Other signs or symptoms of illness and injury (such as drainage from eyes, vomiting, diarrhea, cuts/lacerations, pain, or feeling ill).

The caregiver/teacher should gain information necessary to complete the daily health check by direct observation of the child, by querying the parent/guardian, and, where applicable, by conversation with the child.

RATIONALE: Daily health checks seek to identify potential concerns about a child’s health including recent illness or injury in the child and the family. Health checks may serve to reduce the transmission of infectious diseases in child care settings by identifying children who should be excluded, and enable the caregivers/teachers to plan for necessary care while the child is in care at the facility.

COMMENTS: The daily health check 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 child care health consultant should train the caregiver/teacher(s) in conducting a health check. The items in the standard can serve as a checklist to guide learning the procedure until it becomes routine.

The obtaining of information from the parent/guardian should take place at the time of transfer of care from the parent/guardian to the staff of the child care facility. If this exchange of information happens outside the facility (e.g., when the child is put on a bus), the facility should use an alternative means to accurately convey important information. Handwritten notes, electronic communications, health checklists, and/or daily logs are examples of how parents/guardians and staff can exchange information when face-to-face is not possible.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

STANDARD 3.1.1.2: Documentation of the Daily Health Check

The caregiver/teacher should conduct and document a daily health check of each child upon arrival. The daily health check documentation should be kept for one month.

RATIONALE: The vast majority of infectious diseases of concern in child care have incubation periods of less than twenty-one days (1). This information may be helpful to public health authorities investigating occasional outbreaks.

COMMENTS: The documentation should note that the daily health check was done and any deviation from the usual status of the child and family.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. California Childcare Health Program. CCHP health and safety checklist. Rev. ed. http://www.ucsfchildcarehealth.org/html/pandr/formsmain.htm#hscr/.

3.1.2 Routine Health Supervision

STANDARD 3.1.2.1: Routine Health Supervision and Growth Monitoring

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Paige, D. M. 1988. Clinical nutrition. 2nd ed. St. Louis: Mosby.

2. Kleinman, R. E. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

4. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health.

5. Centers for Disease Control and Prevention. 2011. About BMI for children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.

3.1.3 Physical Activity and Limiting Screen Time

STANDARD 3.1.3.1: Active Opportunities for Physical Activity

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

COMMENTS: There are many ways to promote tummy time with infants:

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

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

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

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

The National Association for Sport and Physical Education’s Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5, 2nd Edition at http://www.aahperd.org/naspe/standards/
nationalGuidelines/ActiveStart.cfm and Physical Activity for Children: A Statement of Guidelines for Children 5 - 12, 2nd Edition at http://www.aahperd
.org/naspe/standards/nationalGuidelines/PA
-Children-5-12.cfm;
U.S. Department of Health and Human Services’ 2008 Physical Activity Guidelines for Americans at http://www.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf;
U.S. Department of Health and Human Services and the U.S. Department of Agriculture’s Dietary Guidelines for Americans, 2010 at http://www.cnpp.usda
.gov/DGAs2010-DGACReport.htm.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Brown, W. H., K. A. Pfeiffer, K. L. Mclver, M. Dowda, C. L. Addy, R. R. Pate. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Devel 80:45-58.

2. Burdette, H. L., R. C. Whitaker. 2005. Resurrecting free play in young children: Looking beyond fitness and fatness to attention, affiliation, and affect. Arch Pediatr Adolesc Med 159:46-50.

3. Burdette, H. L., R. C. Whitaker, S. R. Daniels. 2004. Parental report of outdoor playtime as a measure of physical activity in preschool-aged children. Arch Pediatr Adolesc Med 158:353-57.

4. Bower, J. K., D. P. Hales, D. F. Tate, D. A. Rubin, S. E. Benjamin, D. S. Ward. 2008. The childcare environment and children’s physical activity. Am J Prev Med 34:23-29.

5. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. The nutrition and physical activity self-assessment for child care (NAP SACC). Rev ed. Raleigh and Chapel Hill, NC: UNC Center for Health Promotion and Disease Prevention, Center of Excellence for Training and Research Translation. http://www.center-trt.org/downloads/obesity_prevention/interventions/napsacc/NAPSACC_Template.pdf.

6. National Association for Sport and Physical Education (NASPE). 2002. Active start: A statement of physical activity guidelines for children birth to five years. Washington, DC: NASPE.

7. Patrick, K., B. Spear, K. Holt, D. Sofka, eds. 2001. Bright futures in practice: Physical activity. Arlington, VA: National Center for Education in Maternal and Child Health. http://www.brightfutures
.org/physicalactivity/pdf/index.html.

8. Pellegrini, A., C. Bohn. 2005. The role of recess in children’s cognitive performance and school adjustment. Educ Res 34:13-19.

9. Mahar, M. T., S. K. Murphy, D. A. Rowe, J. Golden, A. T. Shields, T. D. Raedeke. 2006. Effects of a classroom-based program on physical activity and on-task behavior. Med Sci Sports Exerc 38:2086-94.

10. Pate, R. R., K. A. Pfeiffer, S. G. Trost, P. Ziegler, M. Dowda. 2004. Physical activity among children attending preschools. Pediatrics 114:1258-63.

11. Pate, R. R., K. McIver, M. Dowda, W. H. Brown, A. Cheryl. 2008. Directly observed physical activity levels in preschool children. J Sch Health 78:438-44.

12. McKenzie, T. L., J. F. Sallis, J. P. Elder, C. C. Berry, P. L. Hoy, P. R. Nader, M. M. Zive, S. L. Broyles. 1997. Physical activity levels and prompts in young children at recess: A two-year study of a bi-ethnic sample. Res Q Exerc Sport 68:195-202.

13. McKenzie, T. L., J. F. Sallis, P. R. Nader, S. L. Broyles, J. A. Nelson. 1992. Anglo- and Mexican-American preschoolers at home and at recess: Activity patterns and environmental influences. J Dev Behav Pediatr 13:173-80.

14. Sallis, J. F., T. L. McKenzie, J. P. Elder, S. L. Broyles, P. R. Nader. 1997. Factors parents use in selecting play spaces for young children. Arch Pediatr Adolesc Med 151:414-17.

15. Sallis, J. F., P. R. Nader, S. L. Broyles, J. P. Elder, T. L. McKenzie, J. A. Nelson. 1993. Correlates of physical activity at home in Mexican-American and Anglo-American preschool children. Health Psychol 12:390-98.

16. Davis, K., K. K. Christoffel. 1994. Obesity in preschool and school-age children: Treatment early and often may be best. Arch Pediatr Adolesc Med 148:1257-61.

17. Sallis, J. F., C. C. Berry, S. L. Broyles, T. L. McKenzie, P. R. Nader. 1995. Variability and tracking of physical activity over 2 yr in young children. Med Sci Sports Exerc 27:1042-49.

18. Pate, R. R., T. Baranowski, S. G. Trost. 1996. Tracking of physical activity in young children. Med Sci Sports Exerc 28:92-96.

19. Birch, L. L., J. O. Fisher. 1998. Development of eating behaviors among children and adolescents. Pediatrics 101:539-49.

20. Sallis, J. F., J. J. Prochaska, W. C. Taylor. 2000. A review of correlates of physical activity of children and adolescents. Med Sci Sports Exerc 32:963-75.

21. Skinner, J. D., B. R. Carruth, W. Bounds, P. Ziegler, K. Reidy. 2002. Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? J Nutr Educ Behav 34:310-15.

22. Skinner, J. D., B. R. Carruth, B. Wendy, P. J. Ziegler. 2002. Children’s food: A longitudinal analysis. J Am Diet Assoc 102:1638-47.

23. Oliver, M., G. M. Schofield, G. S. Kolt. 2007. Physical activity in preschoolers: Understanding prevalence and measurement issues. Sports Med 37:1045-70.

24. American Academy of Pediatrics, Council on Sports Medicine and Fitness, and Council on School Health. 2006. Active healthy living: Prevention of childhood obesity through increased physical activity. Pediatrics 117:1834-42.

25. Physical Activity Guidelines Advisory Committee. 2008. Physical activity guidelines advisory committee report, 2008. Washington, DC: U.S. Department of Health and Human Services. http://www
.health.gov/PAGuidelines/Report/pdf/CommitteeReport.pdf.

26. American Physical Therapy Association. 2008. Lack of time on tummy shown to hinder achievement of developmental milestones, say physical therapists. News Release.

27. American Academy of Pediatrics (AAP). 2008. Back to sleep, tummy to play. Elk Grove Village, IL: AAP. http://www.healthychildcare.org/pdf/SIDStummytime.pdf.

STANDARD 3.1.3.2: Playing Outdoors

Children should play outdoors when the conditions do not pose a safety risk, individual child health risk, or significant health risk of frostbite or of heat related illness. Caregivers/teachers must protect children from harm caused by adverse weather, ensuring that children wear appropriate clothing and/or appropriate shelter is provided for the weather conditions. Outdoor play for infants may include riding in a carriage or stroller; however, infants should be offered opportunities for gross motor play outdoors, as well.

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

Sunny weather:

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

Warm weather:

Children should be well hydrated before engaging in prolonged periods of physical activity and encouraged to drink water during periods of prolonged physical activity;
Caregivers/teachers should encourage parents/guardians to have children dress in clothing that is light-colored, lightweight, and limited to one layer of absorbent material that will maximize the evaporation of sweat;
On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first six months of life. Infants receiving formula and water can be given additional formula in a bottle.

Cold weather:

Children should wear layers of loose-fitting, lightweight clothing. Outer garments such as coats should be tightly woven, and be at least water repellent when precipitation is present, such as rain or snow;
Children should wear a hat, coat, and gloves/mittens kept snug at the wrist;
Caregivers/teachers should check children’s extremities for maintenance of normal color and warmth at least every fifteen minutes.

Caregivers/teachers should also be aware of environmental hazards such as contaminated water, loud noises, and lead in soil when selecting an area to play outdoors. Children should be observed closely when playing in dirt/soil, so that no soil is ingested. Play areas should be secure and away from heavy traffic areas.

RATIONALE: Outdoor play is not only an opportunity for learning in a different environment; it also provides many health benefits. Outdoor play allows for physical activity that supports maintenance of a healthy weight (2). Short exposure of the skin to sunlight promotes the production of vitamin D that growing children require.

Open spaces in outdoor areas, even those confined to screened rooftops in urban play spaces, encourage children to develop gross motor skills and fine motor play in ways that are difficult to duplicate indoors. Nevertheless, some weather conditions make outdoor play hazardous.

Children need protection from adverse weather and its effects. Wind chill conditions that pose a risk of frostbite as well as heat and humidity that pose a significant risk of heat-related illness are defined by the NWS and are announced routinely.

Heat-induced illness and cold injury are preventable. Children have greater surface area-to-body mass ratio than adults. Therefore, children do not adapt to extremes of temperature as effectively as adults when exposed to a high climatic heat stress or to cold. Children produce more metabolic heat per mass unit than adults when walking or running. They also have a lower sweating capacity and cannot dissipate body heat by evaporation as effectively (1).

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

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

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

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

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

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

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

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

Frostbite is an injury to the body caused by freezing body tissue. The most susceptible parts of the body are the extremities such as fingers, toes, ear lobes, or the tip of the nose. Symptoms include a loss of feeling in the extremity and a white or pale appearance. Medical attention is needed immediately for frostbite. The affected area should be SLOWLY re-warmed by immersing frozen areas in warm water (around 100° Fahrenheit) or apply warm compresses for thirty minutes. If warm water is not available, wrap gently in warm blankets (4).

Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. An infant with hypothermia may have bright red, cold skin and very low energy. A child‘s symptoms may include shivering, clumsiness, slurred speech, stumbling, confusion, poor decision making, drowsiness or low energy, apathy, weak pulse, or shallow breathing (3). Call 9-1-1 if a child has these symptoms.

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

The thought is often expressed that children are more likely to become sick if exposed to cold air, however upper respiratory infections and flu are caused by viruses, not exposure to cold air. These viruses spread easily during the winter when children are kept indoors in close proximity. The best protection against the spread of illness is regular and proper hand hygiene for children and caregivers/teachers, as well as proper sanitation procedures during mealtimes, and when there is any contact with bodily fluids.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. 2007. Policy statement: Climatic heat stress and the exercising child and adolescent. Pediatrics 120:683-84.

2. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Promoting physical activity. In Bright futures: Guidelines for health supervision of infants, children, and adolescents, 147-54. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. Mayo Clinic. 2009. Hypothermia: Symptoms. http://www
.mayoclinic.com/health/hypothermia/DS00333/.

4. Kids Health. 2008. Frostbite. Nemours. http://kidshealth.org/parent/firstaid_safe/emergencies/frostbite.html.

STANDARD 3.1.3.3: Protection from Air Pollution While Children Are Outside

Supervising adults should check the air quality index (AQI) each day and use the information to determine whether all or only certain children should be allowed to play outdoors.

RATIONALE: Children need protection from air pollution. Air pollution can contribute to acute asthma attacks in sensitive children and, over multiple years of exposure, can contribute to permanent decreased lung size and function (1,2).

COMMENTS: The federal Clean Air Act requires that the Environmental Protection Agency (EPA) establish ambient air quality health standards. Most local health departments monitor weather and air quality in their jurisdiction and make appropriate announcements. AQI is usually reported with local weather reports on media outlets or individuals can sign up for email or text message alerts at http://www
.enviroflash.info.

The AQI (available at http://www.airnow.gov) is a cumulative indicator of potential health hazards associated with local or regional air pollution. The AQI is divided into six categories; each category corresponds to a different level of health concern. The six levels of health concern and what they mean are:

“Good” AQI is 0 - 50. Air quality is considered satisfactory, and air pollution poses little or no risk.
“Moderate” AQI is 51 - 100. Air quality is acceptable, however, for some pollutants there may be a moderate health concern for a very small number of people. For example, people who are unusually sensitive to ozone may experience respiratory symptoms.
“Unhealthy for Sensitive Groups” AQI is 101 - 150. Although general public is not likely to be affected at this AQI range, people with heart and lung disease, older adults, and children are at a greater risk from exposure to ozone and the presence of particles in the air.
“Unhealthy” AQI is 151 - 200. Everyone may begin to experience some adverse health effects, and members of the sensitive groups may experience more serious effects.
“Very Unhealthy” AQI is 201 - 300. This would trigger a health alert signifying that everyone may experience more serious health effects.
“Hazardous” AQI greater than 300. This would trigger a health warning of emergency conditions. The entire population is more likely to be affected.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Gauderman, W. J., E. Avol, F. Gilliland, et al. 2004. The effect of air pollution on lung development from 10 to 18 years of age. N Engl J Med 351:1057-67.

2. Hao, M., S. Comier, M. Wang, J. J. Lee, A. Nel. 2003. Diesel exhaust particles exert acute effects on airway inflammation and function in murine allergen provocation models. J Allergy Clin Immunol 112:905-14.

STANDARD 3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical Activity

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

Lead structured activities to promote children’s activities two or more times per day;
Wear clothing and footwear that permits easy and safe movement (2);
Not sit during active play;
Provide prompts for children to be active (3,4), e.g., “good throw”;
Encourage children’s physical activities that are appropriate and safe in the setting, e.g., do not prohibit running on the playground when it is safe to run;
Have orientation and annual training opportunities to learn about age-appropriate gross motor activities and games that promote children’s physical activity (1,3);
Limit screen time (TV, DVD, computer, etc.), except for 1) school-age children completing homework assignments and 2) children with special health care needs who require and consistently use assistive and adaptive computer technology.

RATIONALE: Children learn from the modeling of healthy and safe behavior.

Chairs for adults on playgrounds inhibit the promotion of children’s physical activity. They may also pose a safety hazard if caregivers/teachers sitting in them cannot see all parts of the playground.

COMMENTS: Caregivers/teachers may not feel comfortable promoting active play, perhaps due to inhibitions about their own physical activity skills, or due to lack of training. Caregivers/teachers may feel that their sole role on the playground is to supervise and keep children safe, rather than to promote physical activity. Continuing education activities are useful in disseminating knowledge about effective games to promote physical activity in early care and education while keeping children safe (1). Caregivers/teachers should consider incorporating structured activities into the curriculum indoors, or after children have been on playground for ten to fifteen minutes, as children tend to be less active after the first ten to fifteen minutes on the playground. Caregivers/teachers, if they are facilitating physical activity with a small group, must ensure that there is adequate supervision of all children on the playground.

Caregivers/teachers should be aware that there is often a high level of TV and computer exposure in the home. Early care and education settings offer caregivers/teachers the opportunity to model the limitation of media and computer time and to educate parents/guardians about alternative activities that families can do with their children (3).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Ward, D. S., A. Vaughn, C. McWilliams, D. Hales. 2010. Interventions for increasing physical activity at child care. Med Sci Sports Exercise 42:526-34.

2. Copeland, K. A., S. N. Sherman, C. A. Kendeigh, B. E. Saelens, H. J. Kalkwarf. 2009. Flip-flops, dress clothes and no coat: Clothing barriers to children’s physical activity in child-care centers. Int J Behav Nutr Activ 74(6).

3. Trost, S. G., D. S. Ward, M. Senso. 2010. Effects of child care policy and environment on physical activity. Med Sci Sports Exercise 42:520-25.

4. Brown, W. H., K. A. Pfeiffer, K. L. McIver, M. Dowda, C. L. Addy, R. R. Pate. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Devel 80:45-58.

3.1.4 Safe Sleep

STANDARD 3.1.4.1: Safe Sleep Practices and SIDS/Suffocation Risk Reduction

Facilities should develop a written policy that describes the practices to be used to promote safe sleep when infants are napping or sleeping. The policy should explain that these practices aim to reduce the risk of sudden infant death syndrome (SIDS) or suffocation death and other infant deaths that could occur when an infant is in a crib or asleep.

All staff, parents/guardians, volunteers and others approved to enter rooms where infants are cared for should receive a copy of the Safe Sleep Policy and additional educational information and training on the importance of consistent use of safe sleep policies and practices before they are allowed to care for infants (i.e., first day of employment/volunteering/subbing). Documentation that training has occurred and that these individuals have received and reviewed the written policy should be kept on file.

All staff, parents/guardians, volunteers and others who care for infants in the child care setting should follow these required safe sleep practices as recommended by the American Academy of Pediatrics (AAP) (1):

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

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

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

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

Facilities should be aware of the current recommendation of the AAP about pacifier use (1). If pacifiers are allowed, facilities should have a written policy that describes relevant procedures and guidelines. Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.

RATIONALE: Despite the decrease in deaths attributed to SIDS and the decreased frequency of prone (tummy) infant sleep positioning over the past two decades, many caregivers/teachers continue to place infants to sleep in positions or environments that are not safe. Deaths in child care facilities attributable to SIDS continue to occur at an alarming rate, with a majority occurring in the first day or first week that an infant starts attending a child care program (2,3). Many of these deaths appear to be associated with prone positioning, especially when the infant is unaccustomed to being placed in that position (2,4).

Infants who are cared for by adults other than their parent/guardian or primary caregiver/teacher are at increased risk for dying from SIDS. Recent research and demonstration projects (2) have revealed that:

Caregivers/teachers are unaware of the dangers or risks associated with prone or side infant sleep positioning, and many believe that they are using the safest practices possible, even when they are not;
Although training programs are effective in improving the knowledge of caregivers/teachers, these programs alone do not always lead to changes in caregiver/teacher practices, beliefs, or attitudes;
Caregivers/teachers report the following major barriers to implementing safe sleep practices:
They have been misinformed about methods shown to reduce the risk of SIDS;
Facilities do not have or use written “safe sleep” policies or guidelines;
State child care regulations do not mandate the use of supine (wholly on their back) sleep position for infants in child care and/or training for infant caregivers/teachers;
Other caregivers/teachers or parents/guardians have objections to use of safe sleep practices, either because of their concern for choking or aspiration, and/or their concern that some infants do not sleep well in the supine position;
Parents/guardians model their practices after what happens in the hospital or what others recommend. Infants who were placed to sleep in other positions in the hospital or home environments may have difficulty transitioning to supine positioning at home and later in child care.

Training that includes observations and addresses barriers to changing caregiver/teacher practices would be most effective. Use of safe sleep policies, continued education of parents/guardians, expanded training efforts for child care professionals, statewide regulations and mandates, and increased monitoring and observation are critical to reduce the risk of SIDS and other infant deaths in child care (3).

Loose or ill-fitting sheets have caused infants to be strangled or suffocated (8).

COMMENTS: Background: Deaths of infants who are asleep in child care (whether attributable to SIDS, suffocation, or other causes) may be under-reported because of the lack of consistency in training and regulating death scene investigations and determining and reporting cause of death. Not all states require documentation that clarifies that an infant died while being cared for by someone other than their parents/guardians.

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

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

Challenges: National recommendations for reducing the risk of SIDS or suffocation and other infant deaths are provided for use in the general population. Most research reviewed to guide the development of these recommendations was not conducted on children in child care. Because infants are at increased risk for dying from SIDS in child care (5) and because caregivers/teachers are liable for their actions, they must err on the side of caution and must provide the safest sleep environment for the infants in their care for liability and other reasons.

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

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

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

Use of Blankets: AAP recommendations state that blankets may be hazardous, and use of blankets is not advisable.¹

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

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

For children in the general population, the AAP recommends:

Consider offering a pacifier when placing the infant down for nap and sleep time;
If the infant refuses the pacifier, s/he should not be forced to take it;
If the infant falls asleep and the pacifier falls out of the infant’s mouth, it should be removed from the crib and does not need to be reinserted. A pacifier has been shown to reduce the risk of SIDS, even if the pacifier falls out during sleep (1);
Pacifiers should not be coated in any sweet solution, and they should be cleaned and replaced regularly;
For breastfed infants, delay pacifier introduction until fifteen days of age to ensure that breastfeeding is well-established (7);
Written permission from the child’s parent/guardian is required for pacifier use in the facility.

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

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

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

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

The California Childcare Health Program has available a Safe Sleep Policy for infants in child care programs at http://ucsfchildcarehealth.org/pdfs/forms/SafeSleep_policy1108.pdf (6). AAP provides a free online course on safe sleep practices at http://www.healthychildcare.org/sids.html.

1. This represents a change from the printed version of CFOC3 based on the AAP's new policy statement on SIDS and other sleep-related infant deaths (http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. 2009. Policy statement: The changing concept of SIDS: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 123:188.

2. Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-79.

3. American Academy of Pediatrics, Back to Sleep, Healthy Child Care America, First Candle. 2008. Reducing the risk of SIDS in child care. http://www.healthychildcare.org/pdf/SIDSfinal.pdf.

4. ECELS, Healthy Child Care Pennsylvania. 2007. Car seats and swings are not safe for sleeping. Health Link Online 18:1-2. http://www.ecels-healthychildcarepa.org/content/3-27-07 April-May 2007 HL Online.pdf.

5. Leonard, V. 2009. Health and safety notes: Reducing the risk of SIDS for infants in our care. Berkeley, CA: California Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/SIDS_en1009.pdf.

6. California Childcare Health Program (CCHP). 2008. Safe sleep policy for infants in child care. Berkeley, CA: CCHP. http://ucsfchildcarehealth.org/pdfs/forms/SafeSleep_policy1108.pdf.

7. Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and Breastfeeding Trial Group. 2009. Does the recommendation to use a pacifier influence the prevalence of breastfeeding? J Pediatrics 155:350-54.

8. National MCH Center for Child Death Review. Sudden infant death syndrome (SIDS)/Sudden unexplained infant death (SUID): Fact sheet. http://www.childdeathreview.org/causesSI.htm.

STANDARD 3.1.4.2: Swaddling

In child care settings, swaddling is not necessary or recommended.

RATIONALE: There is evidence that swaddling can increase the risk of serious health outcomes, especially in certain situations. The risk of sudden infant death is increased if an infant is swaddled and placed on his/her stomach to sleep (4) or if the infant can roll over from back to stomach. Loose blankets around the head can be a risk factor for sudden infant death syndrome (SIDS) (3). With swaddling, there is an increased risk of developmental dysplasia of the hip, a hip condition that can result in long-term disability (1,5). Hip dysplasia is felt to be more common with swaddling because infants’ legs can be forcibly extended. With excessive swaddling, infants may overheat (i.e., hyperthermia) (2).

COMMENTS: Most infants in child care centers are at least six-weeks-old. Even with newborns, research does not provide conclusive data about whether swaddling should or should not be used. Benefits of swaddling may include decreased crying, increased sleep periods, and improved temperature control. However, temperature can be maintained with appropriate infant clothing and/or an infant sleeping bag. Although swaddling may decrease crying, there are other, more serious health concerns to consider, including SIDS and hip disease. If swaddling is used, it should be used less and less over the course of the first few weeks and months of an infant’s life.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, W. Kuis, T. W. J. Schulpen, M. P. L’Hoir. 2007. Swaddling: A systematic review. Pediatrics 120:e1097-e1106.

2. Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, A. Kahn. 2005. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 115:1307-11.

3. Contemporary Pediatrics. 2004. Guide for parents: Swaddling 101. http://www.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module1/swadling.pdf.

4. Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants. J Pediatrics 157:85-91.

5. Mahan, S. T., Kasser J. R. 2008. Does Swaddling Influence Developmental Dysplasia of the Hip? Pediatrics 121:177-78.

STANDARD 3.1.4.3: Pacifier Use

Facilities should be informed and follow current recommendations of the American Academy of Pediatrics (AAP) about pacifier use (1-3).

If pacifiers are allowed, facilities should have a written policy that indicates:

Rationale and protocols for use of pacifiers;
Written permission and any instructions or preferences from the child’s parent/guardian;
If desired, parent/guardian should provide at least two new pacifiers (labeled with their child’s name using a waterproof label or non-toxic permanent marker) on a regular basis for their child to use. The extra pacifier should be available in case a replacement is needed;
Staff should inspect each pacifier for tears or cracks (and to see if there is unknown fluid in the nipple) before each use;
Staff should clean each pacifier with soap and water before each use;
Pacifiers with attachments should not be allowed; pacifiers should not be clipped, pinned, or tied to an infant’s clothing, and they should not be tied around an infant’s neck, wrist, or other body part;
If an infant refuses the pacifier, s/he should not be forced to take it;
If the pacifier falls out of the infant’s mouth, it does not need to be reinserted;
Pacifiers should not be coated in any sweet solution;
Pacifiers should be cleaned and stored open to air; separate from the diapering area, diapering items, or other children’s personal items.

Infants should be directly observed by sight and sound at all times, including when they are going to sleep, are sleeping, or are in the process of waking up. The lighting in the room must allow the caregiver/teacher to see each infant’s face, to view the color of the infant’s skin, and to check on the infant’s breathing and placement of the pacifier.

Pacifier use outside of a crib in rooms and programs where there are mobile infants or toddlers is not recommended.

Caregivers/teachers should work with parents/guardians to wean infants from pacifiers as the suck reflex diminishes between three and twelve months of age. Objects which provide comfort should be substituted for pacifiers (6).

RATIONALE: Mobile infants or toddlers may try to remove a pacifier from an infant’s mouth, put it in their own mouth, or try to reinsert it in another child’s mouth. These behaviors can increase risks for choking and/or transmission of infectious diseases.

Cleaning pacifiers before and after each use is recommended to ensure that each pacifier is clean before it is inserted into an infant’s mouth (5). This protects against unknown contamination or sharing. Cleaning a pacifier before each use allows the caregiver/teacher to worry less about whether the pacifier was cleaned by another adult who may have cared for the infant before they did. This may be of concern when there are staffing changes or when parents/guardians take the pacifiers home with them and bring them back to the facility.

If a caregiver/teacher observes or suspects that a pacifier has been shared, the pacifier should be cleaned and sanitized. Caregivers/teachers should make sure the nipple is free of fluid after cleaning to ensure the infant does not ingest it. For this reason, submerging a pacifier is not recommended. If the pacifier nipple contains any unknown fluid, or if a caregiver/teacher questions the safety or ownership, the pacifier should be discarded (4).

While using pacifiers to reduce the risk of sudden infant death syndrome (SIDS) seems prudent (especially if the infant is already sleeping with a pacifier at home), pacifier use has been associated with an increased risk of ear infections and oral health issues (7).

COMMENTS: To keep current with the AAP’s recommendations on the use of pacifiers, go to http://www.aap.org.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

2. Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: What should we recommend? Pediatrics 117:1811-12.

3. Mitchell, E. A., P. S. Blair, M. P. L’Hoir. 2006. Should pacifiers be recommended to prevent sudden infant death syndrome? Pediatrics 117:1755-58.

4. Reeves, D. L. 2006. Pacifier use in childcare settings. Healthy Child Care 9:12-13.

5. Cornelius, A. N., J. P. D’Auria, L. M. Wise. 2008. Pacifier use: A systematic review of selected parenting web sites. J Pediatric Health Care 22:159-65.

6. American Academy of Pediatrics, Back to Sleep, Healthy Child Care America, First Candle. 2008. Reducing the risk of SIDS in child care. http://www.healthychildcare.org/pdf/SIDSfinal.pdf.

7. Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they good for your baby? http://www.mayoclinic.com/health/pacifiers/PR00067/.

STANDARD 3.1.4.4: Scheduled Rest Periods and Sleep Arrangements

The facility should provide an opportunity for, but should not require, sleep and rest. The facility should make available a regular rest period for preschool and school-aged children, if the child desires. For children who are unable to sleep, the facility should provide time and space for quiet play.

Facilities that offer infant care should use a written Safe Sleep Policy that describes the practices to be used to reduce the risk of sudden infant death syndrome (SIDS) and other infant deaths.

RATIONALE: Conditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, regular times for rest (1), and use of similar routines and safe practices. 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 (1).

Studies suggest that sleep is essential for optimal health and growth for young children. There are studies that show the amount of time young children sleep in a twenty-four-hour period is related to obesity later in life (2). Preschool children who sleep less than other children are at higher risk of being obese adults. In a meta-analysis of the association between sleep duration and childhood obesity, children with shorter sleep durations had a 58% higher risk of developing obesity compared to children with longer sleep durations (3). Children with ten hours or less of sleep ages six to seven years of age are more likely to be obese adults than children who sleep more than ten hours.

In a nationally representative sample, three-year-olds slept an average of ten and one-half hours and five-year-olds slept an average of ten hours on weekdays (2). Daytime naps supplement the nighttime sleep period to meet the total sleep requirement. Daily sleep duration of less than twelve hours during infancy also appears to be a risk factor for overweight and adiposity in preschool-aged children (4).

COMMENTS: In the young infant, favorable conditions for sleep and rest include being dry, well-fed, and comfortable. Infants may need one or two (or sometimes more naps during the time they are in child care). As infants age, they typically transition to one nap per day, and having one nap per day is consistent with the schedule that most facilities follow. A facility that includes preschool and school-age children should make available books, board games and other forms of quiet play. Different practices such as rocking, holding a child while swaying, singing, reading, patting an arm or back, etc. could be included. Lighting does not need to be turned off during nap time.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.

2. Snell, E. K., E. K. Adam, G. J. Duncan. 2007. Sleep and body mass index and overweight status of children and adolescents. Child Development. 78:309-23.

3. Chen, Z., M. A. Beydoun, Y. Wang. 2008. Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity. 16:265-74.

4. Taveras, E. M., S. L. Rifas-Shiman, E. Oken, E. P. Gunderson, M. W. Gillman. 2008. Short sleep duration in infancy and risk of childhood overweight. Arch Pediatr Adolesc Med 162:305-11.

STANDARD 3.1.4.5: Unscheduled Access to Rest Areas

All children should have access to rest or nap areas whenever the child desires to rest. These rest or nap areas should be set up to reduce distraction or disturbance from other activities. All facilities should provide rest areas for children, including children who become ill, at least until the child leaves the facility for care elsewhere. Children need to be within sight and hearing of caregivers/teachers when resting.

RATIONALE: Any child, especially children who are ill (1), may need more opportunity for rest or quiet activities.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious Diseases, 153. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3.1.5 Oral Health

STANDARD 3.1.5.1: Routine Oral Hygiene Activities

Caregivers/teachers should promote the habit of regular tooth brushing. All children with teeth should brush or have their teeth brushed at least once during the hours the child is in child care. Children under two years of age should have only a smear of flouride toothpaste (rice grain) on the brush when brushing. Those over two years of age should use a pea-sized amount of fluoride toothpaste. An ideal time to brush is after eating. The caregiver/teacher should either brush the child’s teeth or supervise as the child brushes his/her own teeth. Disposable gloves should be worn by the caregiver/teacher if contact with a child’s oral fluids is anticipated. The younger the child, the more the caregiver/teacher needs to be involved. The caregiver/teacher should 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/teacher should monitor the tooth brushing activity and thoroughly brush the child’s teeth after the child has finished brushing, preferably for a total of two minutes. Children whose teeth are brushed at home twice a day may be exempted since additional brushing has little additive benefit and may expose a child to excess fluoride toothpaste.

The cavity-causing effect of frequent exposure to food or juice should be reduced by offering the children rinsing water after snacks and meals when tooth brushing is not possible. Local dental health professionals can facilitate compliance with these activities by offering education and training for the child care staff and providing oral health presentations for the children and parents/guardians.

RATIONALE: Regular tooth brushing with fluoride toothpaste is encouraged to reinforce oral health habits and prevent gingivitis and tooth decay. There is currently no (strong) evidence that shows any benefit to wiping the gums of a baby who has no teeth. Good oral hygiene is as important for a six-month-old child with one tooth as it is for a six-year-old with many teeth (2). Tooth brushing at least once a day reduces build-up of decay-causing plaque (2,3). The development of tooth decay-producing plaque begins when an infant’s first tooth appears in his/her mouth (1). Tooth decay cannot develop without this plaque which contains the acid-producing bacteria in a child’s mouth. The ability to do a good job brushing the teeth is a learned skill, improved by practice and age. There is general consensus that children do not have the necessary hand eye coordination for independent brushing until around age six so either caregiver/teacher brushing or close supervision is necessary in the preschool child. Tooth brushing and activities at home may not suffice to develop this skill or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care.

COMMENTS: The caregiver/teacher should use a small amount of fluoride toothpaste (a smear about the size of a rice grain spread across the width of the toothbrush for children under two years of age and a pea-sized amount for children two years of age and over). Children should attempt to spit out excess toothpaste after brushing. 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. Young children may occasionally swallow a small amount of toothpaste and this is not a health risk. However, if children swallow more than recommended amounts of fluoride toothpaste on a consistent basis, they are at risk for fluorosis, a condition caused by ingesting excessive levels of fluoride (6). Other products such as fluoride rinses can pose a poisoning hazard if ingested (7).

The children can also rinse with water and spit out after a snack or a meal if their teeth have already been brushed earlier. Rinsing with water helps to remove food particles from teeth, diluting sugars and may help 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, brush and then spit excess toothpaste into the cup.

Caregivers/teachers should encourage replacement of toothbrushes when the bristles become worn or frayed or approximately every three to four months (4,5).

Caregivers/teachers should encourage parents/guardians to establish a dental home for their child within six months after the first tooth erupts or by one year of age, whichever is earlier (1). The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family-centered way. Currently there are insufficient numbers of dentists who are able to incorporate infants and toddlers into their practices so primary care providers may provide oral health screening during well child care in this population while promoting the establishment of a dental home (2).

Fluoride varnish applied at primary care visits reduce decay rates by one-third, and lead to significant cost savings in restorative dental care and associated hospital costs. Coupled with parent/guardian and caregiver/teacher education, fluoride varnish is an important tool to improve children’s health (8,9).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845.

2. American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.

3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry 30:112-18.

4. American Academy of Pediatric Dentistry. Early childhood caries. Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf.

5. American Dental Association. ADA positions and statements. ADA statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx.

6. Centers for Disease Control and Prevention, Fluoride Recommendations Work Group. 2001. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 50(RR14): 1-42.

7. Centers for Disease Control and Prevention. 2009. Community water fluoridation. Other fluoride products. http://www.cdc.gov/fluoridation/other.htm.

8. Marinho, V. C., et al. 2002. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database System Rev 3, no. CD002279. http://www2.cochrane.org/reviews/en/ab002279.html.

9. American Academy of Pediatric Dentistry. 2006. Talking points: AAPD perspective on physicians or other non-dental providers applying fluoride varnish. Dental Home Resource Center. http://www.aapd.org/dentalhome/1225.pdf.

STANDARD 3.1.5.2: Toothbrushes and Toothpaste

In facilities where tooth brushing is an activity, each child should have a personally labeled, age-appropriate toothbrush. No sharing or borrowing should be allowed. After use, toothbrushes should be stored on a clean surface with the bristle end of the toothbrush up to air dry in such a way that the toothbrushes cannot contact or drip on each other and the bristles are not in contact with any surface (6). Racks and devices used to hold toothbrushes for storage should be labeled and disinfected as needed. The toothbrushes should be replaced at least every three to four months, or sooner if the bristles become frayed (2-4,6). When a toothbrush becomes contaminated through contact with another brush or use by more than one child, it should be discarded and replaced with a new one.

If toothpaste is used, each child should have his/her own labeled toothpaste tube. If toothpaste from a single tube is shared among the children, it should be dispensed onto a clean piece of paper or paper cup for each child rather than directly on the toothbrush (1,6). Children under two years of age should have only a smear of fluoride toothpaste (rice grain) on the brush when brushing. Those over two years of age should use a pea-sized amount of fluoride toothpaste. Toothpaste should be stored out of children’s reach.

When children require assistance with brushing, caregivers/teachers should wash their hands thoroughly between brushings for each child. Caregivers/teachers should wear gloves when assisting such children with brushing their teeth.

RATIONALE: Toothbrushes and oral fluids that collect in the mouth during tooth brushing are contaminated with infectious agents and must not be allowed to serve as a conduit of infection from one individual to another (6). Individually labeling the toothbrushes will prevent different children from sharing the same toothbrush. As an alternative to racks, children can have individualized, labeled cups and their brush can be stored bristle-up in their cup. Some bleeding may occur during tooth brushing in children who have inflammation of the gums. In child care, saliva is considered an infectious vehicle if it contains blood, so caregivers/teachers should protect themselves from exposure to blood in such situations, as required by standard precautions. The Occupational Safety and Health Administration (OSHA) regulations apply where there is potential exposure to blood.

COMMENTS: Children can use an individually labeled or disposable cup of water to brush their teeth (6).

Toothpaste is not necessary if removal of food and plaque is the primary objective of tooth brushing. However, no anti-caries benefit is achieved from brushing without fluoride toothpaste.

Some risk of infection is involved when numerous children brush their teeth into sinks that are not sanitized between uses.

Toothbrushing ability varies by age. Preschool children most likely will require assistance. Adults helping children brush their teeth not only help them learn how to brush, but also improve the removal of plaque and food debris from all teeth (5).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Davies, R. M., G. M. Davies, R. P. Ellwood, E. J. Kay. 2003. Prevention. Part 4: Toothbrushing: What advice should be given to patients? Brit Dent Jour 195:135-41.

2. American Dental Association, Council on Scientific Affairs. 2005. ADA statement on toothbrush care: Cleaning, storage, and replacement. http://www.ada.org/1887.aspx.

3. American Academy of Pediatric Dentistry. 2004. Early childhood caries (ECC). http://www.aapd.org/media/ECCstats.pdf.

4. American Dental Hygienists’ Association. Proper brushing. http://www.adha.org/oralhealth/brushing.htm.

5. 12345 First Smiles. 2006. Oral health considerations for children with special health care needs (CSHCN). http://www
.first5oralhealth.org/page.asp?page_id=432.

6. Centers for Disease Control and Prevention. 2005. Infection control in dental settings: The use and handling of toothbrushes. http://www.cdc.gov/OralHealth/InfectionControl/factsheets/toothbrushes.htm.

STANDARD 3.1.5.3: Oral Health Education

All children with teeth should have oral hygiene education as a part of their daily activity.

Children three years of age and older should have developmentally appropriate oral health education that includes:

Information on what plaque is;
The process of dental decay;
Diet influences on teeth, including the contribution of sugar-sweetened beverages and foods to cavity development; and
The importance of good oral hygiene behaviors.

School-age children should receive additional information including:

The preventive use of fluoride;
Dental sealants;
Mouth guards for protection when playing sports;
The importance of healthy eating behaviors; and
Regularly scheduled dental visits.

Adolescent children should be informed about the effect of tobacco products on their oral health and additional reasons to avoid tobacco.

Caregivers/teachers and parents/guardians should be taught to not place a child’s pacifier in the adult’s mouth to clean or moisten it or share a toothbrush with a child due to the risk of promoting early colonization of the infant oral cavity with Streptococcus mutans (5).

Caregivers/teachers should limit juice consumption to no more than four to six ounces per day for children one through six years of age.

RATIONALE: Studies have reported that the oral health of participants improved as a result of educational programs (1).

COMMENTS: Caregivers/teachers are encouraged to advise parents/guardians on the following recommendations for preventive and early intervention dental services and education:

Dental or primary care provider visits to evaluate the need for supplemental fluoride therapy (prescription pills or drops if tap water does not contain fluoride) starting at six months of age, and professionally applied topical fluoride treatments for high risk children (4);
First dental visit within six months after the first tooth erupts or by one year of age, whichever is earlier and whenever there is a question of an oral health problem;
Dental sealants generally at six or seven years of age for first permanent molars, and for primary molars if deep pits and grooves or other high risk factors are present (2,3).

Caregivers/teachers should provide education for parents/guardians on good oral hygiene practices and avoidance of behaviors that increase the risk of early childhood caries, such as inappropriate use of a bottle, frequent consumption of carbohydrate-rich foods, and sweetened beverages such as juices with added sweeteners, soda, sports drinks, fruit nectars, and flavored teas.

For more resources on oral health education, see:

Parent’s Checklist for Good Dental Health Practices in Child Care, a parent handout in English and Spanish, developed by the National Resource Center for Health and Safety in Child Care and Early Education at http://nrckids.org/
dentalchecklist.pdf;

Bright Futures for Oral Health at http://brightfutures.aap.org/practice_guides_and_other_resources.html;

California Childcare Health Program Health and Safety in the Child Care Setting: Promoting Children’s Oral Health A Curriculum for Health Professionals and Child Care Providers (in English and Spanish) at http://www.ucsfchildcarehealth.org and its 12345 first smiles program at http://first5oralhealth.org; and

National Training Institute for Child Care Health Consultant’s Healthy Smiles Through Child Care Health Consultation course at http://nti.unc.edu/healthy_smiles/.

TYPE OF FACILITY: Center

REFERENCES:

1. Dye, B. A., J. D. Shenkin, C. L. Ogden, T. A. Marshould, S. M. Levy, M. J. Kanellis. 2004. The relationship between healthful eating practices and dental caries in children aged 2-5 years in the United States. J Am Dent Assoc 135:55-66.

2. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845.

3. American Academy of Pediatrics, Section on Pediatric Dentistry.2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.

4. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry 30:112-18.

5. American Academy of Pediatrics, Oral Health Initiative. Protecting all children’s teeth (PACT): A pediatric oral health training program. Factors in development: Bacteria. http://www.aap.org/oralhealth/pact/ch4_sect2.cfm.

3.2 Hygiene

3.2.1 Diapering and Changing Soiled Clothing

STANDARD 3.2.1.1: Type of Diapers Worn

Diapers worn by children should be able to contain urine and stool and minimize fecal contamination of children, caregivers/teachers, environmental surfaces, and objects in the child care setting. Only disposable diapers with absorbent material (e.g., polymers) 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 should be documented by the child’s primary care provider. Children of all ages who are incontinent of urine or stool should wear a barrier method to prevent contamination of their environment.

If cloth diapers are used, the diaper should have an absorbent inner lining completely contained within an outer covering made of waterproof material that prevents the escape of feces and urine. An alternative is the use of cloth diapers that contain a waterproof cover that is adherent to the cloth material. If a cloth diaper with a separate lining is used, the outer covering and inner lining should be changed together at the same time as a unit and should not be reused in the child care facility. No rinsing or dumping of the contents of cloth diapers should be performed at the child care facility. Soiled cloth diapers should be completely wrapped in a non-permeable material, stored in a location inaccessible to children, and given directly to the parent/ guardian upon discharge of the child.

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/teachers and children. Procedures that reduce fecal contamination, such as minimal handling of soiled diapers and clothing, thorough hand hygiene, and containment of fecal matter and articles containing fecal matter control the spread of these diseases. Diapering practices that require significant 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/teachers’ hands, the child, and consequently, objects and surfaces in the environment. Environmental contamination has been associated with increased diarrheal rates in child care facilities (1). Fecal contamination in the center environment may be less when single-use, disposable diapers are used than when cloth diapers worn with pull-on waterproof pants are used (3). When clothes are worn over either disposable or cloth diapers with pull-on waterproof pants, there is a reduction in contamination of the environment (1,3).

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 and ointments, thereby decreasing the likelihood for fecal contamination of caregivers/teachers’ 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 (1). 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 (1,2). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (1). Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the diaper used (1). The use of modern disposable diapers with absorbent material has been associated with less frequent and less severe diaper dermatitis in some children than with the use of cloth diapers and pull-on pants made of a waterproof material (3).

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 material, 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, meets 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.

Caregivers/teachers should follow this recommendation unless they have a care plan noting a different procedure from the child’s primary care provider.

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 should not be permitted 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. Therefore, single-use disposable diapers should be encouraged for use in child care facilities.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Van, R., A. L. Morrow, R. R. Reves, L. K. Pickering. 1991. Environmental contamination in child day care centers. Am J Epidemiol 133:460-70.

2. Gorski, P. A. 1999. Toilet training guidelines: Day care providers-the role of the day care provider in toilet training. Pediatrics 103:1367-68.

3. Kubiak, M., B. Kressner, W. Raynor, J. Davis, R. E. Syverson. 1993. Comparison of stool containment in cloth and single-use diapers using a simulated infant feces. Pediatrics 91:632-36.

STANDARD 3.2.1.2: Handling Cloth Diapers

If cloth diapers are used, soiled cloth diapers and/or soiled training pants should never be rinsed or carried through the child care area to place the fecal contents in a toilet. Reusable diapers should be laundered by a commercial diaper service. Soiled cloth diapers should 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 should be sent home with the child at the end of the day. The containers or sealed diaper bags of soiled cloth diapers should not be accessible to any child (1).

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 (2). There is no reason to use the toilet for stool if disposable diapers are being used. Commercial diaper laundries use a procedure that separates solid components from the diapers and does not require prior dumping of feces into the toilet.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Healthy Child Care. Diapering. 2006. http://www
.globalhealthychildcare.org/default.aspx?page=poi&content_id=4&language=content.

2. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.2.1.3: Checking For the Need to Change Diapers

Diapers should 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 should be changed when they are found to be wet or soiled.

RATIONALE: Frequency and severity of diaper dermatitis is lower when diapers are changed more often, regardless of the type of diaper used (1). 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 (2). 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 (1,2). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (2).

Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents can be assessed by odor. 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

REFERENCES:

1. Healthy Children. 2010. Ages and stages: When diaper rash strikes. http://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/When-Diaper-Rash-Strikes.aspx.

2. Shelov, S. P., T. R. Altmann, eds. 2009. Caring for your baby and young child: Birth to age 5. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.2.1.4: Diaper Changing Procedure

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

An EPA-registered disinfectant suitable for the surface material that is being disinfected should be used. If an EPA-registered product is not available, then household bleach diluted with water is a practical alternative. All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to Appendix J, Selecting an Appropriate Sanitizer or Disinfectant.

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

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

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

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.

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, or a dampened cloth or wet paper towel to clean the skin on the child's genitalia and buttocks and prevent recontamination from a soiled diaper. Remove stool and urine from front to back and use a fresh wipe, or a dampened cloth or wet paper towel each time you swipe. Put the soiled wipes or paper towels into the soiled diaper or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm's reach of diaper changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.

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

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/guardians or laundry service;
Put soiled clothes in a plastic-lined, hands-free plastic bag;
Check for spills under the child. If there are any, use the corner of the paper to fold the paper that extends under the child's feet over the soiled area so a fresh, unsoiled paper surface is now under the child's buttocks;
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 fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child's hands. Put the wipes into the plastic-lined, hands-free covered can.

Step 5: Put on a clean diaper and dress the child.

Slide a fresh diaper under the child;
Use a facial or toilet tissue or wear clean disposable glove to apply any necessary diaper creams, discarding the tissue or glove in a covered, plastic-lined, hands-free covered can;
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 warm water, between 60°F and 120°F, at a sink to wash the child’s hands, if you can.

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

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

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

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

RATIONALE: The procedure for diaper changing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (1,3). Posting the multi-step procedure may help caregivers/teachers maintain the routine.

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

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

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

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

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

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

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

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

Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, application and storage. If the disinfectant is applied using a spray bottle, always assume that the outside of the spray bottle could be contaminated. Therefore, the spray bottle should be put away before hand hygiene is performed, (the last and essential part of every diaper change) (4).

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book 2009: Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. National Association for the Education of Young Children. 2007. Keeping healthy: Parents, teachers, and children. Rev ed. Washington, DC: NAEYC.

3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

4. North Carolina Child Care Health and Safety Resource Center. Diapering procedure poster. http://www.healthychildcarenc.org/PDFs/diaper_procedure_english.pdf.

STANDARD 3.2.1.5: Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing

The following changing procedure for soiled pull-ups or underwear and clothing should be posted in the changing area, should be followed for all changes, and should be used as part of staff evaluation of caregivers/teachers who change pull-ups or underwear and clothing. The signage should be simple and should be in multiple languages if caregivers/teachers who speak multiple languages are involved in changing pull-ups or underwear. All employees who will change pull-ups or underwear and clothing should undergo training and periodic assessment of these practices.

Changing a child from the floor level or on a chair puts the adult in an awkward position and increases the risk of contamination of the environment. Using a toddler changing table helps establish a well-organized changing area for both the child and the caregiver/teacher. Changing tables with steps that allow the child to climb with the caregiver/teacher’s help and supervision are a good idea. This would help reduce the risk of back injury for the adults that may occur from lifting the child onto the table (1).

Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the changing surface. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.

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

Non-absorbent paper liner large enough to cover the changing surface from the child’s shoulders to beyond the child’s feet;
Unused pull-up or underwear, clean clothes (if you need them);
Wipes, dampened cloths or wet paper towels for cleaning the child's genitalia and buttocks readily available;
A wet cloth or paper towel;
A plastic bag for any soiled clothes, including underwear, or pull-ups;
Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or pull-ups) and remove them before handling clean pull-ups or underwear and clothing.

Step 2: Avoid contact with soiled items.

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

Step 3: Clean the child’s skin.

Lift the child's legs as needed to use disposable wipes, or a dampened cloth or wet paper towel to clean the skin on the child's genitalia and buttocks. Remove stool and urine from front to back and use a fresh wipe, dampened cloth or wet paper towel each time you swipe. Put the soiled wipes or paper towels into the soiled pull-up or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm's reach of diaper changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects;
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 fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child's hands. Put the wipes into the plastic-lined, hands-free covered can;

Step 4: Put on a clean pull-up or underwear and clothing, if necessary.

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

Step 5: Wash the child’s hands and return the child to a supervised area.

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

Step 6: Clean and disinfect the changing surface.

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

Step 7: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the change in the child’s daily log.

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

RATIONALE: Children who are learning to use the toilet may still wet/soil their pull-ups or underwear and clothing. Changing these undergarments can lead to risk for spreading infection due to the contamination of surfaces from urine or feces (1). The procedure for changing a child’s soiled undergarment and clothing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (2,4). Posting the multi-step procedure may help caregivers/teachers maintain the routine.

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. ECELS-Healthy Child Care Pennsylvania. Changing soiled underwear for toddlers. http://www.ecels-healthychildcarepa.org/content/2-11-10 v2ChangingSoiledUnderwear.pdf.

2. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book 2009: Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3. National Association for the Education of Young Children. 2007. Keeping healthy: Parents, teachers, and children. Rev ed. Washington, DC: NAEYC.

4. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

5. North Carolina Child Care Health and Safety Resource Center. Diapering procedure poster. http://www.healthychildcarenc.org/PDFs/diaper_procedure_english.pdf.

3.2.2 Hand Hygiene

STANDARD 3.2.2.1: Situations that Require Hand Hygiene

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

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

Situations or times that children and staff should perform hand hygiene should be posted in all food preparation, hand hygiene, diapering, and toileting areas.

RATIONALE: Hand hygiene is the most important way to reduce the spread of infection. Many studies have shown that improperly cleansed hands are the primary carriers of infections. Deficiencies in hand hygiene have contributed to many outbreaks of diarrhea among children and caregivers/teachers in child care centers (1).

In child care centers that have implemented hand hygiene training program, the incidence of diarrheal illness has decreased by 50% (2). Several studies demonstrate a reduction in upper respiratory symptoms (colds) when frequent and proper hand hygiene practices were incorporated into a child care center’s curriculum (2-4).

Hand hygiene after exposure to soil and sand will reduce opportunities for the ingestion of zoonotic parasites that could be present in contaminated sand and soil (6,7).

Thorough handwashing with soap for at least twenty seconds using comfortably warm, running water (between 60°F and 120°F) removes organisms from the skin and allows them to be rinsed away (5). Hand hygiene is effective in preventing transmission of disease. Hand hygiene with an alcohol-based sanitizer is an alternative to traditional handwashing with soap and water when visible soiling is not present.

Infectious organisms 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 live organisms on it;
In droplets of body fluids, such as those produced by sneezing and coughing, that travel through the air.

Since many infected people carry infectious organisms without symptoms and many are contagious before they experience a symptom, caregivers/teachers routine hand hygiene is the safest practice (4).

If caregivers/teachers smoke off premises before starting work, they should wash their hands before caring for children to prevent children from receiving third-hand smoke exposure (8).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Hawks, D., J. Ascheim, G. S. Giebink, S. Graville, A. J. Solnit. 1994. Science, prevention, and practice VII: Improving child day care, a concurrent summary of the American Public Health Association/American Academy of Pediatrics National health and safety guidelines for child-care programs; featured standards and implementation. Pediatrics 94:1110-12.

2. Soto. J. C., M. Guy, L. Belanger. 1994. Science, prevention and practice II: Preventing infectious diseases, abstracts on handwashing and infection control in day-care centers. Pediatrics 94:1030.

3. Roberts, L., E. Mapp, W. Smith, L. Jorm, M. Pate, R. M. Douglas, C. McGilchrist. 2000. Effect of infection control measures on the frequency of upper respiratory infection in child care: A randomized, controlled trial. Pediatrics 105:738-42.

4. Niffenegger, J. P. 1997. Proper handwashing promotes wellness in child care. J Pediatr Health Care 11:26-31.

5. Donowitz, L. G., ed. 1996. Infection control in the child care center and preschool, 18, 19, 68. 2nd ed. Baltimore, MD: Williams and Wilkins.

6. Palmer, S. R., L. Soulsby, D. I. H. Simpson, eds. 1998. Zoonoses: Biology, clinical practice, and public health control. New York: Oxford University Press.

7. Weinberg, A. N. and D. J. Weber, eds. 1991. Respiratory infections transmitted from animals. Infect Dis Clin North Am 5:649-61.

8. Mayo Clinic. 2010. Secondhand smoke: Avoid dangers in the air. http://www.mayoclinic.com/health/secondhand-smoke/CC00023/.

STANDARD 3.2.2.2: Handwashing Procedure

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

Check to be sure a clean, disposable paper (or single-use cloth) towel is available;
Turn on warm water, between 60°F and 120°F, to a comfortable temperature;
Moisten hands with water and apply soap (not antibacterial) to hands;
Rub hands together vigorously until a soapy lather appears, hands are out of the water stream, and continue for at least twenty seconds (sing Happy Birthday silently twice) (2). Rub areas between fingers, around nail beds, under fingernails, jewelry, and back of hands. Nails should be kept short; acrylic nails should not worn (3);
Rinse hands under running water, between 60°F and 120°F, until they are free of soap and dirt. Leave the water running while drying hands;
Dry hands with the clean, disposable paper or single use cloth towel;
If taps do not shut off automatically, turn taps off with a disposable paper or single use cloth towel;
Throw the disposable paper towel into a lined trash container; or place single-use cloth towels in the laundry hamper; or hang individually labeled cloth towels to dry. Use hand lotion to prevent chapping of hands, if desired.

The use of alcohol based hand sanitizers is an alternative to traditional handwashing with soap and water by children over twenty-four months of age and adults on hands that are not visibly soiled. A single pump of an alcohol-based sanitizer should be dispensed. Hands should be rubbed together, distributing sanitizer to all hand and finger surfaces and hands should be permitted to air dry.

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

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

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

RATIONALE: Running water over the hands removes visible soil. Wetting the hands before applying soap helps to create a lather that can loosen soil. The soap lather loosens soil and brings it into solution on the surface of the skin. Rinsing the lather off into a sink removes the soil from the hands that the soap brought into solution. Warm water, between 60°F and 120°F, is more comfortable than cold water; using warm water also promotes adequate rinsing during handwashing (1).

Acceptable forms of soap include liquid and powder.

COMMENTS: Pre-moistened 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 or impractical, the use of alcohol-based hand sanitizer (Standard 3.2.2.5) is a suitable alternative.

Outbreaks of disease have been linked to shared wash water and wash basins (4). Water basins should not be used as an alternative to running water. Camp sinks and portable commercial sinks with foot or hand pumps dispense water as for a plumbed sink and are satisfactory if filled with fresh water daily. The staff should clean and disinfect the water reservoir container and water catch basin daily.

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

The use of cloth roller towels is not recommended for the following reasons:

Children often use cloth roll dispensers improperly, resulting in more than one child using the same section of towel; and
Incidents of unintentional strangulation have been reported (U.S. Consumer Product Safety Commission Data Office, pers. comm.)

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Donowitz, L. G., ed. 1996. Infection control in the child care center and preschool. 2nd ed. Baltimore, MD: Williams and Wilkins.

2. Centers for Disease Control and Prevention. 2011. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.

3. McNeil, S. A., C. L. Foster, S. A. Hedderwick, C. A. Kauffman. 2001. Effect of hand clensing with antimicrobial soap or alcohol-based gel on microbial colonization of artificial fingernails worn by health care workers. Clin Infect Dis 32:367-72.

4. Ogunsola, F. T., Y. O. Adesiji. 2008. Comparison of four methods of hand washing in situations of inadequate water supply. West Afr J Med 27:24-28.

STANDARD 3.2.2.3: Assisting Children with Hand Hygiene

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

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

For examples of handwashing posters, see:

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Centers for Disease Control and Prevention. 2009. Preventing the spread of influenza (the flu) in child care settings: Guidance for administrators, caregivers/teachers, and other staff. http://www.cdc.gov/flu/professionals/infectioncontrol/childcaresettings.htm.

STANDARD 3.2.2.4: Training and Monitoring for Hand Hygiene

The program should ensure that staff members and children who are developmentally able to learn personal hygiene are instructed in, and monitored on performing hand hygiene as specified in Standard 3.2.2.2.

RATIONALE: Education of the staff and children regarding hand hygiene and other cleaning procedures can reduce the occurrence of illness in the group of children in care (1,2).

Staff training and monitoring of hand hygiene has been shown to reduce transmission of organisms that cause disease (3-6). Periodic training and monitoring is needed to result in sustainable changes in practice (7).

COMMENTS: Training programs may utilize some type of verbal cue such as singing the alphabet song, twinkle, twinkle little star or the birthday song during handwashing.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Hawks, D., J. Ascheim, G. S. Giebink, S. Graville, A. J. Solnit. 1994. Science, prevention, and practice VII: Improving child day care, a concurrent summary of the American Public Health Association/American Academy of Pediatrics national health and safety guidelines for child-care programs; featured standards and implementation. Pediatrics 95:1110-12.

2. Roberts, L., E. Mapp, W. Smith, L. Jorm, M. Pate, R. M. Douglas, C. McGilchrist. 2000. Effect of infection control measures on the frequency of upper respiratory infection in child care: A randomized, controlled trial. Pediatrics 105:738-42.

3. Black, R. E., A. C. Dykes, K. E. Anderson. 1981. Handwashing to prevent diarrhea in day care centers. Am J Epidemiol 113:445-51.

4. Roberts, L., L. Jorm, M. Patel, W. Smith, R. M. Douglas, C. McGilchrist. 2000. Effect of infection control measures on the frequency of diarrheal episodes in child care: A randomized, controlled trial. Pediatrics 105:743-46.

5. Carabin, H., T. W. Gyorkos, J. C. Soto, L. Joseph, P. Payment, J. P. Collet. 1999. Effectiveness of a training program in reducing infections in toddlers attending daycare centers. Epidemiol 10:219-27.

6. Bartlett, A. V., B. A. Jarvis, V. Ross, T. M. Katz, M. A. Dalia, S. J. Englender, L. J. Anderson. 1988. Diarrheal illness among infants and toddlers in day care centers: Effects of active surveillance and staff training without subsequent monitoring. Am J Epidemiol 127:808-17.

7. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.

STANDARD 3.2.2.5: Hand Sanitizers

The use of hand sanitizers by children over twenty-four months of age and adults in child care programs is an appropriate alternative to the use of traditional handwashing with soap and water. For visibly dirty hands, rinsing under running water or wiping with a water-saturated towel should be used to remove as much dirt as possible before using a hand sanitizer.

Hand sanitizers using an alcohol-based active ingredient must contain 60% to 95% alcohol in order to be effective to kill germs, including multi-drug resistant pathogens. Child care programs should follow the manufacturer’s instructions for use, check instructions to determine how long the hand sanitizer needs to remain on the skin surface to be effective.

Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of hand sanitizers with eyes and mucous membranes.

When alcohol based hand sanitizers are offered in a child care facility, the facility should encourage parents/guardians to teach their children about their use at home.

Where alcohol-based hand sanitizer dispensers are used:

The maximum individual dispenser fluid capacity should be as follows:
0.32 gal (1.2 L) for dispensers in rooms, corridors, and areas open to corridors;
0.53 gal (2.0 L) for dispensers in suites of rooms;
Where aerosol containers are used, the maximum capacity of the aerosol dispenser should be 18 oz. (0.51 kg) and should be limited to Level 1 aerosols as defined in NFPA 30B: Code for the Manufacture and Storage of Aerosol Products;
Wall mounted dispensers should be separated from each other by horizontal spacing of not less than 48 in. (1,220 mm);
Wall mounted dispensers should not be installed above or adjacent to ignition sources such as electrical outlets;
Wall mounted dispensers installed directly over carpeted floors should be permitted only in child care facilities protected by automatic sprinklers (1).

RATIONALE: Studies have demonstrated that using an alcohol-based hand sanitizer after washing hands with soap and water is effective in reducing illness transmission in the home, in child care centers and in health care settings (2-5). Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately.

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount. As with any hand hygiene product, supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes.

COMMENTS: Even in health care settings, the Centers for Disease Control and Prevention (CDC) guidelines recommend washing hands that are visibly soiled or contaminated with organic material with soap and water as an adjunct to the use of alcohol-based sanitizers (6).

Some hand sanitizing products contain non-alcohol and “natural” ingredients. The efficacy of non-alcohol containing hand sanitizers is variable and therefore a non-alcohol-based product is not recommended for use.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.

2. Boyce, J. M., D. Pittet, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. 2002. Guideline for hand hygiene in health-care settings. MMWR 25:1-45.

3. Lennell, A., S. Kuhlmann-Berenzon, P. Geli, K. Hedin, C. Petersson, O. Cars, et al. 2008. Alcohol-based hand-disinfection reduced children’s absence from Swedish day care centers. Acta Paediatrica 97:1672-80.

4. Sandora, T. J., E. M. Taveras, M. C. Shih, E. A. Resnick, G. M. Lee, D. Ross-Degnan, et al. 2005. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics 116:587-94.

5. Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. Comparing hand washing to hand sanitizers in reducing elementary school students’ absenteeism. Pediatric Nurs 33:368-72.

6. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2011. Handwashing: Clean hands save lives! http://www.cdc.gov/handwashing/.

3.2.3 Exposure to Body Fluids

STANDARD 3.2.3.1: Procedure for Nasal Secretions and Use of Nasal Bulb Syringes

Staff members and children should blow or wipe their noses with disposable, single use tissues and then discard them in a plastic-lined, covered, hands-free trash container. After blowing the nose, they should practice hand hygiene, as specified in Standards 3.2.2.1 and 3.2.2.2.

Use of nasal bulb syringes is permitted. Nasal bulb syringes should be provided by the parents/guardians for individual use and should be labeled with the child’s name.

If nasal bulb syringes are used, facilities should have a written policy that indicates:

Rationale and protocols for use of nasal bulb syringes;
Written permission and any instructions or preferences from the child’s parent/guardian;
Staff should inspect each nasal bulb syringe for tears or cracks (and to see if there is unknown fluid in the nasal bulb syringe) before each use;
Nasal bulb syringes should be cleaned with warm soapy water and stored open to air.

RATIONALE: Hand hygiene is the most effective way to reduce the spread of infection (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.2.3.2: Cough and Sneeze Etiquette

Staff members and children should be taught to cover their mouths and noses with a tissue when they cough or sneeze. Staff members and children should also be taught to cough or sneeze into their inner elbow/upper sleeve and to avoid covering the nose or mouth with bare hands. Hand hygiene, as specified in Standards 3.2.2.1 and 3.2.2.2, should follow a cough or sneeze that could result in the spread of respiratory droplets to the skin.

RATIONALE: Proper respiratory etiquette can prevent transmission of respiratory pathogens (1).

COMMENTS: Multi-lingual videos, posters, and handouts should be part of an active educational effort of caregivers/teachers and children to reinforce this practice. For free downloadable posters and flyers in multiple languages, go to http://www.cdc.gov/flu/protect/covercough.htm.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Centers for Disease Control and Prevention. 2010. Seasonal flu: Cover your cough. http://www.cdc.gov/flu/protect/covercough.htm.

STANDARD 3.2.3.3: Cuts and Scrapes

Cuts or sores that are actively dripping, oozing, or draining body fluids should be covered with a dressing to avoid contamination of surfaces in child care. The caregiver/teacher should wear gloves if there is contact with any wound (cut or scrape) that has material that could be transmitted to another surface.

A child or caregiver/teacher with a cut or sore that is leaking a body fluid that cannot be contained or cannot be covered with a dressing, should 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 (1).

Gloves can provide a protective barrier against infectious organisms that may be present in body fluids.

COMMENTS: Covering sores on lips and on eyes is difficult. Children or caregivers/teachers who are unable to prevent contact with these exposed lesions should be excluded until lesions do not present a risk of transmission of a pathogen.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

STANDARD 3.2.3.4: Prevention of Exposure to Blood and Body Fluids

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

In child care settings:

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

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

Procedures for Standard Precautions should include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. De Queiroz, M., S. Combet, J. Berard, A. Pouyau, H. Genest, P. Mouriquand, D. Chassard. 2009. Latex allergy in children: Modalities and prevention. Pediatric Anesthesia 19:313-19.

2. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf.

3. Kotch, J. B., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and diapering equipment reduces disease among children in out-of-home child care centers. Pediatrics 120: e29-e36.

4. Rutala, W. A., D. J. Weber, HICPAC. 2008. Guideline for disinfection and sterilization in healthcare facilities. Center for Disease Control and Prevention. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf.

5. Email communication from Amy V. Kindrick, MD, MPH, Senior Consultant, National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline), UCSF School of Medicine at San Francisco General Hospital to Elisabeth L.M. Miller, BSN, RN, BC, PA Chapter American Academy of Pediatrics, Early Childhood Education Linkage System – Healthy Child Care Pennsylvania. November 11, 2009.

6. American Association of Nurse Anesthetists. 2003. Creating a latex-safe school for latex-sensitive children. http://www
.anesthesiapatientsafety.com/patients/latex/school.asp.

3.3 Cleaning, Sanitizing, and Disinfecting

STANDARD 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting

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

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

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

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

RATIONALE: Young children sneeze, cough, drool, use diapers and are just learning to use the toilet. They hug, kiss, and touch everything and put objects in their mouths (1). Illnesses may be spread in a variety of ways, such as by coughing, sneezing, direct skin-to-skin contact, or touching a contaminated object or surface. Respiratory tract secretions that can contain viruses (including respiratory syncytial virus and rhinovirus) contaminate environmental surfaces and may present an opportunity for infection by contact (2-4).

COMMENTS: The terms cleaning, sanitizing and disinfecting are sometimes used interchangeably which can lead to confusion and result in cleaning procedures that are not effective (3).

For example, a spray bottle containing a mixture of bleach and water might be incorrectly used as the “first step” to clean a soiled diaper change table or a table surface after a meal. The solution in the spray bottle cannot be used as a “first step” because the purpose of the bleach and water solution is to sanitize (it is not designed to clean and is not effective as a disinfectant on dirty surfaces). In this example, cleaning with detergent and water, and then rinsing the surface with water, should occur before spraying the surface with the bleach and water solution (5).

Each term has a specific purpose and there are many methods that may be used to achieve such purpose.

Task	Purpose
Clean	To physically remove all dirt and contamination. The friction of cleaning removes most germs and exposes any remaining germs to the effects of a sanitizer or disinfectant used later.
Sanitize	To reduce germs on inanimate surfaces to levels considered safe by public health codes or regulations.
Disinfect	To destroy or inactivate most germs on any inanimate object, but not bacterial spores.

Note: The term “germs” refers to bacteria, viruses, fungi and molds that may cause infectious disease. Bacterial spores are dormant bacteria that have formed a protective shell, enabling them to survive extreme conditions for years. The spores reactivate after entry into a host (such as a person), where conditions are favorable for them to live and reproduce (6).

Only U.S. Environmental Protection Agency (EPA)-registered products that have an EPA registration number on the label can make public health claims that can be relied on for reducing or destroying germs. The EPA registration label will also describe the product as a cleaner, sanitizer, or disinfectant. It is important to use the least toxic cleaner, sanitizer and disinfectant for the particular job. Products that are labeled as “green” sanitizers and disinfectants should be EPA-registered. Products must be used according to manufacturer’s instructions.

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. California Childcare Health Program. 2009. Sanitize safely and effectively: Bleach and alternatives in child care programs. Health and Safety Notes (July). http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/SanitizeSafely_En0709.pdf.

2. Thompson, S. C. 1994. Infectious diarrhoea in children: Controlling transmission in the child care setting. J Paediatric Child Health 30:210-19.

3. Butz, A. M., P. Fosarelli, D. Dick, et al. 1993. Prevalence of rotavirus on high-risk fomites in day-care facilities. Pediatrics 92:202-5.

4. Grenier, D., D. Leduc, eds. 2008. Well beings: A guide to health in child care. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society.

5. North Carolina Child Care Health and Safety Resource Center. Diapering procedure poster. http://www.healthychildcarenc.org/training_materials.htm.

6. Microbiology Procedure. Sporulation in bacteria. http://www.microbiologyprocedure.com/microorganisms/sporulation-in-bacteria.htm.

STANDARD 3.3.0.2: Cleaning and Sanitizing Toys

Toys that cannot be cleaned and sanitized should not be used. Toys that children have placed in their mouths or that are otherwise contaminated by body secretion or excretion should be set aside until they are cleaned by hand with water and detergent, rinsed, sanitized, and air-dried or in a mechanical dishwasher that meets the requirements of Standard 4.9.0.11 through Standard 4.9.0.13. Play with plastic or play foods, play dishes and utensils, should be closely supervised to prevent shared mouthing of these toys.

Machine washable cloth toys should be used by one individual at a time. These toys should be laundered before being used by another child.

Indoor toys should 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 (1). 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 hand hygiene. Using a mechanical dishwasher is an acceptable labor-saving approach for sanitizing plastic toys as long as the dishwasher can wash and sanitize the surfaces and dishes and cutlery are not washed at the same time (1).

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 preferred cleaning possible.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well beings. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society.

STANDARD 3.3.0.3: Cleaning and Sanitizing Objects Intended for the Mouth

Thermometers, pacifiers, teething toys, and similar objects should be cleaned, and reusable parts should be sanitized between uses. Pacifiers should 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 (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well beings. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society.

STANDARD 3.3.0.4: Cleaning Individual Bedding

Bedding (sheets, pillows, blankets, sleeping bags) should be of a type that can be washed. Each child’s bedding should be kept separate from other children’s bedding, on the bed or stored in individually labeled bins, cubbies, or bags. Bedding that touches a child’s skin should be cleaned weekly or before use by another child.

RATIONALE: Toddlers often nap or sleep on mats or cots and the mats or cots are taken out of storage during nap time, and then placed back in storage. 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 are appropriate hygienic practices (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

STANDARD 3.3.0.5: Cleaning Crib Surfaces

Cribs and crib mattresses should have a nonporous, easy-to-wipe surface. All surfaces should be cleaned as recommended in Appendix K, Routine Schedule for Cleaning, Sanitizing, and Disinfecting.

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 (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well beings. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society.

3.4 Health Protection in Child Care

3.4.1 Tobacco and Drug Use

STANDARD 3.4.1.1: Use of Tobacco, Alcohol, and Illegal Drugs

Tobacco use, alcohol, and illegal drugs should be prohibited on the premises of the program (both indoor and outdoor environments) and in any vehicles used by the program at all times. Caregivers/teachers should not use tobacco, alcohol, or illegal drugs off the premises during the child care program’s paid time including break time.

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 (1-5). Separation of smokers and nonsmokers within the same air space does not eliminate or minimize exposure of nonsmokers to secondhand smoke. Tobacco smoke contamination lingers after a cigarette is extinguished and children come in contact with the toxins (6). Thirdhand smoke exposure also presents hazards. Thirdhand smoke refers to gases and particles clinging to smokers’ hair and clothing, cushions and carpeting, and outdoor equipment, after tobacco smoke has dissipated (1). The residue includes heavy metals, carcinogens and radioactive materials that young children can get on their hands and ingest, especially if they’re crawling or playing on the floor. Residual toxins from smoking at times when the children are not using the space can trigger asthma and allergies when the children do use the space (1,2).

Cigarettes used by adults are the leading cause of ignition of fatal house fires (7-9).

Adults under the influence of alcohol and other drugs cannot take care of young children and keep them safe. Alcohol use, illegal drug use and misuse of prescription or over the counter (OTC) drugs prevent caregivers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and response time. Safe child care necessitates alert, unimpaired caregivers/teachers.

The use of alcoholic beverages in family child care homes after children are not in care is not prohibited.

COMMENTS: The age, defenselessness, and dependence upon the judgment of caregivers/teachers 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

REFERENCES:

1. U.S. Department of Health and Human Services. 2007. Children and secondhand smoke exposure. Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

2. Schwartz, J., K. L. Timonen, J. Pekkanen. 2000. Respiratory effects of environmental tobacco smoke in a panel study of asthmatic and symptomatic children. Am J Resp Crit Care Med 161:802-6.

3. Stenstrom, R., P. A. Bernard, H. Ben-Simhon. 1993. Exposure to environmental tobacco smoke as a risk factor for recurrent acute otitis media in children under the age of five years. Inter J Pediatr Otorhinolaryngol 27:127-36.

4. Pershagen, G. 1999. Accumulating evidence on health hazards of passive smoking. Acta Paediatr 88:490-92.

5. Gergen, P. J., J. A. Fowler, K. R. Maurer, et al. 1998. The burden of environmental tobacco smoke exposure on the respiratory health of children 2 months through 5 years of age in the United States: Third national health and nutritional examination survey, 1988 to 1994. Pediatrics 101: e8.

6. Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, M. F. Hovell, R. C. McMillen. 2009. Beliefs about the health effects of “thirdhand” smoke and home smoking bans. Pediatrics 123: e74-e79.

7. Runyan, C. W., S. I. Bangdiwala, M. A. Linzer, et al. 1992. Risk factors for fatal residential fires. N Eng J Med 327:856-63.

8. Brigham, P. A., A. McGuire 1995. Progress towards a fire-safe cigarette. J Public Health Policy 16:433-39.

9. Ballard, J. E., T. D. Koepsell, F. Rivara. 1992. Association of smoking and alcohol drinking with residential fire injuries. Am J Epidemiol 135:26-34.

3.4.2 Animals

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

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

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

Fish are permissible but must be inaccessible to children.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Gilchrist, J., J. J. Sacks, D. White, M. J. Kresnow. 2008. Dog bites: Still a problem? Injury Prevention 14:296-301.

2. Reisner, I. R., F. S. Shofer. 2008. Effects of gender and parental status on knowledge and attitudes of dog owners regarding dog aggression toward children. J Am Vet Med Assoc 233:1412-19.

3. Information from Your Family Doctor. 2004. Dog bites: Teaching your child to be safe. Am Family Physician 69:2653.

4. Bernardo, L. M., M. J. Gardner, R. L. Rosenfield, B. Cohen, R. Pitetti. 2002. A comparison of dog bite injuries in younger and older children treated in a pediatric emergency department. Pediatric Emergency Care 18:247-49.

5. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13. 6. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.

7. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2000. Compendium of measures to control Chlamydia psittaci infection among humans (psittacosis) and pet birds (avian chlamydiosis). MMWR 49:3-17.

8. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Pregnant women and Toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm.

9. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
ab1007.pdf.

10. Massachusetts Department of Public Health Division of Epidemiology and Immunization. 2001. Recommendations for petting zoos, petting farms, animal fairs, and other events and exhibits where contact between animals and people is permitted. http://www.mass.gov/Eeohhs2/docs/dph/cdc/rabies/reduce_zoos
_risk.pdf.

11. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to nontraditional pets at home and to animals in public settings: risks to children. Pediatrics 122:876-86.

12. Centers for Disease Control and Prevention. 2010. Lymphocytic choriomeningitis (LCMV). http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/lcmv.htm.

13. Hemsworth, S., B. Pizer. 2006. Pet ownership in immunocompromised children – A review of the literature and survey of existing guidelines. Eur J Oncol Nurs 10:117-27.

STANDARD 3.4.2.2: Prohibited Animals

The following animals should not be kept at or brought onto the grounds of the child care facility (4,6,7):

Bats;
Hermit crabs;
Poisonous animals - Inclusive of spiders, venomous insects, venomous reptiles (including snakes), and venomous amphibians;
Wolf-dog hybrids - These animals are crosses between a wolf and a domestic dog and have shown a propensity for aggression, especially toward young children;
Stray animals - Stray animals should never be present at a child care facility because the health and vaccination status of these animals is unknown;
Chickens and ducks - These animals excrete E. coli O157:H7, Salmonella, Campylobacter, S. paratyphoid;
Aggressive animals - Animals which are bred or trained to demonstrate aggression towards humans or other animals, or animals which have demonstrated such aggressive behavior in the past, should not be permitted on the grounds of the child care facility. Exceptions may be sentry or canine corps dogs for a demonstration. These dogs must be under the control of trained military or law enforcement officials;
Reptiles and amphibians - Inclusive of non-venomous snakes, lizards, and iguanas, turtles, tortoises, terrapins, crocodiles, alligators, frogs, tadpoles, salamanders, and newts;
Psittacine birds unless tested for psittacosis - Inclusive of parrots, parakeets, budgies, and cockatiels. Psittacine birds can carry diseases that can be transferred to humans;
Ferrets - Ferrets have a propensity to bite when startled;
Animals in estrus - Female dogs and cats should be determined not to be in estrus (heat) when at the child care facility;
Animals less than one year of age - Incorporating young animals (animal that are less than one year of age) into child care programs is not permitted because of issues regarding unpredictable behavior and elimination control. Additionally, the immune systems of very young puppies and kittens are not completely developed, thereby placing the health of these animals at risk.

RATIONALE: Animals, including pets, are a source of illness for people, and people may be a source of illness for animals (1-2,4-5). Reptiles usually carry salmonella and pose a risk to children who are likely to put unwashed hands in their mouths (3,5).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections transmitted from animals. Infect Dis Clin North Am 5:649-61.

2. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13.

3. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
ab1007.pdf.

4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.

5. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to nontraditional pets at home and to animals in public settings: risks to children. Pediatrics 122:876-86.

6. PETCO Animal Supplies. 2006. Hermit crab: Care sheet. http://www.petco.com/caresheets/invertebrates/HermitCrab.pdf.

7. Kahn, C. M., S. Line, eds. 2010. The Merck veterinary manual. 10th ed. Whitehouse Station, NJ: Merck.

STANDARD 3.4.2.3: Care for Animals

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

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

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

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

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

Live animals should be prohibited from:

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

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

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

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

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

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

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

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

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

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

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

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

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

COMMENTS: Ensuring animal welfare is a human responsibility that includes consideration for all aspects of animal well-being, inclusive of secure housing, suitable temperature, adequate exercise and proper diet, disease prevention and treatment, humane handling, and, when necessary, humane euthanasia (6). Animal well-being also includes continued care of animals during the days that child care is not in session and in the event of an emergency evacuation.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections transmitted from animals. Infect Dis Clin North Am 5:649-61.

2. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13.

3. Centers for Disease Control and Prevention (CDC). Pregnant women and toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm.

4. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
ab1007.pdf.

5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.

6. American Veterinary Medical Association. Animal welfare principles. http://www.avma.org/issues/animal_welfare/default.asp.

3.4.3 Emergency Procedures

STANDARD 3.4.3.1: Emergency Procedures

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

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

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

RATIONALE: The staff must know how to carry out the written disaster and emergency plans as described in Standard 9.2.4.3 to help prevent or minimize severe injury to children and other staff. The staff should review and practice the emergency plan regularly (1).

COMMENTS: First aid instructions are available from the American Academy of Pediatrics (AAP) and the American Red Cross.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Aronson, S. 2005. Pediatric first aid for caregivers and teachers. Sudbury, MA: Jones and Bartlett; Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.4.3.2: Use of Fire Extinguishers

The staff should demonstrate the ability to locate and operate the fire extinguishers. Facilities should develop a plan for responding in the event of a fire in or near the facility that includes staff responsibilities and protocols regarding evacuation, notifying emergency personnel, and using fire extinguishers. The staff should demonstrate the ability to recognize a fire that is larger than incipient stage and should not be fought with a portable fire extinguisher.

RATIONALE: A fire extinguisher may be used to put out a small fire or to clear an escape path (1). Developing a plan that includes staff use of fire extinguishers and conducting fire drills/exercises can increase preparedness and help staff better understand what to do to respond to a fire. It is just as important that staff know when not to try to fight a fire with portable fire extinguishers.

COMMENTS: Staff should be trained that the first priority is to remove the children from the facility safely and quickly. Putting out the fire is secondary to the safe exit of the children and staff. However, depending upon the situation at hand and the number of available staff, the facility’s plan could identify which caregivers/teachers evacuate the children, where they will all meet outside, who should call emergency personnel, and who should locate/use the fire extinguishers. These efforts can take place simultaneously.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2000. Reducing the number of deaths and injuries from residential fires. Pediatrics 105:1355-57.

STANDARD 3.4.3.3: Response to Fire and Burns

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

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

RATIONALE: Running when garments have been ignited will fan the fire. Removing heat from the affected area will prevent continued burning and aggravation of tissue damage. Asphyxiation causes more deaths in house fires than does thermal injury (1).

COMMENTS: For resources for children: see Stop, Drop, and Roll – A Jessica Worries Book: Fire Safety.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2000. Reducing the number of deaths and injuries from residential fires. Pediatrics 105:1355-57.

3.4.4 Child Abuse and Neglect

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

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Hussey, J. M., J. J. Chang, J. B. Kotch. 2006. Child maltreatment in the United States: Prevalence, risk factors, and adolescent health consequences. Pediatrics 118:933-42.

2. Jenny, C. 2007. Recognizing and responding to medical neglect. Pediatrics 120:1385-89.

3. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, and Children’s Bureau. Child welfare information gateway: State statutes. http://www.childwelfare.gov/systemwide/laws_policies/state/.

5. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, and Children’s Bureau. What is child abuse and neglect? Child Welfare Information Gateway. http://www.childwelfare.gov/pubs/factsheets/whatiscan.cfm.

STANDARD 3.4.4.2: Immunity for Reporters of Child Abuse and Neglect

Caregivers/teachers who report suspected abuse and neglect in the settings where they work should be immune from discharge, retaliation, or other disciplinary action for that reason alone, unless it is proven that the report was malicious.

RATIONALE: Cases which are reported suggest that sometimes workers are intimidated by superiors in the centers where they work, and for that reason, fail to report abuse and neglect (1). In some cases the abuser may be a staff member or superior.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Goldman, R. 1990. An educational perspective on abuse. In Children at risk: An interdisciplinary approach to child abuse and neglect. Ed. R. Goldman, R. Gargiulo. Austin, TX: Pro-Ed.

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

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

RATIONALE: Over the past several years there has been increasing recognition of shaken baby syndrome/abusive head trauma which is the occurrence of brain injury in young children under three years of age due to shaking a child. Even mild shaking can result in serious, permanent brain damage or death. The brain of the young child may bounce inside of the skull resulting in brain damage, hemorrhaging, blindness, or other serious injuries or death. There have been several reported incidents occurring in child care (1). Caregivers/teachers experience young children who may be fussy or constantly crying. It is important for caregivers/teachers to be educated about the risks of shaking and provided with strategies to cope if they are frustrated (3). Many states have passed legislation requiring education and training for caregivers/teachers. Caregivers/teachers should check their individual state’s specific requirements (2). Staff can also recognize the signs and symptoms of shaken baby syndrome/abusive head trauma in children in their care.

COMMENTS: For more information and resources on shaken baby syndrome/abusive head trauma, contact the National Center on Shaken Baby Syndrome at http://www.dontshake.org.

TYPE OF FACILITY: Center; Large Family child Care Home; Small Family child Care Home

REFERENCES:

1. American Academy of Pediatrics, Committee on Child Abuse and Neglect. 2009. Abusive head trauma in infants and children. Pediatrics 123:1409-11.

2. National Resource Center for Health and Safety in Child Care and Early Education. State licensing database. http://nrckids.org/STATES/states.htm.

3. Calm a Crying Baby. Shaken baby syndrome prevention. http://www.calmacryingbaby.com.

STANDARD 3.4.4.4: Care for Children Who Have Been Abused/Neglected

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

RATIONALE: All children who have been abused or neglected have had their physical and emotional boundaries violated and crossed. With this violation often comes a breach of the child’s sense of security and trust. Abused and neglected children may come to believe that the world is not a safe place and that adults are not trustworthy. Abused and neglected children may have more emotional needs and may require more individual staff time and attention than children who are not maltreated. Children who are victims of abuse or neglect, in addition to having more developmental problems, also have behavior problems such as emotional lability, depression, and aggressive behaviors (3). These problems may persist long after the maltreatment occurred and may have significant psychiatric and medical consequences into adulthood. In particular, children who have suffered abuse or neglect or been exposed to violence, including domestic violence, often have excessive responses to environmental stress. Their responses are often misinterpreted by caregivers/teachers and responded to inappropriately which, in turn, reinforces their hyper-vigilance and maladaptive behavior in a counter-productive feedback cycle (1,2). Child care staff may need to work closely with the child’s primary care provider, therapist, social worker, and parents/guardians to formulate a more personalized behavior management plan.

COMMENTS: Centers serving children with a history of maltreatment related behavior problems may require professionally trained staff. Resources on caring for a child who has been abused or neglected are available from the National Children’s Advocacy Center at http://www.nationalcac
.org/professionals/.

TYPE OF FACILITY: Center

REFERENCES:

1. American Academy of Pediatrics. 2008. Understanding the behavioral and emotional consequences of child abuse. Pediatrics 122:667-73.

2. Felitti, V. J., R. F. Anda, P. Nordenber, D. F. Williamson, A. M. Spitz, V. Edwards, M. P. Koss, J. S. Marks. 1998. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14:245-58.

3. Child Welfare Information Gateway. 2008. Parenting a child who has been sexually abused: A guide for foster and adoptive parents – factsheet for families. Washington, DC: U.S. Department of Health and Human Services. http://www.childwelfare.gov/pubs/f_abused/.

STANDARD 3.4.4.5: Facility Layout to Reduce Risk of Child Abuse and Neglect

The physical layout of facilities should be arranged so that there is a high level of visibility in the inside and outside areas as well as diaper changing areas and toileting areas used by children. All areas should be viewed by at least one other adult in addition to the caregiver/teacher at all times when children are in care. For center-based programs, rooms should be designed so that there are windows to the hallways to keep classroom activities from being too private. Ideally each area of the facility should have two adults at all times. Such an arrangement reduces the risk of child abuse and neglect and the likelihood of extended periods of time in isolation for individual caregivers/teachers with children, especially in areas where children may be partially undressed or in the nude.

Caregivers/teachers should have increased awareness regarding risk of abuse and neglect when a caregiver/teacher is alone with a child. Other caregivers/teachers should periodically walk into a room with one caregiver/teacher to ensure there is no abuse and neglect.

RATIONALE: The presence of multiple caretakers greatly reduces the risk of serious abusive injury. Maltreatment tends to occur in privacy and isolation, and especially in toileting areas (1). A significant number of cases of abuse have been found involving young children being diapered in diaper changing areas (1).

COMMENTS: This standard does not mean to disallow privacy for children who are developmentally able to toilet independently and who may need privacy (2).

TYPE OF FACILITY: Center; Large Family child Care Home; Small Family child Care Home

REFERENCES:

1. Goldman, R. 1990. An educational perspective on abuse. In Children at risk: An interdisciplinary approach to child abuse and neglect. R. Goldman, R. Gargiulo, eds. Austin, TX: Pro-Ed.

2. Child Development Institute. 2010. Child development. http://childdevelopmentinfo.com/development/.

3.4.5 Sun Safety and Insect Repellent

STANDARD 3.4.5.1: Sun Safety Including Sunscreen

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

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

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

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

Sunscreen should be applied thirty minutes before going outdoors as it needs time to absorb into the skin. If the children will be out for more than one hour, sunscreen will need to be reapplied every two hours as it can wear off. If children are playing in water, reapplication will be needed more frequently. Children should also be protected from the sun by using shade and sun protective clothing. Sun exposure should be limited between the hours of 10 AM and 2 PM when the sun’s rays are the strongest.

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics. 2008. Sun safety. http://www.healthychildren.org/english/safety-prevention/at-play/pages/Sun-Safety.aspx.

2. American Academy of Dermatology. 2010. Skin, hair and nail care: Protecting skin from the sun. Kids Skin Health.

http://www.kidsskinhealth.org/grownups/skin_habits_sun.html.

3. Kenfield, S., A. Geller, E. Richter, S. Shuman, D. O’Riordan, H. Koh, G. Colditz. 2005. Sun protection policies and practices at child care centers in Massachusetts. J Comm Health 30:491-503.

4. Maguire-Eisen, M., K, Rothman, M. F. Demierre. 2005. The ABCs of sun protection for children. Dermatology Nurs 17:419-22,431-33.

5. Weinberg, N., M. Weinberg, S. Maloney. Traveling safely with infants and children. Medic8. http://www.medic8.com/travel/child-safety.htm.

6. Yan, X. S., G. Riccardi, M. Meola, A. Tashjian, J. SaNogueira, T. Schultz. 2008. A tear-free, SPF50 sunscreen product. Cutan Ocul Toxicol 27:231-39.

7. Norval, M., H. C. Wulf. 2009. Does chronic sunscreen use reduce vitamin D production

to insufficient levels? British J Dermatology 161:732-36.

8. Misra, M., D. Pacaud, A. Petryk, P. F. Collett-Solberg, M. Kappy. 2008. Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics 122:398-417.

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

Insect repellents offer varying levels of protection from insect bites. Most insects do not carry human disease and most bites only cause mild irritation. Insect repellents may be used with children in child care in areas of the country due to specific disease outbreaks and alerts. Parents/guardians and caregivers/teachers should decide about the use of repellents depending upon the likelihood that local insects are carrying diseases (e.g., local cases of meningitis from mosquito bites). Caregivers/teachers should consult with a child care health consultant, the primary care provider, or the local health department about the appropriateness of use.

Insect repellent used for preventive purposes does not require a written authorization from a primary care provider. Parent/guardian written permission is required, and all label instructions must be followed. If the skin is broken or an allergic reaction is observed, discontinue use and notify the parent/guardian.

Repellents with 10%-30% DEET offer the broadest protection against mosquitoes, ticks, flies, chiggers, and fleas. The concentration of DEET that is used should be dependent upon how much time the child will be exposed. Products with 10% DEET are effective for approximately two hours whereas products with 24% DEET offers protection for approximately five hours. Caregivers/teachers should read the product label and confirm that the product is safe for children and contains a concentration of 30% DEET or less. Some repellents may contain up to 100% DEET and could be very dangerous if applied to a child. DEET is not approved for infants less than two months of age.

Application of this product for children older than two months is acceptable using the following guidelines:

Apply insect repellent to the caregiver/teacher’s hands first and then put it on the child;
Use just enough repellent to cover exposed skin;
Do not apply under clothing;
Do not use DEET on the hands of young children;
Avoid applying to areas around the eyes and mouth;
Do not use over cuts or irritated skin;
Do not use near food;
Do not use products that combine insect repellent and sunscreen. If sunscreen is used, apply sunscreen first;
Do not apply a second application to the skin (1);
DEET concentration should not exceed 30% for use with children (1);
After returning indoors, wash treated skin immediately with soap and water;
If the child gets a rash or other bad reaction from an insect repellent, stop using the repellent, wash the repellent off with mild soap and water, and call a local poison center (1-800-222-1222) for further guidance. (1,3,4)

Oil of lemon and eucalyptus products should NOT be used on CHILDREN UNDER THREE YEARS OF AGE (1). Most product labels for registrations containing DEET recommend consultation with a physician if applying to a child less than six months of age.

Picaridin and IR3535 are other products registered at the Environmental Protection Agency (EPA) identified as providing repellent activity sufficient to help people avoid the bites of disease carrying mosquitoes (3).

Caregivers/teachers should practice hand hygiene after applying insect repellent to the children in the group.

Written parent/guardian permission is required before applying any insect repellent to children.

In places where ticks are likely to be found, caregivers/teachers should take the following steps to protect children in their care from ticks:

Wear light colored clothing, long sleeves and pants, tuck pants into socks;
Conduct tick checks when returning indoors (2).
Caregivers/teachers should also take the following protective measures against ticks and mosquitoes with children’s play areas:
Remove stagnant water sources to prevent breeding grounds for mosquito larvae;
Remove leaf litter and clear tall grasses and brush around homes and buildings and at the edges of lawns;
Place wood chips or gravel between lawns and wooded areas to restrict tick migration to recreational areas;
Mow the lawn and clear brush and leaf litter frequently;
Keep playground equipment, decks, and patios away from yard edges and trees.

RATIONALE: Ticks and mosquitoes can carry pathogens that may cause life threatening diseases (i.e., vector-borne diseases such as Lyme Disease) (2).

COMMENTS: Repellent does not have to contain DEET but must be approved for use in the child’s age range. If not approved, the parent/guardian must obtain a prescription from the child’s primary care provider.

Aerosol sprays are not recommended. Pump sprays are a better choice. Regardless of the type of spray used, caregivers/teachers should spray the insect repellent into her/his hand and then apply to the child. It is not recommended to directly spray the child with the insect repellent to prevent unintentional injury to eyes and mouth. Preschool children, toddlers, and infants should not apply insect repellent to themselves. School age children can apply insect repellent to themselves if they are supervised to make sure that they are applying it correctly.

Parents/guardians should be notified when insect repellent is applied to their child since it is recommended that treated skin is washed with soap and water.

If a product gets in the eyes, flush with water and consult the poison center at 1-800-222-1222.

How to Remove a Tick:

It is important to remove the tick as soon as possible. Use the following steps:

If possible, clean the area with an antiseptic solution or soap and water. Take care not to scrub the tick too hard. Just clean the skin around it;
Use blunt, fine tipped tweezers or gloved fingers to grasp the tick as close to the skin as possible;
Pull slowly and steadily upwards to allow the tick to release;
If the tick’s head breaks off in the skin, use tweezers to remove it like you would a splinter;
Wash the area around the bite with soap;
Following the removal of the tick, wash your hands, the tweezers, and the area thoroughly with soap and warm water.

Take care not to do the following:

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

Several resources are available on reducing exposure to ticks and mosquitoes based on habits, protective attire, and insect repellent use. The following Websites offer detailed information on preventing exposure to ticks and mosquitoes which may cause disease: “Integrated Pest Management (IPM) of Mosquitoes in Early Childhood Education (ECE) Settings” by the California Childcare Health Program at http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/Mosquitoes_en_0709.pdf, and Protect Yourself from Tick Bites by the Centers for Disease Control and Prevention at http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld_Prevention_Avoid.htm.

Additional resources:

http://www.cdc.gov/ncidod/diseases/list_mosquitoborne.htm;
http://www.epa.gov/pesticides/health/mosquitoes/ai_insectrp.htm; and
http://www.lymediseaseassociation.org/index.php?option=com_content&view=category&id=29&Itemid=180.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Committee on Environmental Health. 2003. Follow safety precautions when using DEET on children. AAP News 22. http://aapnews.aappublications.org/cgi/content/full/e200399v1/.

2. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2010. Lyme disease: Protect yourself from tick bites. http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld_Prevention_Avoid.htm.

3. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2009. West nile virus: Updated information regarding insect repellents. http://www.cdc.gov/ncidod/dvbid/westnile/RepellentUpdates.htm.

4. Roberts J. R., Weil W. B., Shannon, M. W. 2005. DEET alternatives considered to be effective mosquito repellents. AAP News. http://aap.org/family/wnv-jun05.htm.

3.4.6 Strangulation

STANDARD 3.4.6.1: Strangulation Hazards

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Consumer Product Safety Commission. Strings and straps on toys can strangle young children. http://www.cpsc.gov/CPSCPUB/PUBS/5100.html.

2. Window Covering Safety Council. Basic cord safety. http://www.windowcoverings.org/basic_cord_safety.html.

3. U.S. Consumer Product Safety Commission (CPSC). 1999. Guidelines for drawstrings on children’s outerwear. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/208.pdf.

4. U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe? Washington, DC: CPSC.

5. Window Covering Safety Council. 2011. New study released on window covering safety awareness. http://www.windowcoverings.org/nr_2011-3.html.

3.5 Care Plans and Adaptations

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

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

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

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

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

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

RATIONALE: Children with special health care needs could have a variety of different problems ranging from asthma, diabetes, cerebral palsy, bleeding disorders, metabolic problems, cystic fibrosis, sickle cell disease, seizure disorder, sensory disorders, autism, severe allergy, immune deficiencies, or many other conditions (2). Some of these conditions require daily treatments and some only require observation for signs of impending illness and ability to respond in a timely manner (3).

COMMENTS: A collaborative approach in which the primary care provider and the parent/guardian complete the Care Plan and the parent/guardian works with the child care staff to implement the plan is helpful. Although it is usually the primary care provider in the medical home completing the Care Plan, sometimes management is shared by specialists, nurse practitioners, and case managers, especially with conditions such as diabetes or sickle cell disease.

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. McPherson, M., P. Arango, H. Fox, C. Lauver, M. McManus, P. Newacheck, J. Perrin, J. Shonkoff, B. Strickland. 1998. A new definition of children with special health care needs. Pediatrics 102:137-40.

2. U.S. Department of Health and Human Services, Health Resources and Services Administration. The national survey of children with special health care needs: Chartbook 2005-2006. http://mchb.hrsa.gov/cshcn05/.

3. American Association of Nurse Anesthetists. 2003. Creating a latex-safe school for latex-sensitive children. http://www
.anesthesiapatientsafety.com/patients/latex/school.asp.

4. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.5.0.2: Caring for Children Who Require Medical Procedures

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

RATIONALE: The specialized skills required to implement these procedures are not traditionally taught to early childhood caregivers/teachers, or educational assistants as part of their academic or practical experience. Skilled nursing care may be necessary in some circumstances.

COMMENTS: Parents/guardians are responsible for supplying the required equipment. The facility should offer staff training and allow sufficient staff time to carry out the necessary procedures. Caring for children who require intermittent catheterization or maintaining supplemental oxygen is not as demanding as it first sounds, but the implication of this standard is that facilities serving children who have complex medical problems need special training, consultation, and monitoring.

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

Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (1). Confidentiality should be maintained at each step in compliance with any laws or regulations that are pertinent to all parties such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Insurance Portability and Accountability Act (commonly known as HIPAA) (1).

TYPE OF FACILITY: Center; Large Family Child Care; Small Family Child Care Home

REFERENCES:

1. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.

3.6 Management of Illness

3.6.1 Inclusion/Exclusion Due to Illness

STANDARD 3.6.1.1: Inclusion/Exclusion/Dismissal of Children

(Adapted from: Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide, 39-43. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.)

Preparing for managing illness:

Caregivers/teachers should:

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

Daily health checks as described in Standard 3.1.1.1 should be performed upon arrival of each child each day. Staff should objectively determine if the child is ill or well. Staff should determine which children with mild illnesses can remain in care and which need to be excluded.

Staff should notify the parent/guardian when a child develops new signs or symptoms of illness. Parent/guardian notification should be immediate for emergency or urgent issues. Staff should notify parents/guardians of children who have symptoms that require exclusion and parents/guardians should remove the child from the child care setting as soon as possible. For children whose symptoms do not require exclusion, verbal or written notification of the parent/guardian at the end of the day is acceptable. Most conditions that require exclusion do not require a primary care provider visit before reentering care.

Conditions/symptoms that do not require exclusion:

Common colds, runny noses (regardless of color or consistency of nasal discharge);
A cough not associated with a infectious disease (such as pertussis) or a fever;
Watery, yellow or white discharge or crusting eye discharge without fever, eye pain, or eyelid redness;
Yellow or white eye drainage that is not associated with pink or red conjunctiva (i.e., the whites of the eyes);
Pink eye (bacterial conjunctivitis) indicated by pink or red conjunctiva with white or yellow eye mucous drainage and matted eyelids after sleep. Parents/guardians should discuss care of this condition with their child’s primary care provider, and follow the primary care provider’s advice. Some primary care providers do not think it is necessary to examine the child if the discussion with the parents/guardians suggests that the condition is likely to be self-limited. If two unrelated children in the same program have conjunctivitis, the organism causing the conjunctivitis may have a higher risk for transmission and a child health care professional should be consulted;
Fever without any signs or symptoms of illness in children who are older than six months regardless of whether acetaminophen or ibuprofen was given. Fever (temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method) is an indication of the body’s response to something, but is neither a disease nor a serious problem by itself. Body temperature can be elevated by overheating caused by overdressing or a hot environment, reactions to medications, and response to infection. If the child is behaving normally but has a fever of below 102ºF per rectum or the equivalent, the child should be monitored, but does not need to be excluded for fever alone;
Rash without fever and behavioral changes;
Lice or nits (exclusion for treatment of an active lice infestation may be delayed until the end of the day);
Ringworm (exclusion for treatment may be delayed until the end of the day);
Molluscum contagiosum (do not require exclusion or covering of lesions);
Thrush (i.e., white spots or patches in the mouth or on the cheeks or gums);
Fifth disease (slapped cheek disease, parvovirus B19) once the rash has appeared;
Methicillin-resistant Staphylococcus aureus, or MRSA, without an infection or illness that would otherwise require exclusion. Known MRSA carriers or colonized individuals should not be excluded;
Cytomegalovirus infection;
Chronic hepatitis B infection;
Human immunodeficiency virus (HIV) infection;
Asymptomatic children who have been previously evaluated and found to be shedding potentially infectious organisms in the stool. Children who are continent of stool or who are diapered with formed stools that can be contained in the diaper may return to care. For some infectious organisms, exclusion is required until certain guidelines have been met. Note: These agents are not common and caregivers/teachers will usually not know the cause of most cases of diarrhea;
Children with chronic infectious conditions that can be accommodated in the program according to the legal requirement of federal law in the Americans with Disabilities Act. The act requires that child care programs make reasonable accommodations for children with disabilities and/or chronic illnesses, considering each child individually.

Key criteria for exclusion of children who are ill:

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

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

If any of the above criteria are met, the child should be excluded, regardless of the type of illness. The child should be removed from direct contact with other children and should be monitored and supervised by a single staff member known to the child until dismissed from care to the care of a parent/guardian or a primary care provider. The area should be where the toys, equipment, and surfaces will not be used by other children or adults until after the ill child leaves and after the surfaces and toys have been cleaned and disinfected.

Temporary exclusion is recommended when the child has any of the following conditions:

The illness prevents the child from participating comfortably in activities;
The illness results in a need for care that is greater than the staff can provide without compromising the health and safety of other children;
An acute change in behavior - this could include lethargy/lack of responsiveness, irritability, persistent crying, difficult breathing, or having a quickly spreading rash;
Fever (temperature above 101°F [38.3°C] orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method) and behavior change or other signs and symptoms (e.g., sore throat, rash, vomiting, diarrhea). An unexplained temperature above 100°F (37.8°C) axillary (armpit) or 101°F (38.3°C) rectally in a child younger than six months should be medically evaluated. Any infant younger than two months of age with any fever should get urgent medical attention. See COMMENTS Below for important information about taking temperatures;
Diarrhea is defined by watery stools or decreased form of stool that is not associated with changes of diet. Exclusion is required for all diapered children whose stool is not contained in the diaper and toilet-trained children if the diarrhea is causing soiled pants or clothing. In addition, diapered children with diarrhea should be excluded if the stool frequency exceeds two or more stools above normal for that child, because this may cause too much work for the caregivers/teachers. Readmission after diarrhea can occur when diapered children have their stool contained by the diaper (even if the stools remain loose) and when toilet-trained children are continent. Special circumstances that require specific exclusion criteria include the following (2):
1. Toxin-producing E. coli or Shigella infection, until stools are formed and the test results of two stool cultures obtained from stools produced twenty-four hours apart do not detect these organisms;
2. Salmonella serotype Typhi infection, until diarrhea resolves. In children younger than five years with Salmonella serotype Typhi, three negative stool cultures obtained with twenty-four-hour intervals are required; people five years of age or older may return after a twenty-four-hour period without a diarrheal stool. Stool cultures should be collected from other attendees and staff members, and all infected people should be excluded;
Blood or mucus in the stools not explained by dietary change, medication, or hard stools;
Vomiting more than two times in the previous twenty-four hours, unless the vomiting is determined to be caused by a non-infectious condition and the child remains adequately hydrated;
Abdominal pain that continues for more than two hours or intermittent pain associated with fever or other signs or symptoms of illness;
Mouth sores with drooling unless the child’s primary care provider or local health department authority states that the child is noninfectious;
Rash with fever or behavioral changes, until the primary care provider has determined that the illness is not a infectious disease;
Active tuberculosis, until the child’s primary care provider or local health department states child is on appropriate treatment and can return;
Impetigo, until treatment has been started;
Streptococcal pharyngitis (i.e., strep throat or other streptococcal infection), until twenty-four hours after treatment has been started;
Head lice until after the first treatment (note: exclusion is not necessary before the end of the program day);
Scabies, until after treatment has been given;
Chickenpox (varicella), until all lesions have dried or crusted (usually six days after onset of rash);
Rubella, until six days after the rash appears;
Pertussis, until five days of appropriate antibiotic treatment;
Mumps, until five days after onset of parotid gland swelling;
Measles, until four days after onset of rash;
Hepatitis A virus infection, until one week after onset of illness or jaundice if the child’s symptoms are mild or as directed by the health department. (Note: immunization status of child care contacts should be confirmed; within a fourteen-day period of exposure, incompletely immunized or unimmunized contacts from one through forty years of age should receive the hepatitis A vaccine as post exposure prophylaxis, unless contraindicated.) Other individuals may receive immune globulin. Consult with a primary care provider for dosage and recommendations;
Any child determined by the local health department to be contributing to the transmission of illness during an outbreak.

Procedures for a child who requires exclusion:

The caregiver/teacher will:

Provide care for the child in a place where the child will be comfortable and supervised by someone who knows the child well and who will continue to observe the child for new or worsening symptoms. A potentially contagious child should be separated from other children by at least three feet. Each facility should have a predetermined physical location(s) where an ill child(ren) could be placed until care can be transferred to a parent/guardian or primary care provider;
Ask the family to pick up the child as soon as possible;
Discuss the signs and symptoms of illness with the parent/guardian who is assuming care. Review guidelines for return to child care. If necessary, provide the family with a written communication that may be given to the primary care provider. The communication should include onset time of symptoms, observations about the child, vital signs and times (e.g., temperature 101.5°F at 10:30 AM) and any actions taken and the time actions were taken (e.g., one children’s acetaminophen given at 11:00 AM). The nature and severity of symptoms and or requirements of the local or state health department will determine the necessity of medical consultation. Telephone advice, electronic transmissions of instructions are acceptable without an office visit;
Follow the advice of the child’s primary care provider;
Contact the local health department if there is a question of a reportable (harmful) infectious disease in a child or staff member in the facility. If there are conflicting opinions from different primary care providers about the management of a child with a reportable infectious disease, the health department has the legal authority to make a final determination;
Document actions in the child’s file with date, time, symptoms, and actions taken (and by whom); sign and date the document;
In collaboration with the local health department, notify the parents of contacts to the child or staff member with presumed or confirmed reportable infectious infection.

The caregiver/teacher should make the decision about whether a child meets or does not meet the exclusion criteria for participation and the child’s need for care relative to the staff’s ability to provide care. If parents/guardians and the child care staff disagree, and the reason for exclusion relates to the child’s ability to participate or the caregiver’s/teacher’s ability to provide care for the other children, the caregiver/teacher should not be required to accept responsibility for the care of the child.

Reportable conditions:

The current list of infectious diseases designated as notifiable in the United States at the national level by the Centers for Disease Control and Prevention (CDC) are listed at http://www.cdc.gov/osels/ph_surveillance/.

The caregiver/teacher should contact the local health department:

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

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

RATIONALE: Excluding children with mild illnesses is unlikely to reduce the spread of most infectious agents (germs) caused by bacteria, viruses, parasites and fungi. Most infections are spread by children who do not have symptoms. They spread the infectious agent (germs) before or after their illnesses and without evidence of symptoms. Exposure to frequent mild infections helps the child’s immune system develop in a healthy way. As a child gets older s/he develops immunity to common infectious agents and will become ill less often. Since exclusion is unlikely to reduce the spread of disease, the most important reason for exclusion is the ability of the child to participate in activities and the staff to care for the child.

The terms contagious, infectious and communicable have similar meanings. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts. Hand and personal hygiene is paramount in preventing transmission of these organisms. Written notes should not be required for return to child care for common respiratory illnesses that are not specifically listed in the excludable condition list above.

For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 2nd Edition has educational handouts that can be copied and distributed to parents/guardians, health professionals, and caregivers/teachers. This publication is available from the American Academy of Pediatrics (AAP) at http://www
.aap.org.

For more detailed rationale regarding inclusion/exclusion, return to care, when a health visit is necessary, and health department reporting for children with specific symptoms, please see Appendix A, Signs and Symptoms Chart.

State licensing law or code defines the conditions or symptoms for which exclusion is necessary. States are increasingly using the criteria defined in Caring for Our Children and the Managing Infectious Diseases in Child Care and Schools publications. Usually, the criteria in these two sources are more detailed than the state regulations so can be incorporated into the local written policies without conflicting with state law.

In this edition of Caring for Our Children, the exclusion criteria for bacterial conjunctivitis (pink eye) and diarrhea have changed. Exclusion is no longer required for pink eye and treatment is not required. This change reflects the recognition that conjunctivitis is a self-limiting infection and there is not any evidence that treatment or exclusion reduces its spread. Children with diarrhea may remain in care as long as the stool is contained in the diaper or the child can maintain continence. If additional criteria are met, such as an inability to participate in activities or requiring more care than staff can provide, then a child should be excluded until the criteria for return of care are met. A provision was included that if the stool frequency is two or more stools per day above the normal then exclusion could be indicated. This accounts for the increased staff time involved in diaper changing. Infants should routinely receive rotavirus vaccine, which has been the most common cause of viral diarrhea in this age group.

COMMENTS: When taking a child’s temperature, remember that:

The amount of temperature elevation varies at different body sites;
The height of fever does not indicate a more or less severe illness;
The method chosen to take a child’s temperature depends on the need for accuracy, available equipment, the skill of the person taking the temperature, and the ability of the child to assist in the procedure;
Oral temperatures are difficult to take for children younger than four years of age;
Rectal temperatures should be taken only by persons with specific health training in performing this procedure and permission given by parents/guardians;
Axillary (armpit) temperatures are accurate only when the thermometer remains within the closed armpit for the time period recommended by the device;
Electronic devices for measuring temperature require periodic calibration and specific training in proper technique;
Any device used improperly may give inaccurate results;
Mercury thermometers should not be used;
Aural (ear) devices may underestimate fever and should not be used in children less than four months.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.1.2: Staff Exclusion for Illness

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

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

Chickenpox, until all lesions have dried and crusted, which usually occurs by six days;
Shingles, only if the lesions cannot be covered by clothing or a dressing until the lesions have crusted;
Rash with fever or joint pain, until diagnosed not to be measles or rubella;
Measles, until four days after onset of the rash (if the staff member or substitute is immunocompetent);
Rubella, until six days after onset of rash;
Diarrheal illness, stool frequency exceeds two or more stools above normal for that individual or blood in stools, until diarrhea resolves; if E. coli 0157:H7 or Shigella is isolated, until diarrhea resolves and two stool cultures are negative, for Salmonella serotype Typhi, three stool cultures collected at twenty-four hour intervals and resolution of diarrhea is required;
Vomiting illness, two or more episodes of vomiting during the previous twenty-four hours, until vomiting resolves or is determined to result from non-infectious conditions;
Hepatitis A virus, until one week after symptom onset or as directed by the health department;
Pertussis, until after five days of appropriate antibiotic therapy;
Skin infection (such as impetigo), until treatment has been initiated; exclusion should continue if lesion is draining AND cannot be covered;
Tuberculosis, until noninfectious and cleared by a health department official or a primary care provider;
Strep throat or other streptococcal infection, until twenty-four hours after initial antibiotic treatment and end of fever;
Head lice, from the end of the day of discovery until after the first treatment;
Scabies, until after treatment has been completed;
Haemophilus influenzae type b (Hib), prophylaxis, until antibiotic treatment has been initiated;
Meningococcal infection, until appropriate therapy has been administered for twenty-four hours;
Respiratory illness, if the illness limits the staff member’s ability to provide an acceptable level of child care and compromises the health and safety of the children.

Caregivers/teachers who have herpes cold sores should not be excluded from the child care facility, but should:

Cover and not touch their lesions;
Carefully observe hand hygiene policies.

RATIONALE: Adults are as capable of spreading infectious disease as children (1-3). See also the rationale for Standard 3.6.1.1 Inclusion/Exclusion/Dismissal of Children.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Reves, R. R., L. K. Pickering. 1992. Impact of child day care on infectious diseases in adults. Infect Dis Clin North Amer 6:239-50.

3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.1.3: Thermometers for Taking Human Temperatures

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Healthy Children. 2010. Health issues: How to take a child’s temperature. American Academy of Pediatrics. http://www.healthychildren.org/English/health-issues/conditions/fever/pages/How-to-Take-a-Childs-Temperature.aspx.

2. Dodd, S. R., G. A. Lancaster, J. V. Craig, R. L. Smyth, P. R. Williamson. 2006. In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity. J Clin Epidemiol 59:354-57.

STANDARD 3.6.1.4: Infectious Disease Outbreak Control

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

RATIONALE: Secondary spread of infectious disease has been proven to occur in child care. Control of outbreaks of infectious diseases in child care may include age-appropriate immunization, antibiotic prophylaxis, observing well children for signs and symptoms of disease and for decreasing opportunities for transmission of that may sustain an outbreak. Removal of children known or suspected of contributing to an outbreak may help to limit transmission of the disease by preventing the development of new cases of the disease (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.

STANDARD 3.6.1.5: Sharing of Personal Articles Prohibited

Combs, hairbrushes, toothbrushes, personal clothing, bedding, and towels should not be shared and should be labeled with the name of the child who uses these objects.

RATIONALE: Respiratory and gastrointestinal infections are common infectious diseases in child care. These diseases are transmitted by direct person-to-person contact or by sharing personal articles such as combs, brushes, towels, clothing, and bedding. Prohibiting the sharing of personal articles and providing space so that personal items may be stored separately helps prevent these diseases from spreading.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

3.6.2 Caring for Children Who Are Ill

STANDARD 3.6.2.1: Exclusion and Alternative Care for Children Who Are Ill

At the discretion of the person authorized by the child care provider to make such decisions, children who are ill should be excluded from the child care facility for the conditions defined in Standard 3.6.1.1. When children are not permitted to receive care in their usual child care setting and cannot receive care from a parent/guardian or relative, they should be permitted to receive care in one of the following arrangements, if the arrangement meets the applicable standards:

Care in the child’s usual facility in a special area for care of children who are ill;
Care in a separate small family child care home or center that serves only children with illness or temporary disabilities;
Care by a child care provider in the child’s own home.

RATIONALE: Young children who are developing trust, autonomy, and initiative require the support of familiar caregivers and environments during times of illness to recover physically and avoid emotional distress (1). Young children enrolled in group care experience a higher incidence of mild illness (such as upper respiratory infections or otitis media) and other temporary disabilities (such as exacerbation of asthma) than those who have less interaction with other children. Sometimes, these illnesses preclude their participation in the usual child care activities. Most state regulations require that children with certain conditions be excluded from their usual care arrangement (2). To accommodate situations where parents/guardians cannot provide care for their own children who are ill, several types of alternative care arrangements have been established. The majority of viruses are spread by children who are asymptomatic, therefore, exposure of children to others with active symptoms or who have recently recovered, does not significantly raise the risk of transmission over the baseline (3).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Crowley, A. 1994. Sick child care: A developmental perspective. J Pediatric Health Care. 8:261-67.

2. National Resource Center for Health and Safety in Child Care and Early Education. 2010. Individual states child care licensure regulations. http://nrckids.org/STATES/states.htm.

3. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.2.2: Space Requirements for Care of Children Who Are Ill

Environmental space utilized for the care of children who are ill with infectious diseases and cannot receive care in their usual child care group should meet all requirements for well children and include the following additional requirements:

If the program for children who are ill is in the same facility as the well-child program, well children should not use or share furniture, fixtures, equipment, or supplies designated for use with children who are ill unless it has been cleaned and sanitized before use by well children;
Indoor space that the facility uses for children who are ill, including hallways, bathrooms, and kitchens, should be separate from indoor space used with well children; this reduces the likelihood of mixing supplies, toys, and equipment. The facility may use a single kitchen for ill and well children if the kitchen is staffed by a cook who has no child care responsibilities other than food preparation and who does not handle soiled dishes and utensils until after food preparation and food service are completed for any meal;
Children whose symptoms indicate infections of the gastrointestinal tract (often with diarrhea) who receive care in special facilities for children who are ill should receive this care in a space separate from other children with other illnesses to reduce the likelihood of disease being transmitted between children by limiting child-to-child interaction, separating staff responsibilities, and not mixing supplies, toys, and equipment;
If the facility cares for children with chickenpox, these children require a room with separate ventilation with exhaust to, and air exchange with, the outside (3);
Each child care room should have a handwashing sink that can provide a steady stream of water, between 60°F and 120°F, at least for ten seconds. Soap and disposable paper towels should be available at the handwashing sink at all times. A hand sanitizing dispenser is an alternative to traditional handwashing;
Each room where children who wear diapers receive care should have its own diaper changing area adjacent to a handwashing sink and/or hand sanitizer dispenser.

RATIONALE: Transmission of infectious diseases in child care settings may be influenced by the design, construction, and maintenance of the physical environment (2). The population that uses centers should in time become less susceptible to chickenpox through immunization. Some children, however, are too young to be routinely immunized and may be susceptible; and, although universal immunization with varicella vaccine is recommended, full compliance with the recommendation has not been achieved.

Chickenpox is readily spread by airborne droplets (1) or direct contact.

Handwashing sinks should be stationed in each room, to promote hand hygiene and also to give the caregivers/teachers an opportunity for continuous supervision of the other children in care when washing their hands. The sink must deliver a consistent flow of water for ten seconds so that the user does not need to touch the faucet handles. Diaper changing areas should be adjacent to sinks to foster cleanliness and also to enable caregivers/teachers to provide continuous supervision of other children in care. The provision of alcohol-based hand sanitizing dispensers may be an alternative to traditional handwashing with soap and water.

COMMENTS: Some facilities have staffed “get well” rooms typically caring for fewer than six children who are ill.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

2. Staes, C., S. Balk, K. Ford, R. J. Passantino, A. Torrice. 1994. Environmental factors to consider when designing and maintaining a child’s day-care environment. Pediatrics 94:1048-50.

3. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.2.3: Qualifications of Directors of Facilities That Care for Children Who Are Ill

The director of a facility that cares for children who are ill should have the following minimum qualifications, in addition to the general qualifications described in Director’s Qualifications, Standards 1.3.1.1 and 1.3.1.2:

At least forty hours of training in prevention and control of infectious diseases and care of children who are ill, including subjects listed in Standard 3.6.2.5;
At least two prior years of satisfactory performance as a director of a regular facility;
At least twelve credit hours of college-level training in child development or early childhood education.

RATIONALE: The director should be college-prepared in early childhood education and have taken college-level courses in illness prevention and control, since the director is the person responsible for establishing the facility’s policies and procedures and for meeting the training needs of new staff members (1).

TYPE OF FACILITY: Center

REFERENCES:

1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

STANDARD 3.6.2.4: Program Requirements for Facilities That Care for Children Who Are Ill

Any facility that offers care for the child who is ill of any age should:

Provide a caregiver/teacher who is familiar to the child;
Provide care in a place with which the child is familiar and comfortable away from other children in care;
Involve a caregiver/teacher who has time to give individual care and emotional support, who knows of the child’s interests, and who knows of activities that appeal to the level of child development age group and to a sick child;
Offer a program with trained personnel planned in consultation with qualified health care personnel and with ongoing medical direction.

RATIONALE: When children are ill, they are stressed by the illness itself. Unfamiliar places and caregivers/teachers add to the stress of illness when a child is sick. Since illness tends to promote regression and dependency, children who are ill need a person who knows and can respond to the child’s cues appropriately.

COMMENTS: Because children are most comfortable in a familiar place with familiar people, the preferred arrangement for children who are ill will be the child’s home or the child’s regular child care arrangement, when the child care facility has the resources to adapt to the needs of such children.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

STANDARD 3.6.2.5: Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill

Each caregiver/teacher in a facility that cares for children who are ill should have at least two years of successful work experience as a caregiver/teacher in a regular well-child facility prior to employment in the special facility. In addition, facilities should document, for each caregiver/teacher, twenty hours of pre-service orientation training on care of children who are ill beyond the orientation training specified in Standards 1.4.2.1 through Standard 1.4.2.3. This training should include the following subjects:

Pediatric first aid and CPR, and first aid for choking;
General infection-control procedures, including:
1. Hand hygiene;
2. Handling of contaminated items;
3. Use of sanitizing chemicals;
4. Food handling;
5. Washing and sanitizing of toys;
6. Education about methods of disease transmission.
Care of children with common mild childhood illnesses, including:
1. Recognition and documentation of signs and symptoms of illness including body temperature;
2. Administration and recording of medications;
3. Nutrition of children who are ill;
4. Communication with parents/guardians of children who are ill;
5. Knowledge of immunization requirements;
6. Recognition of need for medical assistance and how to access;
7. Knowledge of reporting requirements for infectious diseases;
8. Emergency procedures.
Child development activities for children who are ill;
Orientation to the facility and its policies.

This training should be documented in the staff personnel files, and compliance with the content of training routinely evaluated. Based on these evaluations, the training on care of children who are ill should be updated with a minimum of six hours of annual training for individuals who continue to provide care to children who are ill.

RATIONALE: Because meeting the physical and psychological needs of children who are ill requires a higher level of skill and understanding than caring for well children, a commitment to children and an understanding of their general needs is essential (1). Work experience in child care facilities will help the caregiver/teacher develop these skills. States that have developed rules regulating facilities have recognized the need for training in illness prevention and control and management of medical emergencies. Staff members caring for children who are ill in special facilities or in a get well room in a regular center should meet the staff qualifications that are applied to child care facilities generally.

Caregivers/teachers have to be prepared for handling illness and must understand their scope of work. Special training is required of caregivers/teachers who work in special facilities for children who are ill because the director and the caregivers/teachers are dealing with infectious diseases and need to know how to prevent the spread of infection. Each caregiver/teacher should have training to decrease the risk of transmitting disease (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Heymann, S. J., P. Hong Vo, C. A. Bergstrom. 2002. Child care providers’ experiences caring for sick children: Implications for public policy. Early Child Devel Care 172:1-8.

STANDARD 3.6.2.6: Child-Staff Ratios for Facilities That Care for Children Who Are Ill

Each facility for children who are ill should maintain a child-to-staff ratio no greater than the following:

Age of Children	Child to Staff Ratio
3-35 months	3 children to 1 staff member
36-71 months	4 children to 1 staff member
72 months and older	6 children to 1 staff member

RATIONALE: Some states stipulate the ratios for caring for children who are ill in their regulations. The expert consensus is based on theories of child development including attachment theory and recognition of children’s temporary emotional regression during times of illness (1-3); the lowest ratios used per age group seem appropriate.

COMMENTS: These ratios do not include other personnel, such as bus drivers, necessary for specialized functions such as transportation.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Davies, D. 1999. Child development: A practitioner’s guide. New York: The Guilford Press.

2. Schumacher, R. 2008. Charting progress for babies in child care: CLASP center ratios and group sizes – Research based rationale. http://www.clasp.org/admin/site/babies/make_the_case/files/cp_rationale6.pdf.

3. Crowley, A. A. 1994. Sick child care: A developmental perspective. J Pediatric Health Care 8:261-67.

STANDARD 3.6.2.7: Child Care Health Consultants for Facilities That Care for Children Who Are Ill

Each special facility that provides care for children who are ill should use the services of a child care health consultant for ongoing consultation on overall operation and development of written policies relating to health care. The child care health consultant should have the knowledge, skills and preparation as stated in Standard 1.6.0.1.

The facility should involve the child care health consultant in development and/or implementation, review, and sign-off of the written policies and procedures for managing specific illnesses. The facility staff and the child care health consultant should review and update the written policies annually.

The facility should assign the child care health consultant the responsibility for reviewing written policies and procedures for the following:

Admission and readmission after illness, including inclusion/exclusion criteria;
Health evaluation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance;
Plans for health care and for managing children with infectious diseases;
Plans for surveillance of illnesses that are admissible and problems that arise in the care of children with illness;
Plans for staff training and communication with parents/guardians and primary care providers;
Plans for injury prevention;
Situations that require medical care within an hour.

RATIONALE: Appropriate involvement of child care health consultants is especially important for facilities that care for children who are ill. Facilities should use the expertise of primary care providers to design and provide a child care environment with sufficient staff and facilities to meet the needs of children who are ill (2,3). The best interests of the child and family must be given primary consideration in the care of children who are ill. Consultation by primary care providers, especially those whose specialty is pediatrics, is critical in planning facilities for the care of children who are ill (1).

COMMENTS: Caregivers/teachers should seek the services of a child care health consultant through state and local professional organizations, such as:

Healthy Child Care Consultant Network Support Center (maintains a national registry of NTI-trained CCHCs);
Local chapters of the American Academy of Pediatrics (AAP);
Local Children’s hospital;
American Nurses Association (ANA);
Visiting Nurse Association (VNA);
American Academy of Family Physicians (AAFP);
National Association of Pediatric Nurse Practitioners (NAPNAP);
National Association for the Education of Young Children (NAEYC);
National Association for Family Child Care (NAFCC);
National Association of School Nurses (NASN);
Emergency Medical Services for Children (EMSC) National Resource Center;
National Training Institute for Child Care Health Consultants (NTI);
State or local health department (especially public health nursing, infectious disease, and epidemiology departments).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Donowitz, L. G., ed. 1996. Infection control in the child care center and preschool, 18-19, 68. 2nd ed. Baltimore, MD: Williams and Wilkins.

2. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child care centers. Infect Dis Clin North Am 11:347-65.

3. Crowley A. A. 2000. Child care health consultation: The Connecticut experience. Matern Child Health J 4:67-75.

STANDARD 3.6.2.8: Licensing of Facilities That Care for Children Who Are Ill

A facility may care for children with symptoms requiring exclusion provided that the licensing authority has given approval of the facility, written plans describing symptoms and conditions that are admissible, and procedures for daily care. In jurisdictions that lack regulations and licensing capacity for facilities that care for children who are ill, the child care health consultant with the local health authority should review these plans and procedures annually in an advisory capacity.

RATIONALE: Facilities for children who are ill generally are required to meet the licensing requirements that apply to all facilities of a specific type, for example, small or large family child care homes or centers. Additional requirements should apply when children who are ill will be in care.

This standard ensures that child care facilities are continually reviewed by an appropriate state authority and that facilities maintain appropriate standards in caring for children who are ill.

COMMENTS: If a child care health consultant is not available, than the local health authority should review plans and procedures annually.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

STANDARD 3.6.2.9: Information Required for Children Who Are Ill

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

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

Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (2). Confidentiality should be maintained at each step in compliance with any laws or regulations that are pertinent to all parties such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Insurance Portability and Accountability Act (commonly known as HIPAA) (2).

RATIONALE: The caregiver/teacher must have child-specific information to provide optimum care for each child who is ill and to make appropriate decisions regarding whether to include or exclude a given child. The caregiver/teacher must have contact information for the child’s source of primary health care or specialty health care (in the case of a child with asthma, diabetes, etc.) to assist with the management of any situation that arises.

COMMENTS: For school-age children, documentation of the care of the child during the illness should be provided to the parent to deliver to the school health program upon the child’s return to school. Coordination with the child’s source of health care and school health program facilitates the overall care of the child (1).

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Beierlein, J. G., J. E. Van Horn. 1995. Sick child care. National Network for Child Care. http://www.nncc.org/eo/emp.sick.child
.care.html.

2. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.2.10: Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill

Facilities that care for children who are ill who have conditions that require additional attention from the caregiver/teacher, should arrange for or ask the child care health consultant to arrange for a clinical health evaluation, by a licensed primary care provider, for each child who is admitted to the facility. These facilities should include children with conditions listed in Standard 3.6.1.1 if their policies and plans address the management of these conditions, except for the following conditions which require exclusion from all types of child care facilities that are not medical care institutions (such as hospitals or skilled nursing facilities):

Fever (see COMMENTS section for definition of fever) and a stiff neck, lethargy, irritability, or persistent crying;
Diarrhea (loose stools, not contained in the diaper, that are two or more greater than normal frequency) and one or more of the following:
1. Signs of dehydration, such as dry mouth, no tears, lethargy, sunken fontanelle (soft spot on the head);
2. Blood or mucus in the stool until it is evaluated for organisms tha can cause dysentery;
3. Diarrhea caused by Salmonella, Campylobacter, Giardia, Shigella or E.coli 0157:H7 until specific criteria for treatment and return to care are met.
Vomiting with signs of dehydration and inability to maintain hydration with oral intake;
Contagious stages of pertussis, measles, mumps, chickenpox, rubella, or diphtheria, unless the child is appropriately isolated from children with other illnesses and cared for only with children having the same illness;
Untreated infestation of scabies or head lice;
Untreated infectious tuberculosis;
Undiagnosed rash WITH fever or behavior change;
Abdominal pain that is intermittent or persistent and is accompanied by fever, diarrhea, or vomiting;
Difficulty in breathing;
An acute change in behavior;
Undiagnosed jaundice (yellow skin and whites of eyes);
Other conditions as may be determined by the director or child care health consultant;
Upper or lower respiratory infection in which signs or symptoms require a higher level of care than can be appropriately provided.

RATIONALE: These signs and symptoms may indicate a significant systemic infection that requires professional medical management and parental care (1). Diarrheal illnesses that require an intensity of care that cannot be provided appropriately by a caregiver/teacher could result in temporary exclusion.

COMMENTS: Fever is defined as a temperature above 101°F (38.3°C) orally, above 102°F (38.9°C) rectally, or 100°F (37.8°C) or higher taken axillary (armpit) or measured by an equivalent method.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

3.6.3 Medications

STANDARD 3.6.3.1: Medication Administration

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

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

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.

2. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medications in children. Pediatrics 121:783-87.

3. Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.

4. Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/10_11_07_OralInfantMedicines.aspx.

5. U.S. Department of Health and Human Services, Food and Drug Administration. 2008. Public Health advisory: FDA recommends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm051137.htm.

6. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Slone Survey. Pediatrics 122: e323-29.

7. American Academy of Pediatrics. 2008. AAP Urges caution in use of over-the-counter cough and cold medicines. http://www.aap.org/advocacy/releases/jan08coughandcold.htm.

STANDARD 3.6.3.2: Labeling, Storage, and Disposal of Medications

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

The child’s first and last names;
The date the prescription was filled;
The name of the prescribing health professional who wrote the prescription, the medication’s expiration date;
The manufacturer’s instructions or prescription label with specific, legible instructions for administration, storage, and disposal;
The name and strength of the medication.

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

All medications, refrigerated or unrefrigerated, should:

Have child-resistant caps;
Be kept in an organized fashion;
Be stored away from food;
Be stored at the proper temperature;
Be completely inaccessible to children.

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

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

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

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

COMMENTS: A small lock box can be kept in the refrigerator to hold medications. Programs may also consult with their local pharmacy regarding disposal. For more information on medication take back programs see Teleosis Institute at http://www.teleosis.org/gpp-national.php.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. U.S. Food and Drug Administration. 2010. Disposal by flushing of certain unused medicines: What you should know. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
EnsuringSafeUseofMedicine/SafeDisposalofMedicines/
ucm186187.htm.

2. U.S. Environmental Protection Agency. 2009. Pharmaceuticals and personal care products as pollutants (PPCPs). http://www.epa
.gov/ppcp/.

STANDARD 3.6.3.3: Training of Caregivers/Teachers to Administer Medication

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

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

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

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

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

COMMENTS: Caregivers/teachers need to know the state laws and regulations on training requirements for the administration of medications in out-of-home child care settings. These laws may include requirements for delegation of medication administration from a primary care provider. Training on medication administration for caregivers/teachers is available in several states. Model Child Care Health Policies, 2nd Ed. from Healthy Child Care Pennsylvania is available at http://www.ecels-healthychildcarepa.org/content/
MHP4thEd Total.pdf, and contains sample polices and forms related to medication administration.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and administration in child care settings: A case study. Policy, Politics, and Nursing Practice 6:86-98.

2. Qualistar Early Learning. 2008. Colorado Medication Administration Curriculum. 5th ed. http://www.qualistar.org/medication-administration.html.

3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/hsp/ccquality-ind02/.

4. Calder, J. 2004. Medication administration in child care programs. Health and Safety Notes. Berkeley, CA: California Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/medadminEN102004_adr.pdf.

5. Vernacchio, L., J. P. Kelly, D. W. Kaufman, A. A. Mitchell. 2009. Medication use among children <12 years of age in the United States: Results from the Slone Survey. Pediatrics 124:446-54.

3.6.4 Reporting Illness and Death

STANDARD 3.6.4.1: Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease

Caregivers/teachers should work collaboratively with local and state health authorities to notify parents/guardians about potential or confirmed exposures of their child to a infectious disease. Notification should include the following information:

The names, both the common and the medical name, of the diagnosed disease to which the child was exposed, whether there is one case or an outbreak, and the nature of the exposure (such as a child or staff member in a shared room or facility);
Signs and symptoms of the disease for which the parent/guardian should observe;
Mode of transmission of the disease;
Period of communicability and how long to watch for signs and symptoms of the disease;
Disease-prevention measures recommended by the health department (if appropriate);
Control measures implemented at the facility;
Pictures of skin lesions or skin condition may be helpful to parents/guardians (i.e., chicken pox, spots on tonsils, etc.)

The notice should not identify the child who has the infectious disease.

RATIONALE: Effective control and prevention of infectious diseases in child care depends on affirmative relationships between parents/guardians, caregivers/teachers, public health authorities, and primary care providers.

COMMENTS: The child care health consultant can locate appropriate photographs of conditions for parent/guardian information use. Resources for fact sheets and photographs include: Managing Infectious Diseases in Child Care and Schools, 2nd Edition (1) and the Centers for Disease Control and Prevention Website on conditions and diseases at http://www.cdc.gov/DiseasesConditions/. For a sample letter to parents notifying them of illness of their child or other enrolled children, see Healthy Young Children, available from the National Association for the Education of Young Children (NAEYC) at http://www.naeyc.org.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.4.2: Infectious Diseases That Require Parent/Guardian Notification

In cooperation with the child care regulatory authority and health department, the facility or the health department should inform parents/guardians if their child may have been exposed to the following diseases or conditions while attending the child care program, while retaining the confidentiality of the child who has the infectious disease:

Neisseria meningitidis (meningitis);
Pertussis;
Invasive infections;
Varicella-zoster (Chickenpox) virus;
Skin infections or infestations (head lice, scabies, and ringworm);
Infections of the gastrointestinal tract (often with diarrhea) and hepatitis A virus (HAV);
Haemophilus influenzae type B (Hib);
Parvovirus B19 (fifth disease);
Measles;
Tuberculosis;
Two or more affected unrelated persons affiliated with the facility with a vaccine-preventable or infectious disease.

RATIONALE: Early identification and treatment of infectious diseases are important in minimizing associated morbidity and mortality as well as further reducing transmission (1). Notification of parents/guardians will permit them to discuss with their child’s primary care provider the implications of the exposure and to closely observe their child for early signs and symptoms of illness.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.4.3: Notification of the Facility About Infectious Disease or Other Problems by Parents

Upon registration of each child, the facility should inform parents/guardians that they must notify the facility within twenty-four hours after their child or any member of the immediate household has developed a known or suspected infectious or vaccine-preventable disease (1). When a child has a disease that may require exclusion, the parents/guardians should inform the facility of the diagnosis.

The facility should encourage parents/guardians to inform the caregivers/teachers of any other problems which may affect the child’s behavior.

RATIONALE: This requirement will facilitate prompt reporting of disease and enable the caregiver/teacher to provide better care. Disease surveillance and reporting to local health authorities is crucial to preventing and controlling diseases in the child care setting. The major purpose of surveillance is to allow early detection of disease and prompt implementation of control measures. If it is known that the child attends another center or facility, all facilities should be informed (for example, if the child attends a Head Start program and a child care program that are separate–then both need to be notified and the notification of local health authority should name both facilities).

Ascertaining whether a child who is ill is attending a facility is important when evaluating childhood illnesses. Ascertaining whether an adult with illness is working in a facility or is a parent/guardian of a child attending a facility is important when considering infectious diseases that are more commonly manifest in adults. Cases of illness in family member such as infections of the gastrointestinal tract (with diarrhea), or infections of the liver may necessitate questioning about possible illness in the child attending child care. Information concerning infectious disease in a child care attendee, staff member, or household contact should be communicated to public health authorities, to the child care director, and to the child’s parents/guardians.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

STANDARD 3.6.4.4: List of Excludable and Reportable Conditions for Parents/Guardians

The facility should give to each parent/guardian a written list of conditions for which exclusion and dismissal may be indicated (2).

For the following symptoms, the caregiver/teacher should ask parents to have the child evaluated by a primary care provider. The advice of the primary care provider should be documented for the caregiver/teacher in the following situations:

The child has any of the following conditions: fever, lethargy, irritability, persistent crying, difficult breathing, or other manifestations of possible severe illness;
The child has a rash with fever and behavioral change;
The child has tuberculosis that has not been evaluated;
The child has scabies;
The child has a persistent cough with inability to practice respiratory etiquette.

The facility should have a list of reportable diseases provided by the health department and should provide a copy to each parent/guardian.

RATIONALE: Vomiting with symptoms such as lethargy and/or dry skin or mucous membranes or reduced urine output may indicate dehydration, and the child should be medically evaluated. Diarrhea with fever or other symptoms usually indicates infection. Blood and/or mucus may indicate shigellosis or infection with E. coli 0157:H7, which should be evaluated. Effective control and prevention of infectious diseases in child care depend on affirmative relationships between parents, caregivers, health departments, and primary care providers (1).

COMMENTS: If there is more than one case of vomiting in the facility, it may indicate either contagious illness or food poisoning.

If a child with abdominal pain is drowsy, irritable, and unhappy, has no appetite, and is unwilling to participate in usual activities, the child should be seen by that child’s primary care provider. Abdominal pain may be associated with viral, bacterial, or parasitic gastrointestinal tract illness, which is contagious, or with food poisoning. It also may be a manifestation of another disease or illness such as kidney disease. If the pain is severe or persistent, the child should be referred for medical consultation (by telephone, if necessary).

If the caregiver/teacher is unable to contact the parent/guardian, medical advice should be sought until the parents can be located.

The facility should post the health department’s list of infectious diseases as a reference. The facility should inform parents/guardians that the program is required to report infectious diseases to the health department.

For information on assisting families in finding a medical home or primary care provider, consult the local chapter of the American Academy of Pediatrics (AAP), the facility’s child care health consultant, Nurse Practitioner Central (3), the local public health department, or the American Academy of Family Physicians (AAFP). For more information, see also the AAP Managing Infectious Diseases in Child Care and Schools, 2nd ed., available at http://www.aap.org.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long. 2009. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics.

2. Donowitz, L. G., ed. 1996. Infection control in the child care center and preschool, 18-19, 68. 2nd ed. Baltimore, MD: Williams and Wilkins.

3. Nurse Practitioner Central. 2003. National nurse practitioner directory. http://www.npclinics.com.

STANDARD 3.6.4.5: Death

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

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

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

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

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

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

RATIONALE: Following the steps described in this standard would constitute prudent action (1-3). Accurate information given to parents/guardians and children will help them understand the event and facilitate their support of the caregiver/teacher (4-7).

COMMENTS: It is important that caregivers/teachers are knowledgeable about SIDS and that they take proper steps so that they are not falsely accused of child abuse and neglect. The licensing agency and/or a SIDS agency support group (e.g., CJ Foundation for SIDS at http://www.cjsids
.org, the National Sudden and Unexpected Infant/Child Death and Pregnancy Loss Resource Center at http://www
.sidscenter.org, and First Candle at http://www.firstcandle
.org) can offer support and counseling to caregivers/teachers.

TYPE OF FACILITY: Center; Large Family Child Care Home; Small Family Child Care Home

REFERENCES:

1. Moon, R. Y., K. M. Patel, S. J. M. Shaefer. 2000. Sudden infant death syndrome in child care settings. Pediatrics 106:295-300.

2. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.

3. Moon, R. Y., L. Kotch, L. Aird. 2006. State child care regulations regarding infant sleep environment since the Healthy Child Care America – Back to Sleep Campaign. Pediatrics 118:73-83.

4. Boston Medical Center. Good grief program. http://www.bmc.org/pediatrics-goodgrief.htm.

5. Rivlin, D. The good grief program of Boston Medical Center: What do children need? Boston Medical Center. http://www.wayland.k12.ma.us/claypit_hill/GoodGriefHandout.pdf.

6. Trozzi, M. 1999. Talking with children about Loss: Words, strategies, and wisdom to help children cope with death, divorce, and other difficult times. New York: Berkley Publishing Group.

7. Knapp, J., D. Mulligan-Smith, Committee on Pediatric Emergency Medicine. 2005. Death of a child in the emergency department. Pediatrics 115:1432-37.