CHILD:STAFF RATIO AND GROUP SIZE
RATIOs for SMALL FAMILY CHILD CARE Homes
The small family child care home provider child:staff ratios shall conform to the following table:
If the small family child care home provider has no children under two years of age in care,
|
then the small family child care home provider may have 1-6 children over two years of age in care
|
If the small family child care home provider has 1 child under two years of age in care,
|
then the small family child care home provider may have 1-3 children over two years of age in care
|
If the small family child care home provider has 2 children under two years of age in care,
|
then the small family child care home provider may have no children over two years of age in care
|
The small family child care home provider's own children shall be included in the child:staff ratio.
RATIONALE: Although child:staff ratios alone do not predict the quality of care, direct warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Care - givers must be recognized as performing a job for groups of children that parents of twins, triplets, or quadruplets would rarely be left to handle alone.
In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes.
Low child:staff ratios are most critical for infants and young toddlers (0 to 24 months) (
1). Infant development and caregiving quality improves when group size and child:staff ratios are smaller (
2). Improved verbal interactions are correlated with lower child:staff ratios (
3). For 3- and 4-year old children, the size of the group is even more important than ratios. The recommended group size and child:staff ratio allow 3- to 5- year old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (
4).
The National Fire Protection Association (NFPA) requires in the
NFPA-101 Life Safety Code that small family child care homes serve no more than 2 clients incapable of self-preservation (
6).
COMMENTS: Some states are setting limits on the number of school-age children that are allowed to be cared for in small family child care homes, e.g., two school-age children in addition to the maximum number allowed for infants/preschool children. No data are available to support using a different ratio where school-age children are in family child care homes. Since school-age children require focused caregiver time and attention for supervision and adult-child interaction, this standard applies the same ratio to all children over two years of age. The family child care provider must be able to have a positive relationship and provide guidance for each child in care.
Unscheduled inspections encourage compliance with this standard.
For more information regarding brain development in children in child care, see STANDARD 1.010.
TYPE OF FACILITY:
Small Family Child Care Home
RATIOS FOR LARGE FAMILY CHILD CARE HOMES AND CENTERS
Child:staff ratios in centers and large family child care homes shall be maintained as follows during all hours of operation, including transport and nap times:
During nap time, at least one adult shall be physically present in the same space as the children.
Other adults who are included in the child:staff ratio need not be in the same space with the children when all the children are napping. However, in case of emergency, these adults shall be on the same floor and shall have no barrier to their coming to help immediately. The caregiver who is in the same space with the children shall be able to summon these adults without leaving the children.
When there are mixed age groups in the same room, the child:staff ratio and group size shall be consistent with the age of most of the children when no infants or toddlers are in the mixed age group. When infants or toddlers are in the mixed age group, the child:staff ratio and group size for infants and toddlers shall be maintained. In large family child care homes with two or more care-givers caring for no more than 12 children, no more than three children younger than 2 years of age shall be in care.
RATIONALE: These child:staff ratios are within the range of recommendations for each age group that the National Association for the Education of Young Children (NAEYC) uses in its accreditation program (
5). The NAEYC recommends a range that assumes the director and staff are highly trained and, by virtue of the accreditation process, has determined a staffing pattern that enables effective staff function. The standard for child:staff ratios in this document uses a single desired ratio, rather than a range, for each age group. In some cases, these child:staff ratios and group sizes are the more stringent ratios and group sizes recommended in the National Research Council's report,
Who Cares for America's Children? Child Care Policy for the 1990s (
1). According to the National Research Council, child:staff ratios and group size are two of the four most important areas to be addressed in national standards.
Children with special health care needs may require additional staff on-site, depending on their special need and extent of disability (
1).
Low child:staff ratios for non-ambulatory children are essential for fire safety. The National Fire Protection Association, in its
NFPA-101 Life Safety Code, recommends that no more than three children younger than 2 years of age be cared for in large family child care homes where two staff members are caring for up to 12 children (
6).
Children benefit from social interactions with peers. However, larger groups are generally associated with less positive interactions and developmental outcomes. Group size and ratio of children to adults are limited to allow for one to one interaction, intimate knowledge of individual children, and consistent caregiving (
7).
Although child:staff ratios alone do not predict the quality of care, direct warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers must be recognized as performing a job for groups of children that parents of twins, triplets, or quadruplets would rarely be left to handle alone.
In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes.
Low child:staff ratios are most critical for infants and young toddlers (0 to 24 months) (
1). Infant development and caregiving quality improves when group size and child:staff ratios are smaller (
2). Improved verbal interactions are correlated with lower ratios (
3). For 3- and 4-year old children, the size of the group is even more important than ratios. The recommended group size and child:staff ratio allow 3- to 5- year old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (
4).
In addition, the children's physical safety and sanitation routines require a staff that is not fragmented by excessive demands. Child:staff ratios in child care settings should be sufficiently low to keep staff stress below levels that might result in anger with children. Caring for too many young children, in particular, increases the possibility of stress to the caregiver, and may result in loss of self-control.
Although observation of sleeping children does not require the physical presence of more than one caregiver, the staff needed for an emergency response or evacuation of the children must remain available for this purpose. Nap time may be the best option for regular staff conferences and staff training, but these activities should take place in an area next to the room where the children are sleeping so no barrier will prevent the staff from assisting if emergency evacuation becomes necessary.
COMMENTS: The child:staff ratio indicates the maximum number of children permitted per caregiver (
8). These ratios assume that caregivers do not have time-consuming bookkeeping and housekeeping duties, so they are free to provide direct care for children. The ratios do not include other personnel (such as bus drivers) necessary for specialized functions (such as driving a vehicle).
Group size is the number of children assigned to a caregiver or team of caregivers occupying an individual classroom or well-defined space within a larger room (
8).The "group" in child care represents the "homeroom" for school-age children. It is the psychological base with which the child identifies and from which the child gains continual guidance and support in various activities. This standard does not prohibit larger numbers of children from joining in collective activities as long as child:staff ratios and the concept of "home room" are maintained.
Unscheduled inspections encourage compliance with this standard.
These standards are based on what children need for quality nurturing care. Those who question whether these ratios are affordable must consider that our efforts to limit costs have resulted in overlooking the basic needs of children and creating a highly stressful work environment for caregivers. Community resources other than parent fees and a greater public investment in child care are critical to achieving the child:staff ratios and group sizes specified in this standard.
For more information regarding brain development in children in child care, see STANDARD 1.010.
TYPE OF FACILITY:
Center; Large Family Child Care Home
RATIOS FOR FACILITIES SERVING CHILDREN WITH SPECIAL HEALTH NEEDS
Facilities enrolling children with special needs shall determine, by an individual assessment of each child's needs, whether the facility requires a lower child:staff ratio.
RATIONALE: The child:staff ratio must allow the needs of the children enrolled to be met. The facility should have sufficient direct care professional staff to provide the required programs and services. Integrated facilities with fewer resources may be able to serve children who need fewer services, and the staffing levels may vary accordingly. Adjustment of the ratio allows for the flexibility needed to meet the child's type and degree of special need. The facility should seek consultation with parents and other professionals regarding the appropriate child:staff ratio and may wish to increase the number of staff members if the child requires significant special assistance.
COMMENTS: These ratios do not include personnel who have other duties that might preclude their involvement in needed supervision while they are performing those duties, such as cooks, maintenance workers, or bus drivers.
TYPE OF FACILITY:
Center; Large Family Child Care Home: Small Family Child Care Home
PRESERVICE QUALIFICATIONS AND SPECIAL TRAINING
PRESERVICE AND ONGOING STAFF TRAINING
In addition to the credentials listed in STANDARD 1.014, prior to employment, a director of a center or a small family child care home network enrolling 30 or more children shall provide documentation of at least 26 clock hours of training in health, psychosocial, and safety issues for out-of-home child care facilities.
Small family child care home providers shall provide documentation of at least 12 hours of training in child development and health management for out-of-home child care facilities prior to initiating operation.
All directors and caregivers shall document receipt of training that revisits the following topics every 3 years:
a) Child development knowledge and best practice, including knowledge about the developmental stages of each child in care;
b) Child care as a support to parents;
d) Ways that communicable diseases are spread;
e) Procedures for preventing the spread of communicable disease, including handwashing, sanitation, diaper changing, food handling, health department notification of reportable diseases, equipment, toy selection and proper washing, sanitizing to reduce the risk for disease and injury, and health issues related to having pets in the facility;
f) Immunization requirements for children and staff, as defined in STANDARD 1.045;
g) Common childhood illnesses and their management, including child care exclusion policies;
h) Organization of the facility to reduce the risks for illness and injury;
i) Teaching child care staff and children about infection control and injury prevention;
j) Staff occupational health and safety practices, such as proper procedures, in accordance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations;
k) Emergency procedures, as defined in STANDARD 3.048 through STANDARD 3.052;
l) Promotion of health in the child care setting, through compliance with STANDARD 3.001 through STANDARD 3.089;
m) Management of a blocked airway, rescue breathing, and other first aid procedures, as required in STANDARD 1.026;
n) Recognition and reporting of child abuse in compliance with state laws;
p) Knowledge of medication administration policies and practices;
q) Caring for children with special needs in compliance with the Americans with Disabilities Act (ADA);
RATIONALE: The director of a center or large family child care home or the small family child care home provider is the person accountable for all policies. Basic entry-level knowledge of health and safety is essential to administer the facility. Caregivers must
be knowledgeable about infectious disease because properly implemented health policies can reduce the spread of disease, not only among the children but also among staff members, family members, and in the greater community. Knowledge of injury prevention measures in child care is essential to control known risks. Pediatric first aid training is important because the director or small family child care home provider is fully responsible for all aspects of the health of the children in care.
COMMENTS: The American Academy of Pediatrics (AAP) and the National Association for the Education of Young Children (NAEYC) published a set of videos, based on the first edition of
Caring for Our Children, that illustrates how to meet the standards in centers and family child care homes. This six-part video series is accompanied by a set of reproducible handouts for training. Other training materials, including videos, workshop curricula, and print materials suitable for training of caregivers, are also available from the AAP and NAEYC. Contact information for the AAP and the NAEYC is located in Appendix BB.
Training in infectious disease control and injury prevention is strongly recommended. This type of training may be obtained from qualified personnel of children's and community hospitals, managed care companies, health agencies, public health departments, pediatric emergency room physicians, or other health professionals in the community.
For more information about training opportunities, contact the AAP, Healthy Child Care America Project, the National Resource Center for Health and Safety in Child Care, or the National Training Institute for Child Care Health Consultants (at the University of North Carolina). Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
GENERAL QUALIFICATIONS OF DIRECTORS
The director of a center enrolling fewer than 60 children shall be at least 21 years old and shall have the following qualifications:
a) A Bachelor's degree in early childhood education, child development, social work, nursing, or other child related field OR a combination of college coursework and experience, including:
1) A minimum of four courses in child development and early childhood education;
2) Two years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children enrolled in the center where the individual will act as the director;
3) A course in business administration or early childhood administration, or at least 6 months of on the job training in an administrative position;
c) A valid certificate in pediatric first aid, including management of a blocked airway, and rescue breathing, as specified in First Aid and CPR, STANDARD 1.026 through
STANDARD 1.028;
d) Knowledge of community resources available to children with special needs and the ability to use these resources to make referrals or achieve interagency coordination;
e) Administrative and management skills in facility operations;
f) Capability in curriculum design;
g) Oral and written communication skills;
h) Demonstrated life experience skills in working with children in more than one setting.
The director of a center enrolling more than 60 children shall have the above and at least 3 years experience as a teacher of children in the age group(s) enrolled in the center where the individual will act as the director, plus at least 6 months experience in administration.
RATIONALE: The director of the facility is the team leader of a small business. Both administrative and child development skills are essential for this individual to manage the facility and set appropriate expectations. College-level coursework has been shown to have a measurable, positive effect on quality child care, whereas experience per se has not (
3,
10,
11).
The director of a center plays a pivotal role in ensuring the day-to-day smooth functioning of the facility within the framework of appropriate child development principles and knowledge of family relationships.
The well-being of the children, the confidence of the parents of children in the facility's care, and the high morale and consistent professional growth of the staff depend largely upon the knowledge, skills, and dependable presence of a director who is able to respond to long-range and immediate needs and able to engage staff in decision-making that affects their day-to-day practice. Management skills are important and should be viewed primarily as a means of support for the key role of educational leadership that a director provides. A skilled director should know how to use community resources and to identify specialized personnel to enrich the staff's understanding of behavior and curriculum content. Past experience working in an early childhood setting is essential to running a facility.
Life experience may include experience rearing one's own children or previous personal experience acquired in any child care setting. Work as a hospital aide or at a camp for children with special needs would qualify, as would experience in school settings. This experience, however, must be supplemented by competency-based training to determine and provide whatever new skills are needed to care for children in child care settings.
COMMENTS: The profession of early childhood education is being informed by research on the association of developmental outcomes with specific practices. The exact combination of college coursework and supervised experience is still being developed. For example, the National Association for the Education of Young Children (NAEYC) has published the
Guidelines for Preparation of Early Childhood Professionals (
12). Additional information on the early childhood education profession is available from Wheelock College Institute for Leadership and Career Initiatives. The National Child Care Association (NCCA) has developed a 40-hour curriculum based on administrator competencies (
13). Contact information for the NAEYC, the Wheelock College Institute for Leadership and Career Initiatives, and the NCCA is located in Appendix BB.
The qualifications stipulated in the AAP/APHA standards, as well as state and local regulations for administrators of child care facilities that serve typically developing children, may require supplementation because of the special requirements of the populations of children with special needs. The center is one component in a network of services for children with special needs in most communities. Every state participating in Part C of IDEA is required to have a directory of services. Having a directory of services available is useful and could fulfill part of the requirement. Many communities have agencies, such as local resource and referral agencies, that gather information about services available to children with special needs.
For additional information on qualifications for directors of centers, see General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.013; and Training, STANDARD 1.023 through STANDARD 1.036.
QUALIFICATIONS OF EDUCATION COORDINATORS, LEAD TEACHERS, AND TEACHERS
Education coordinators, lead teachers, and teachers shall be at least 21 years of age and shall have at least the following education, experience, and skills:
a) A Bachelor's degree in early childhood education, child development, social work, nursing, or other child-related field, or a combination of experience and relevant college coursework;
b) One year or more years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children in care;
c) On-the-job training to provide a nurturing environment and to meet the child's out-of-home needs;
d) A valid certificate in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in First Aid and CPR, STANDARD 1.026 through
STANDARD 1.028;
e) Knowledge of normal child development and early childhood education, as well as knowledge of children who are not developing typically;
f) The ability to respond appropriately to children's needs;
g) The ability to recognize signs of illness and safety hazards;
h) Oral and written communication skills.
Every center, regardless of setting, shall have at least one licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care facility at all times when children are in care.
Additionally, facilities serving children with special needs associated with developmental delay shall have one licensed/certified teacher who is certified in special education.
RATIONALE: Child care that promotes healthy deve-lopment is based on the developmental needs of infants, toddlers, and preschool children. Caregivers are chosen for their knowledge of, and ability to respond appropriately to, the needs of children of this age generally and the unique characteristics of individual children (
2,
7,
9,
12). Both early childhood and special educational experience are useful in a center.
COMMENTS: The profession of early childhood education is being informed by new research on child development practices related to child outcomes. For additional information on qualifications for child care staff, refer to the
Guidelines for Preparation of Early Childhood Professional from the National Association for the Education of Young Children (NAEYC) (
12). Additional information on the early childhood education profession is available from Wheelock College Institute for Leadership and Career Initiatives and the Center for the Child Care Workforce (CCW). Contact information is located in Appendix BB.
GENERAL QUALIFICATIONS OF FAMILY CHILD CARE CAREGIVERS
Caregivers in large and small family child care homes shall be at least 21 years of age, hold an official credential as granted by the authorized state agency, meet the general requirements specified in STANDARD 1.007 through STANDARD 1.012, based on ages of the children served, and shall have the following education, experience, and skills;
a) Current accreditation by the National Association for Family Child Care (including entry-level qualifications and participation in required training) and have a college certificate representing a minimum of 3 credit hours of family child care leadership or master caregiver training or hold an Associate's degree in early childhood education or child development;
b) A valid certificate in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in First Aid and CPR, STANDARD 1.026 through STANDARD 1.028;
c) Preservice training in health management in child care, including the ability to recognize signs of illness and safety hazards;
d) Knowledge of normal child development, as well as knowledge of children who are not developing typically;
e) The ability to respond appropriately to children's needs;
f) Oral and written communication skills.
Additionally, large family child care home care - givers shall have at least 1 year of experience, under qualified supervision, serving the ages and developmental abilities of the children in their large family child care home.
Assistants, aides, and volunteers employed by a large family child care home shall meet the qualifications specified in STANDARD 1.018.
RATIONALE: In both large and small family child care homes, staff members must have the education and experience to meet the needs of the children in care. Small family child care home providers often work alone and are solely responsible for the health and safety of small numbers of children in care.
Age 18 is the earliest age of legal consent. Mature leadership is clearly preferable. Age 21 is more likely to be associated with the level of maturity necessary to independently care for a group of children who are not one's own.
The National Association for Family Child Care (NAFCC) has established an accreditation process to enhance the level of quality and professionalism in small family child care (
23). Contact information for NAFCC is found in Appendix BB.
COMMENTS: A large family child care home provider caring for more than six children and employing one or more assistants functions as a facility director. An operator of a large family-child-care home should be offered training relevant to the management of a small child care center, including training on providing a quality work environment for employees.
For more information on assessing the work environment of family child care employees, see
Creating Better Family Child Care Jobs: Model Work Standards, a publication by the Center for the Child Care Workforce (CCW) (
15). Contact information for the CCW is located in Appendix BB.
TYPE OF FACILITY:
Large Family Child Care Home; Small Family Child Care Home
Support networks for family child care
Large and small family child care home providers shall have active membership in local or state family child care associations (if such associations exist) or in the National Association for Family Child Care (NAFCC), or belong to a network of family child care home providers that offers ongoing training and information on how to provide quality child care.
RATIONALE: Membership in peer professional organizations shows a commitment to quality child care and also provides a conduit for information to otherwise isolated caregivers. Membership in a family child care association and attendance at meetings indicate the desire to gain new knowledge about how to work with children.
COMMENTS: For more information about family child care associations, contact the National Association for Family Child Care (NAFCC). Contact information is located in Appendix BB.
For additional qualifications and responsibilities of large and small family child care home providers, see General Qualifications for All Caregivers, STANDARD 1.007 through STANDARD 1.012; and Training, STANDARD 1.023 through
STANDARD 1.036.
TYPE OF FACILITY:
Large Family Child Care Home; Small Family Child Care Home
QUALIFICATIONS FOR HEALTh aDVOCATES
Each facility shall designate a person as health advocate to be responsible for policies and day-to-day issues related to health, development, and safety of individual children, children as a group, staff, and parents. The health advocate shall be the primary parent contact for health concerns, including health-related parent/staff observations, health-related information, and the provision of resources. The health advocate shall also identify children who have no regular source of health care and refer them to a health care provider who offers competent routine child health services.
For centers, the health advocate shall be licensed/certified/credentialed as a director, lead teacher, teacher, or associate teacher, or shall be a health professional, health educator, or social worker who works at the facility on a regular basis (at least weekly).
The health advocate shall have documented training in the following topics that include:
a) Sudden Infant Death Syndrome (SIDS), for facilities caring for infants;
b) Control of infectious diseases, including Standard/Universal Precautions;
c) How to recognize and handle an emergency;
d) Recognition and handling of seizures;
e) Recognition of safety, hazards, and injury prevention interventions;
f) How to help parents, caregivers, and children cope with death, severe injury, and natural or man-made catastrophes;
g) Recognition of child abuse and neglect and knowledge of when to contact a consultant;
h) Organization and implementation of a plan to meet the emergency needs of children with special health needs.
RATIONALE: The effectiveness of an intentionally designated health advocate in improving the quality of performance in a facility has been demonstrated in all types of early childhood settings (
16). A designated caregiver with health training is effective in developing an ongoing relationship with the parents and a personal interest in the child (
8,
17). Caregivers who are better trained are more able to prevent, recognize, and correct health and safety problems. An internal advocate for issues related to health and safety can help integrate these concerns with other factors involved in formulating facility plans.
COMMENTS: The director should assign the health advocate role to a staff member who seems to have an interest, aptitude and training in this area. This person need not perform all the health and safety tasks in the facility but should serve as the person who raises health and safety concerns. This staff person has designated responsibility for seeing that plans are implemented to ensure a safe and healthful facility (
16).
A health advocate is a regular member of the staff of a center or large or small family child care home network, and is not the same as the health consultant recommended in Health Consultants, STANDARD 1.040 through STANDARD 1.044. For small family child care homes, the health advocate will usually be the caregiver. If the health advocate is not the child's caregiver, the health advocate should work with the child's caregiver. The person who is most familiar with the child and the child's family will recognize atypical behavior in the child and support effective communication with parents.
A plan for personal contact with parents should be developed, even though this contact will not be possible daily. A plan for personal contact and documentation of a designated caregiver as health advocate will ensure specific attempts to have the health advocate communicate directly with caregivers and families on health-related matters.
For additional qualifications and responsibilities of health advocates, see Training, STANDARD 1.023 through STANDARD 1.036; and Direct Care and Provisional Staff, STANDARD 1.009 through STANDARD 1.013.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
initial orientation of all staff
All new full-time and part-time staff shall be oriented to, and demonstrate knowledge of, the items listed below. The director of any center or large family child care home shall provide this training to all newly hired caregivers before they begin to care for children. For centers, the director shall document, for each new staff member, the topics covered and the dates of orientation training. Staff members shall not be expected to take responsibility for any aspect of care for which their orientation and training have not prepared them.
Small family child care home providers shall avail themselves of orientation training offered by the licensing agency, a resource and referral agency, or other such agency. This training shall include evaluation that involves demonstration of the knowledge and skills covered in the training lesson.
The orientation shall address, at a minimum:
a) Regulatory requirements;
b) The goals and philosophy of the facility;
c) The names and ages of the children for whom the caregiver will be responsible, and their specific developmental needs;
d) Any special adaptation(s) of the facility required for a child with special needs for whom the staff member might be responsible at any time;
e) Any special health or nutrition need(s) of the children assigned to the caregiver;
f) The planned program of activities at the facility. See Program of Developmental Activities, STANDARD 2.001 through
STANDARD 2.027;
g) Routines and transitions;
h) Acceptable methods of discipline. See Discipline, STANDARD 2.039 through STANDARD 2.043; and Discipline Policy, STANDARD 8.008 through
STANDARD 8.010;
i) Policies and practices of the facility about relating to parents. See Parent Relationships, STANDARD 2.044 through
STANDARD 2.057;
j) Meal patterns and food handling policies and practices of the facility. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; Food Service Records, STANDARD 8.074; Nutrition and Food Service, STANDARD 4.001 through STANDARD 4.070;
k) Occupational health hazards for caregivers, including attention to the physical health and emotional demands of the job and special considerations for pregnant caregivers. See Occupational Hazards, STANDARD 1.048; and
Major Occupational Health Hazards,
Appendix B;
l) Emergency health and safety procedures. See Plan for Urgent Medical Care or Threatening Incidents, STANDARD 8.022 and STANDARD 8.023; and Emergency Procedures, STANDARD 3.048 through STANDARD 3.052;
m) General health and safety policies and procedures, including but not limited to the following:
1) Handwashing techniques and indications for handwashing. See Handwashing, STANDARD 3.020 through STANDARD 3.024;
2) Diapering technique and toilet use, if care is provided to children in diapers and/or children needing help with toilet use, including appropriate diaper disposal and diaper-changing techniques. See Toilet, Diapering, and Bath Areas, STANDARD 5.116 through STANDARD 5.125; Toilet Use, Diapering, and Toilet Learning/Training, STANDARD 3.012 through STANDARD 3.019; Toilet Learning/Training Equipment, Toilets, and Bathrooms, STANDARD 3.029 through STANDARD 3.033;
3) Identifying hazards and injury prevention;
4) Correct food preparation, serving, and storage techniques if employee prepares food. See Food Safety, STANDARD 4.042 through STANDARD 4.060;
5) Knowledge of when to exclude children due to illness and the means of illness transmission;
6) Formula preparation, if formula is handled. See Plans and Policies for Food Handling, Feeding, and Nutrition, STANDARD 8.035 and STANDARD 8.036; and Nutrition for Infants, STANDARD 4.011 through STANDARD 4.021;
7) Standard precautions and other measures to prevent exposure to blood and other body fluids, as well as program policies and procedures in the event of exposure to blood/body fluid. See Prevention of Exposure to Body Fluids, STANDARD 3.026;
n) Recognizing symptoms of illness. See Daily Health Assessment, STANDARD 3.001 and STANDARD 3.002;
o) Teaching health promotion concepts to children and parents as part of the daily care provided to children. See Health Education for Children, STANDARD 2.060 through STANDARD 2.063;
p) Child abuse detection, prevention, and reporting. See Child Abuse and Neglect, STANDARD 3.053 through
STANDARD 3.059;
q) Medication administration policies and practices;
r) Putting infants down to sleep positioned on their backs and on a firm surface to reduce the risk of Sudden Infant Death Syndrome (SIDS).
Caregivers shall also receive continuing education each year, as specified in Continuing Education, STANDARD 1.029 through STANDARD 1.036.
RATIONALE: Upon employment, staff members should be able to perform basic sanitizing and emergency procedures. Orientation ensures that all staff members receive specific and basic training for the work they will be doing and become acquainted with their new responsibilities. Orientation programs for new employees should be specific to an individual facility since facilities and the children enrolled vary(
20).
Because of frequent staff turnover, directors are obligated to institute orientation programs that protect the health and safety of children and new staff members.
Orientation and ongoing training are especially important for aides and assistant teachers, for whom preservice educational requirements are limited. Entry into the field at the level of aide or assistant teacher should be attractive and easy for members of the families and cultural groups of the children in care to enter the field. Training ensures that staff members are challenged and stimulated, have access to current knowledge, and have access to education that will qualify them for new roles. Offering a career ladder will attract individuals into the child care field, where labor is in short supply. Ongoing training in one role can become preservice training to qualify for another role.
Health training for child care staff not only protects the children in care, infectious disease control in child care helps to prevent spread of infectious disease in the community. Young children in child care have been shown to be associated with community outbreaks.
COMMENTS: Many states have preservice education and experience qualifications for caregivers by role and function. States are including ongoing health training in their licensing requirements; the broader skills have proved important and necessary to teachers in part-day and full-day programs alike. Both full-day and part-day programs require competence in all facets of child development, not just the learning components.
Child care staff members are important figures in the lives of the young children in their care and in the wellbeing of families and the community. In the future, all training for child care staff should include more attention to health issues.
Training in conflict resolution is encouraged. Child abuse includes also children's abuse of their peers. Staff should learn how to handle conflict resolution among the children and among themselves, as well as modeling examples of conflict resolution from which children can learn.
Colleges and accrediting bodies should examine teacher preparation guidelines and substantially increase the health content of early childhood professional preparation.
For definitions of Standard precautions, Transmission-based precautions, Universal precautions, see Glossary.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
orientation for care of children with special health needs
When a child care facility enrolls a child with special needs, the facility shall ensure that staff members have been oriented in understanding that child's special needs and ways of working with that child in a group setting.
Caregivers in small family child care homes, who care for a child with special needs, shall meet with the parents and a health care worker involved with the child (if the parent has provided prior, informed, written consent) about the child's special needs and how these needs may affect his/her developmental progression or play with other children.
In addition to Orientation Training, STANDARD 1.023, the staff in child care facilities shall have orientation training based on the special needs of children in their care. This training may include, but is not limited to, the following topics:
a) Positioning for feeding and handling techniques of children with physical disabilities;
b) Proper use and care of the individual child's adaptive equipment, including how to recognize defective equipment and to notify parents that repairs are needed;
c) How different disabilities affect the child's ability to participate in group activities;
d) Methods of helping the child with special needs to participate in the facility's programs;
e) Role modeling, peer socialization, and interaction;
f) Behavior modification techniques, positive rewards for children, promotion of self-esteem, and other techniques for managing difficult behavior;
g) Grouping of children by skill levels, taking into account the child's age and developmental level;
h) Intervention for children with special health care problems;
RATIONALE: A basic understanding of developmental disabilities and special care requirements of any child in care is a fundamental part of any orientation for new employees. Training is an essential component to ensure that staff members develop and maintain the needed skills. A comprehensive curriculum is required to ensure quality services. However, lack of specialized training for staff does not constitute grounds for exclusion of children with disabilities.
Staff members need information about how to help children use adaptive equipment properly. Staff members need to understand how and why various items are used and how to check for malfunctions. If a problem occurs with adaptive equipment, the staff must recognize the problem and inform the parent so that the parent can notify the health care or equipment provider of the problem and request that it be remedied. While the parent is responsible for arranging for correction of equipment problems, child care staff must be able to observe and report the problem to the parent.
COMMENTS: These training topics are generally applicable to all personnel serving children with special needs and apply to these facilities. The curriculum may vary depending on the type of facility, classifications of disabilities of the children in the facility, and ages of the children. The staff is assumed to have the training described in Orientation Training, STANDARD 1.023, including child growth and development. These additional topics will extend their basic knowledge and skills to help them work more effectively with children who have special needs and their families. Caregivers should have a basic knowledge of special needs, supplemented by specialized training for children with special needs. The types of children with special needs served should influence the selection of the specialized training. The number of hours offered in any inservice training program should be determined by the staff's experience and professional background.
Service plans in small family child care homes may require a modified implementation plan. The option of child care in small family child care homes for children with special needs must include special
Training and other technical assistance can be obtained from the following:
a) The state-designated lead agency responsible for implementing IDEA;
b) American Academy of Pediatrics (AAP);
c) American Nurses' Association (ANA);
d) State and community nursing associations;
e) National therapy associations;
f) Local resource and referral agencies;
g) Federally funded, University Centers for Excellence in Developmental Disabilities Education, Research, and Service programs for individuals with developmental disabilities;
h) Other colleges and universities with expertise in training others to work with children who have special needs;
i) Community-based organizations serving people with disabilities (Easter Seals, American Diabetes Association, American Lung Association, etc.).
The parent is responsible for solving equipment problems unless the parent requests that the child care facility remedy the problem directly and the staff agrees to do it.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
orientation during initial employment
During the first 3 months of employment, the director of a center or the caregiver in a large family home shall document, for all full-time and part-time staff members, additional orientation in, and the employees' satisfactory knowledge of, the following topics:
a) Recognition of symptoms of illness and correct documentation procedures for recording symptoms of illness. This shall include the ability to perform a daily health assessment of children to determine whether any are ill and, if so, whether a child who is ill should be excluded from the facility;
b) Exclusion and readmission procedures
and policies;
c) Cleaning and sanitation procedures and policies;
d) Procedures for administering medication to children and for documenting medication administered to children;
e) Procedures for notifying parents or legal guardians of a
communicable disease occurring in children or staff within the facility;
f) Procedures and policies for notifying public health officials about an outbreak of disease or the occurrence of a reportable disease.
Before being assigned to tasks that involve identifying and responding to illness, staff members shall receive orientation training on these topics. Small family child care home providers shall not commence operation before receiving orientation on these topics.
RATIONALE: Children are ill frequently. Staff members responsible for child care must be able to recognize illness, carry out the measures required to prevent the spread of communicable diseases, and handle ill children appropriately.
COMMENTS: See also Daily Health Assessment, STANDARD 3.001 and STANDARD 3.002.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
first aid training for staff
The director of a center and a large
family child care home
and the caregiver in a small
family child care home shall ensure that all staff members involved in providing direct care have training in pediatric first aid, including management of a blocked airway and rescue breathing, as specified in STANDARD 1.027.
At least one staff person who has successfully completed training in pediatric first aid, as specified in STANDARD 1.027, shall be in attendance at all times and in all places where children are in care.
Instances in which at least one staff member shall be certified in CPR include when children are involved in swimming and wading and when at least one child is known to have a specific special health need as determined by that child's physician (such as cardiac arrhythmia) that makes the child more likely than a typical child to require cardiac resuscitation. In each case of a child with a special health need, the child care provider shall ask the child's physician whether caregivers with skills in the management of a blocked airway and rescue breathing will suffice, or whether caregivers require skills in cardiac resuscitation to meet the particular health needs of the child. Records of successful completion of training in pediatric first aid, as specified in STANDARD 1.027, shall be maintained in the files of the facility.
RATIONALE: To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including management of a blocked airway and rescue breathing, coupled with a facility that has been designed or modified to ensure the safety of children, can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions. Knowledge of pediatric first aid, including management of a blocked airway and rescue breathing, and the confidence to use these skills, are critically important to the outcome of an emergency situation.
The need for cardiac resuscitation is rare. Children who have specific cardiac problems, such as cardiac arrhythmia, or children who are drowning in cold water, require cardiac resuscitation. Except in these two instances, cessation of cardiac function does not occur until respiratory failure causes irreversible and devastating brain damage. Therefore, except in these two instances, caregivers require respiratory resuscitation skills, not CPR skills.
Small family child care home providers often work alone and are solely responsible for the health and safety of children in care. They must have the necessary skills to manage any emergency while caring for all the children in the group.
In a study of incidence of injuries in centers, first aid was sufficient treatment for the majority of incidents (
18). In a survey of over 2,000 child care programs in North Carolina, 16% had used first aid for choking, 2.3% had used rescue breathing, and only 1% had used CPR during the preceding 36 months of the survey. The authors of this report felt that maintaining CPR training and certification was difficult and probably not cost-effective (
24). Minor injuries are common. For emergency situations that require attention from a health professional, first aid procedures can be taken to control the situation until a medical professional can provide definitive care.
Documentation of current certification in the facility assists in implementing and in monitoring for proof of compliance.
COMMENTS: Preparation of the first edition of this document included an extensive discussion of whether the staff should have cardiac resuscitation skills for children.
Many people use the term "CPR" as shorthand for resuscitation and rescue skills. In discussions with the American Academy of Pediatrics' liaison to the American Heart Association pediatric resuscitation committee, this issue was discussed again during the preparation of this edition of the Standards, with the same conclusion related to limited circumstances where CPR training should be required. Ongoing education about the difference between training in pediatric first aid that includes management of a blocked airway and rescue breathing and training in CPR will be necessary because of the public's familiarity with and use of the term "CPR."
CPR training for cardiac resuscitation involves specific courses focused on pulmonary and cardiac resuscitation, not first aid for other, more common injuries. Evaluations of retention of the techniques taught in CPR courses reportedly reveals poor recall within months after completion. The time and other resources required to provide pediatric CPR training could be better spent on learning first aid, including management of a blocked airway and rescue breathing, and other types of training. CPR training for management of adult cardiac emergencies is valuable and appropriate as a staff and community health goal, but as described above, such training is not a standard of practice for routine child care.
For each child with a special health need, the child care health form should have a check-off box or a request for notification about whether caregivers with skills in management of a blocked airway and rescue breathing will suffice, or does the child have a greater risk than a typical child to require cardiac resuscitation. This proactive approach will alert the child's clinician to consider the need for caregivers to acquire cardiac resuscitation skills on a case-by-case basis. If the child's clinician indicates that the child's condition might require that caregivers provide cardiac resuscitation, CPR training should be required for staff who care for the child. Instead of CPR training for all staff in child care, this focused approach is more likely to insure the safety of the few children for whom CPR might be required.
For additional information on first aid and CPR, see STANDARD 2.027, on pediatric first aid training requirements; STANDARD 1.028, which requires staff to have CPR training for activities involving swimming or wading; and RECOMMENDATION 9.038 through RECOMMENDATION 9.040, on state and local training and technical assistance.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
continuing education for directors and caregivers in centers and large family child care homes
All directors and caregivers of centers and large family child care homes shall successfully complete at least 30 clock hours per year of continuing education in the first year of employment, 16 clock hours of which shall be in child development programming and 14 of which shall be in child health, safety, and staff health.
In the second and each of the following years of employment at a facility, all directors and caregivers shall successfully complete at least 24 clock hours of continuing education based on individual competency needs and any special needs of the children in their care, 16 hours of which shall be in child development programming and 8 hours of which shall be in child health, safety, and staff health.
The effectiveness of training shall be assessed by change in performance following participation in training.
RATIONALE: Because of the nature of their care-
giving tasks, caregivers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the staff member(s) involved. Too often, staff members make training choices based on what they like to learn about (their "wants") and not the areas in which their performance should be improved (their "needs"). Participation in training does not ensure that the participant will master the information and skills offered in the training
experience. Therefore, successful completion, not just participation, must be assessed.
In addition to low child:staff ratio, group size, age mix of children, and stability of caregiver, the training/education of caregivers is a specific indicator of child care quality (
14). Most skilled roles require training related to the functions and responsibilities the role requires. Staff members who are better trained are better able to prevent, recognize, and correct health and safety problems. The number of training hours recommended in this standard reflects the central focus of caregivers on child development, health, and safety.
The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training based on the needs of the program and the preservice qualifications of staff. Training should address the following areas:
b) Child growth and development;
d) Planning learning activities;
e) Guidance and discipline techniques;
f) Linkages with community services;
g) Communication and relations with families;
h) Detection of child abuse;
i) Advocacy for early childhood programs;
j) Professional issues (
12).
There are few illnesses for which children should be excluded from child care. Decisions about management of ill children are facilitated by skill in assessing the extent to which the behavior suggesting illness requires special management (
20). Continuing education on managing communicable diseases helps prepare caregivers to make these decisions. All caregivers should be trained to prevent, assess, and treat injuries common in child care settings and to comfort an injured child.
COMMENTS: Tools for assessment of training needs are part of the accreditation self-study tools available from the NAEYC, the National Association for Family Child Care (NAFCC) and the National Child Care Association (NCCA).
Contact information is located in Appendix BB. Successful completion of training can be measured by a performance test at the end of training and by ongoing evaluation of performance on the job.
Resources for training on health issues include:
State and local health departments (especially the public health nursing department);
Resource and referral agencies;
State and local chapters of:
- American Academy of Pediatrics (AAP);
- American Academy of Family Physicians (AAFP);
- American Nurses' Association (ANA);
- Visiting Nurse Association (VNA);
- National Association of Pediatric Nurse Practitioners (NAPNAP);
- National Association for the Education of Young Children (NAEYC);
- National Association for Family Child Care (NAFCC);
- National Training Institute for Child Health Consultants;
- Emergency Medical Services for Children (EMSC) National Resource Center.
For nutrition training, facilities should check to be sure that the nutritionist, who provides advice, has experience with, and knowledge of, food service issues in the child care setting. Most state maternal and child health departments have a Nutrition Specialist on staff. If this Nutrition Specialist has knowledge and experience in child care, facilities might negotiate for this individual to serve or identify someone to serve as a consultant and trainer for the facility.
Many resources are available for nutrition specialists who can provide training in food service and nutrition. See Appendix C, for qualifications of nutrition specialists. Some resources to contact include:
Local, county, and state health departments;
State university and college nutrition departments;
Home economists at utility companies;
State affiliates of the American Dietetic
State and regional affiliates of the American Public Health Association;
The American Association of Family and Consumer Services;
National Resource Center for Health and Safety in Child Care;
Registered dietitian at a hospital;
High school home economics teachers;
The local American Heart Association affiliate;
The local Cancer Society;
The Society for Nutrition Education;
The local Cooperative Extension office.
Nutrition education resources may be obtained from the Food and Nutrition Information Center. Contact information is located in Appendix BB. The staff's continuing education in nutrition may be supplemented by periodic newsletters and/or literature or audiovisual materials prepared or recommended by the Nutrition Specialist. See Appendix C, for information on qualifications for nutrition specialists.
Caregivers should have a basic knowledge of special needs, supplemented by specialized training for children with special needs. The type of special needs of the children in care should influence the selection of the training topics. The number of hours offered in any inservice training program should be determined by the experience and professional background of the staff, which is best achieved through a regular staff conference mechanism.
Financial support and accessibility to training programs requires attention to facilitate compliance with this standard. Many states are using federal funds from the Child Care and Development Block Grant to improve access, quality, and affordability of training for early care and education professionals. Home study, video courses, workshops, training newsletters, telecommunications, and lectures can be used to meet the training hours requirement, as can training conducted on site at the child care facility. Completion of training may be documented by self-declaration or by submitting self-tests. Although on-site training can be costly, it may be a more effective approach than participation in training at a remote location.
See also Technical Assistance and Consultation to Caregivers and Families, RECOMMENDATION 9.030 and RECOMMENDATION 9.036; and Training, RECOMMENDATION 9.038 through RECOMMENDATION 9.040.
See STANDARD 1.052 and STANDARD 1.055, on performance evaluation related to continuing education.
TYPE OF FACILITY:
Center; Large Family Child Care Home
continuing education for small family child care home providers
Small family child care home providers shall have at least 24 clock hours of continuing education in areas determined by self-assessment and, where possible, by a performance review of a skilled mentor or peer reviewer.
RATIONALE: In addition to low child:staff ratio, group size, age mix of children, and stability of caregiver, the training/education of caregivers is a specific indicator of child care quality (
14). Most skilled roles require training related to the functions and responsibilities the role requires. Caregivers who are better trained are better able to prevent, recognize, and correct health and safety problems.
Because of the nature of their caregiving tasks, caregivers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the child care provider. Too often, caregivers make training choices based on what they like to learn about (their "wants") and not the areas in which their performance should be improved (their "needs").
Small family child care home providers often work alone and are solely responsible for the health and safety of small numbers of children in care. Peer review is part of the process for accreditation of family child care. Self-evaluation may not identify training needs or focus on areas in which the caregiver is particularly interested and may be skilled already.
COMMENTS: The content of continuing education for small family child care home providers may include the following topics:
a) Child growth and development;
c) Recognizing and managing minor illness;
d) Managing the care of children who require the special procedures listed in Standard 3.063;
e) Business aspects of the small family child care home;
f) Planning developmentally appropriate activities in mixed age groupings;
g) Nutrition for children in the context of preparing nutritious meals for the family;
h) Acceptable methods of discipline;
i) Organizing the home for child care;
j) Preventing unintentional injuries in the home;
k) Available community services;
l) Detecting, preventing, and reporting child abuse;
n) Pediatric first aid, including management of a blocked airway and rescue breathing. See STANDARD 1.026 and STANDARD 1.027;
o) CPR (if the caregiver takes care of children with special needs or has a swimming/wading pool). See STANDARD 1.028;
p) Methods of effective communication with children and parents;
r) Evacuation drill procedures, as specified in Evacuation Plan, Drills, and Closings, STANDARD 8.024 through 8.027;
s) Occupational health hazards. See Occupational Hazards, STANDARD 1.048; and
Major Occupational Health Hazards,
Appendix B;
t) Death, dying, and the grief cycle;
u) SIDS risk-reduction practices.
In-home training alternatives to group training for small family child care home providers are available, such as distance courses on the Internet, listening to audiotapes or viewing videotapes with self-checklists. These training alternatives provide more flexibility for providers who are remote from central training locations or have difficulty arranging coverage for their child care duties to attend training. Nevertheless, gathering family child care home providers for training when possible provides a break from the isolation of their work and promotes networking and support. Satellite training via down links at local extension service sites, high schools, and community colleges scheduled at convenient evening or weekend times is another way to mix quality training with local availability and some networking.
TYPE OF FACILITY:
Small Family Child Care Home
Use of child care health consultants
Each center, large family child care home, and small family child care home network shall use the services of a health consultant qualified to provide advice for child care as defined in STANDARD 1.041. Centers and large and small family child care home providers shall avail themselves of community resources established for health consultation to child care.
RATIONALE: Few child care staff are trained as health professionals and few health professionals have training about the community child care programs. When physical, mental, social, or health concerns are raised for the child or for the family, they should be addressed appropriately, often through consultation with or referral to resources available in the
community.
Caregivers need to use health consultants in a variety of fields (such as physical and mental health care, nutrition, environmental safety and injury prevention, oral health care, and developmental disabilities). Health consultants should have specific training in the child care setting (
21). Such training is more widely available through efforts such as state programs implementing the Healthy Child Care America Campaign, and national support funded by the Maternal and Child Health Bureau, Health Resources and Services Administration, including the National Resource Center for Health and Safety in Child Care, the national staff of the Healthy Child Care America Campaign at the American Academy of Pediatrics and the National Training Institute for Child Care Health Consultants. Contact information is located in Appendix BB.
In states where health consultation is mandatory, compliance is nearly universal (
22).
COMMENTS: A health consultant should be a health professional who has an interest in and experience with children, has knowledge of resources and regulations, and is comfortable linking health resources with facilities that provide primarily education and social services. State regulatory agencies should maintain or contract for the maintenance of a registry of health consultant resources in the community. For example, in Pennsylvania, the PA Chapter of the American Academy of Pediatrics (AAP) maintains and provides training and support for health professionals in such a registry under contracts with the child care regulatory agency and the state department of health. Additional registries are being developed by the National Resource Center for Health and Safety in Child Care, Healthy Child Care America Campaign from the Maternal and Child Health Bureau, Health Resources and Services Administration, and the National Training Institute for Child Care Health Consultants. Child care health consultants may be employed by public or non-profit agencies such as health departments or resource and referral agencies, other health institutions, or may work as independent health consultants. Caregivers also should not overlook health professionals with pediatric and health consultant experience who are parents of children enrolled in their facility. However, involving parents as health consultants requires caution to avoid crossing boundaries of confidentiality and conflict of interest. To foster access to and accountability of health consultants, some form of compensation should be offered.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Knowledge and skills of child care health consultants
A facility shall have a health consultant who is a health professional with training and experience as a child care health consultant. Graduate students in a discipline related to child health shall be acceptable as child care health consultants supervised by faculty knowledgeable in child care. A child care health consultant shall either have the full knowledge base and skills required for this role, or arrange to partner with other health professionals who can provide the necessary knowledge and skills.
The knowledge base of the child care health consultant (personally or by involving other health professionals) shall include:
a) National health and safety standards for out-of-home child care;
b) How child care facilities conduct their day-to-day operations;
c) Child care licensing requirements;
d) Disease reporting requirements for child care providers;
e) Immunizations for children;
f) Immunizations for child care providers;
g) Injury prevention for children;
h) Staff health, including occupational health risks for child care providers;
i) Oral health for children;
j) Nutrition for children;
k) Inclusion of children with special health needs in child care;
l) Recognition and reporting requirements for child abuse and neglect;
m) Community health and mental health resources for child and parent health.
The skills of the child care health consultant shall include the ability to perform or arrange for performance of the following activities:
a) Teaching child care providers about health and safety issues;
b) Teaching parents about health and safety issues;
c) Assessing child care providers' needs for health and safety training;
d) Assessing parents' needs for health and safety training;
e) Meeting on-site with child care providers about health and safety;
f) Providing telephone advice to child care providers about health and safety;
g) Providing referrals to community services;
h) Developing or updating policies and procedures for child care facilities;
i) Reviewing health records of children;
j) Reviewing health records of child care providers;
k) Helping to manage the care of children with special health care needs;
l) Consulting with a child's health professional about medication;
m) Interpreting standards or regulations and providing technical advice, separate and apart from the enforcement role of a regulation inspector.
Although the child care health consultant may have a dual role, such as providing direct care to some of the children or serving as a regulation inspector, these roles shall not be mixed with the child care health consultation role.
The child care health consultant shall have contact with the facility's administrative authority, the staff, and the parents in the facility. The administrative authority shall review, respond to, and implement the child care health consultant's recommendations. The child care health consultant shall review and approve the written health policies used by center-based facilities.
Programs with a significant number of non-English-speaking families shall seek a child care health consultant who is culturally sensitive and knowledgeable about community health resources for the parents' native culture and languages.
RATIONALE: The specific health and safety consultation needs for an individual facility depend on the characteristics of that facility (
21). All facilities should have an overall child care health consultation.
The special circumstances of group care may not be part of the health professional's usual education. Therefore, child care providers should seek health consultants who have the necessary specialized training or experience. Such training is more readily available now as described in the previous standard.
To be effective, a child care health consultant should know the available resources in the community and should engage in a partnership with the administrative authority for the facility, the staff, and parents in the consultative and policy-setting process. Setting health and safety policies in cooperation with the staff, parents, health professionals, and public health authorities
will help ensure successful implementation of a quality program (
20).
Health professionals who serve as child care health consultants do not always have a public health perspective or the full range of knowledge and skills required. Therefore, public health professionals and other health professionals with appropriate training and skills should serve as a resource to inform those who work in the private sector or whose health professional expertise is specialized and lacking in broader knowledge and skills that may be required. For example, while a sanitarian may provide excellent health consultation on hygiene and infectious disease control, another health professional may need to be consulted about medication administration or playground safety. A Certified Playground Safety Inspector would be able to provide consultation about gross motor play hazards, and would not likely be able to provide sound advice about food safety and nutrition.
COMMENTS: The
policies and procedures reviewed for approval by child care health consultants should include, but not be limited to, the following:
a) Admission and readmission after illness, including inclusion/exclusion criteria;
b) Health evaluation and observation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child's attendance;
c) Plans for health care and management of children with communicable diseases;
d) Plans for surveillance and management of illnesses, injuries, and problems that arise in the care of children;
e) Plans for caregiver training and for communication with parents and health care providers;
f) Policies regarding nutrition, nutrition education, and oral health;
g) Plans for the inclusion of children with special health needs;
i) Safety assessment of facility playground;
j) Policies regarding staff health and safety;
k) Policies for administration of medication.
See Identifiable Governing Body/Accountable Individual, STANDARD 8.001 through STANDARD 8.003, for additional information regarding administrative authority.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
specialized consultation for facilities serving children with disabilities
When children at the facility include those with developmental delay or disabilities, the staff or documented consultants shall include any of the following, with prior informed, written parental consent and as appropriate to each child's needs:
b) A registered dietitian;
c) A registered nurse or pediatric nurse practitioner;
f) An occupational therapist;
h) A respiratory therapist;
j) A parent of a child with special needs;
k) The child care provider.
RATIONALE: The range of professionals needed may vary with the facility, but the listed professionals should be available as consultants when needed. These professionals need not be on staff at the facility, but may simply be available when needed through a variety of arrangements, including contracts, agreements, and affiliations. The parent's participation and written consent in the native language of the parent, including Braille/sign language, is required to include outside consultants.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
frequency of child care health consultation visits
The health consultant shall visit each facility as needed to review and give advice on the facility's health component. Center-based facilities that serve any child younger than 2 years of age shall be visited at least once a month by a health professional with general knowledge and skills in child health and safety. Center-based facilities that are not open at least 5 days a week or that serve only children 2 years of age or older shall be visited at least quarterly, on a schedule that meets the needs of the composite group of children. Small and large family child care homes shall be visited at least annually. Written documentation of health consultant visits shall be maintained at the facility.
RATIONALE: Almost everything that goes on in a facility and almost everything about the facility itself affects the health of the children it serves (
19). Infants are particularly vulnerable to injuries, infections, and psychological harm. Their rapid changes in behavior make regular and frequent visits by the health consultant extremely important. In facilities where health and safety problems or a high turnover of staff occurs, more frequent visits by the health consultant should be arranged.
COMMENTS: For health consultants to facilities serving children with special needs, see STANDARD 1.003, STANDARD 1.042, and STANDARD 1.044. For health consultants serving special facilities for children who are ill, see STANDARD 3.075. For nutrition staffing and consultation, see STANDARD 4.026 and STANDARD 4.027. For additional information on health consultants, see Health Consultation, STANDARD 8.020; Consultation Records, STANDARD 8.073, on documentation of health consultant training and visits; and Consultants,
RECOMMENDATION 9.033 and RECOMMENDATION 9.034.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
registered nurses to provide medical treatment
Child care facilities shall arrange for a registered nurse to provide staff training and ongoing supervision of the health needs and practices of staff and children and to ensure appropriate administration of medication and prescribed medical treatment if an individual assessment of a child reveals that such services are required.
RATIONALE: An on-site health care professional must be available to assess and manage the needs of children who require medical assistance.
COMMENTS: Small family child care home providers may arrange for the services of a registered nurse on an as-needed consultative basis.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
2. PROGRAM ACTIVITIES FOR HEALTHY DEVELOPMENT
program of activities including special interventions
Facilities shall have a Program of Activities to include special interventions for children with any special restriction(s) of activities.
RATIONALE: All care facilities benefit from a regular activity schedule. For the child with special needs, an individualized education program or an individualized family service plan is required by the IDEA. The child's plan for care in an inclusive setting shall include activities with the other children at the facility as part of the child's regularly scheduled activities.
COMMENTS: Children with special needs will be participating in activities, adapted to their abilities, with peers, but may have some separately scheduled activities that may be required to implement the child's Individualized Education Program (IEP).
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The facility shall develop and implement a plan that teaches each child how and when to use the toilet. Toilet learning/training, when initiated, shall follow a prescribed, sequential plan that is developed and coordinated with the parent's plan for implementation in the home environment and shall be based on the child's developmental level rather than chronological age.
To help children achieve bowel and bladder control, caregivers shall enable children to take an active role in using the toilet when they are physically able to do so and when parents support their children's learning to use the toilet. Caregivers shall take into account the preferences and customs of the child's family.
For children who have not yet learned to use the toilet, the facility shall defer toilet learning/training until the child's family is ready to support this learning and the child demonstrates:
a) An understanding of the concept of cause and effect;
b) An ability to communicate;
c) The physical ability to remain dry for up to 2 hours.
For school-age children, toilet learning/training shall include frequent opportunities to use the toilet and an emphasis on appropriate handwashing after using the toilet.
Children with special needs may require specific instructions or precautions.
RATIONALE: A child's achievement of motor and intellectual or developmental skills may be advanced or delayed, depending on the child's abilities, primary disability, or combination of disabilities. The child may not be socially or emotionally ready to learn how to use the toilet, despite the emergence of other skills. Caregivers should enable children to take an active part in controlling the functions of their bodies in a manner that gives them a sense of pride and confidence (
26,
27).
Toilet learning/training is achieved more rapidly once a child is toilet scheduled and demands from adults across environments are consistent. The family may not be prepared, at the time, to extend this learning/training into the home environment.
School-age children may not respond when their
bodies signal a need to use the toilet because they are involved in activities or embarrassed about needing to use the toilet. Holding back stool or urine can lead to constipation and urinary tract problems. Also, unless reminded, many children forget to wash their hands after toileting.
COMMENTS: The area of toilet learning/training for children with special needs is difficult because there are no age-related, disability-specific rules to follow. As a result, support and counseling for parents and caregivers are required to help them deal with this issue. Some children with multiple disabilities do not demonstrate any requisite skills other than being dry for a few hours. Establishing a toilet routine may be the first step toward learning to use the toilet and at the same time improving hygiene and skin care.
Cultural expectations of toilet learning/training need to be recognized and respected.
For more information on toilet learning/training, see
Tiolet Training/Learning: Guideline for Parents, available from the American Academy of Pediatrics (AAP). Contact information is located in Appendix BB.
See also Toilets and Toilet Training Equipment, STANDARD 5.116 through STANDARD 5.124; and Sanitation, Disinfection, and Maintenance of Toilet Learning/Training Equipment, Toilets, and Bathrooms, STANDARD 3.029 through STANDARD 3.033.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
competence and training of transportation staff
At least one adult who accompanies or drives
children for field trips and out-of-facility activities shall receive training by a professional knowledgeable about child development and procedures to ensure the safety of all children. The caregiver shall hold a valid pediatric first aid certificate, including rescue breathing and management of blocked airways, as specified in First Aid and CPR, STANDARD 1.026 through STANDARD 1.028.
All drivers, passenger monitors, chaperones, and assistants shall receive instructions in safety precautions. If transportation is provided, these instructions shall include:
a) Use of developmentally appropriate safety restraints;
b) Proper placement of the child in the motor vehicle;
c) Handling of emergency situations. If a child has a chronic medical condition that could result in an emergency (such as asthma, diabetes, seizures), the driver or chaperone shall have written instructions including parent emergency contacts, child summary health information, special needs, and treatment plans, and shall be trained to;
1) Recognize the signs of a medical emergency;
2) Know emergency procedures to follow;
3) Have on-hand, any emergency supplies or medications necessary;
d) Map and appropriate route to emergency facility;
f) Child supervision during transport, including never leaving a child unattended in a vehicle.
The receipt of such instructions shall be documented in a personnel record for any paid staff or volunteer who participates in field trips or transportation activities. Child:staff ratios shall be maintained on field trips and during transport, as specified in STANDARD 1.001 through STANDARD 1.005.
RATIONALE: Injuries are more likely to occur when a child's surroundings or routine changes. Activities outside the facility may pose increased risk for injury. When children are excited or busy playing in unfa-
miliar areas, they are more likely to forget safety measures unless they are closely supervised at all times.
Children have died from heat stress from being left unattended in closed vehicles. Temperatures in hot cars can reach dangerous levels within 15 minutes (
28).
Adults cannot be assumed to be knowledgeable about the various developmental levels or special needs of children. Training by someone with appropriate knowledge and experience is needed to appropriately address these issues.
COMMENTS: When field trips are planned, it is
recommended that the sites should be visited by child care staff in advance of the actual field trip to ensure
that the site is accessible for the children with special needs. This standard also applies when caregivers are walking with children to and from a destination.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
vehicle safety restraints
When children are driven in a motor vehicle other than a bus, school bus, or a bus operated by a common carrier, the following shall apply:
A child shall be transported only if the child is fastened in an approved developmentally appropriate safety seat, seat belt, or harness appropriate to the child's weight, and the restraint is installed and used in accordance with the manufacturers' instructions for the car seat and the motor vehicle. Each child must have an individual seat belt and be positioned in the vehicle in accordance with the requirements for the safe use of air bags in the back seat;
A child under the age of 4 shall be transported only if the child is securely fastened in a de- velopmentally appropriate child passenger restraint system that meets the federal motor vehicle safety standards contained in the Code of Federal Regulations, Title 49, Section 571.213, and this compliance is so indicated on the safety restraint device;
If small buses or vans have safety restraints installed, children weighing over 40 pounds shall have access to belt-positioning booster
seats with lap and shoulder belts. Children weighing under 40 pounds shall use car safety seats;
Vehicles shall accommodate the placement of wheelchairs with four tie-downs affixed according to the manufactures' instructions in a forward-facing direction. The wheelchair occupant shall be secured by a three-point tie restraint during transport.
RATIONALE: Safety restraints are effective in re-
ducing death and injury when they are used properly. The best car safety seat is one that fits in the vehicle being used, fits the child being transported, has never been in a crash, and is used correctly every time. The use of restraint devices while riding in a vehicle reduces the likelihood of a passenger's suffering serious injury or death if the vehicle is involved in a crash. The use of child safety seats reduces risk of death by 71% for children less than 1 year of age and by 54% for children ages 1-4 (
29).
It is reasonable to require that the license holder ensure that the child be placed in restraint devices that conform to state and federal laws. The standard does not apply when children are being transported in vehicles not routinely or commonly equipped with restraints. The standard, however, does clarify that it is the responsibility of the caregiver to ensure that children are fastened in a restraint system. Federal law applies only to vehicles equipped with factory-installed seat belts after 1967.
The provision of mandatory restraints, regardless of the driver or age of the vehicle, is necessary to ensure children's health and safety. The use of safety restraints and choice of positioning in the vehicle is determined by close inspection of the manufacturer's instructions for seat restraints and for the vehicle.
At all times, vehicles should be ready to transport children who must ride in wheelchairs (
30,
31). Manufacturers' specifications should be followed to assure that safety requirements are met.
COMMENTS: When school buses meet current standards for the transport of school-age children, containment design features help protect children from injury, although the use of seat belts would provide additional protection. To obtain the Code of Federal Regulations, contact the Superintendent of Documents. Contact information is located in Appendix BB.
Many issues are involved in fitting the wide variety of safety restraints into the many different types of motor vehicles. Positioning children in relation to air bags in the vehicle adds a further complication. If the instructions for the safety restraint and for the motor vehicle do not make clear what should be done, contact the National Highway and Transportation Safety Administration (NHTSA) Auto Safety Hotline for more information. Contact information is located in Appendix BB.
Parents and others who transport young children should be aware that incompatibility problems between the design of the car safety seat, vehicle seat, and the seat belt system can be life-threatening and can be avoided by:
Reading the vehicle owner's manual and child restraint device instructions carefully;
Testing the car safety seat for a safe snug fit in the vehicle;
Having the car seat installation checked by a certified car seat technician at an approved car seat check station in the community;
Remembering that the rear vehicle seat is the safest place for a child of any age to ride.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
There shall be no smoking in the vehicles used by the facility at any time.
In each vehicle from a center, a "NO SMOKING" sign shall be posted.
RATIONALE: Children in confined spaces, e.g., closed vehicles, should not be exposed to secondhand smoke, particularly children with respiratory problems. Exposure to smoke and smoke fumes could trigger increased respiratory difficulties.
COMMENTS: Compliance can be measured by interviewing drivers and inspecting vehicles for evidence of smoking.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
emergency supplies for field trips
First aid kits shall be taken on field trips, as specified in STANDARD 5.093. Cellular phones shall be taken on field trips for use in emergency situations.
RATIONALE: The ability to communicate for help in an emergency situation while traveling is critical to the safety of children in a vehicle.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
interior temperature of vehicles
The interior of vehicles used to transport children shall be maintained at a comfortable temperature to children. When the vehicle's interior temperature exceeds 82 degrees F and providing fresh air through open windows cannot reduce the temperature, the vehicle shall be air-conditioned. When the interior temperature drops below 65 degrees F and when children are feeling uncomfortably cold, the interior shall be heated.
RATIONALE: Some children have problems with temperature variations. Whenever possible, open windows to provide fresh air to cool a hot interior is preferable before using air conditioning. Over-use of air conditioning can increase problems with respiratory infections and allergies. Excessively high temperatures in vehicles can cause neurological damage
COMMENTS: In geographical areas that are prone to very cold or very hot weather, a small thermometer should be kept inside the vehicle. In areas that are very cold, adults tend to wear very warm clothing and children tend to wear less clothing than might actually be required. Adults in a vehicle, then, may be comfortable while the children are not. When air conditioning is used, adults might find the cool air comfortable, but the children may find that the cool air is uncomfortably cold. To determine whether the interior of the vehicle is providing a comfortable temperature to children, a thermometer should be used and children in the vehicle should be asked if they are comfortable.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
mutual responsibility of parents and staff
There shall be a reciprocal responsibility of the family and child care staff to observe, participate, and be trained in the care that each child requires.
All aspects of child care programs shall be designed to facilitate parental input and involvement. Involved, non-custodial parents shall have access to the same developmental and behavioral information given to the custodial parent, if they have joint legal custody, permission by court order, or written consent from the custodial parent.
Caregivers shall informally share with parents daily information about their child's needs and activities.
RATIONALE: This plan will help achieve the important goal of carryover of facility components from the child care setting to the child's home environment. The child's learning of new skills is a continuous process occurring both at home and in child care.
Research, practice, and accumulated wisdom attest to the crucially important influence of children's
relationships with those closest to them. Children's
experience in child care will be most beneficial when parents and caregivers develop feelings of mutual respect and trust. In such a situation, children feel a continuity of affection and concern, which facilitates their adjustment to separation and use of the facility.
An ongoing source of stress for an infant or a young child is the separation from those they love and depend upon. Of the various programmatic elements in the facility that can help to alleviate that stress, by far the most important is the comfort in knowing that parents and caregivers know the children and their needs and wishes, are in close contact with each other, and can respond in ways that enable children to deal with separation.
The encouragement and involvement of parents in the social and cognitive leaps of preschoolers provide parents with the confidence vital to their sense of competence. Communication should be sensitive to ethnic and cultural practices. See STANDARD 2.006 through STANDARD 2.008. The parent/caregiver partnership models positive adult behavior for school-age children and demonstrates a mutual concern for the child's well-being (
25,
32-
44).
In families where the parents are separated, it is usually in the child's best interest for both parents to be involved in the child's care, and informed about the child's progress and problems in care. However, it is generally up to the courts to decide who has legal custody of the child. Child care providers should comply with court orders and written consent from the parent with legal authority, and not try to make the determination themselves regarding the best interests of the child.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Along with short informal daily conversations between parents and caregivers, planned communication (for example, parent conferences) shall be scheduled with at least one parent of every child in care:
a) To review the child's development and adjustment to care;
b) To reach agreement on appropriate, nonviolent, disciplinary measures;
c) To discuss the child's strengths, specific health issues, and concerns such as persistent behavior problems, developmental delays, special needs, overweight, underweight, or eating or sleeping problems.
At these planned conferences a caregiver shall review with the parent the child's health report and the health record to identify medical and developmental issues that require follow-up or adjustment of the facility.
Each review shall be documented in the child's facility health record with the signature of the parent and the staff reviewer. These planned conferences shall occur:
a) As part of the intake process;
b) At each health update interval;
c) On a calendar basis, scheduled according to the child's age:
1) Every 6 months for children under 6 years of age;
2) Every year for children 6 years of age and older;
d) Whenever new information is added to the child's facility health record.
Additional conferences shall be scheduled if the parent or caregiver has a concern at any time about a particular child. Any concern about a child's health or development shall not be delayed until a scheduled conference date.
Notes about these planned communications shall be maintained in each child's record at the facility and shall be available for review.
RATIONALE: Parents and caregivers alike should be aware of, and should have arrived at, an agreement concerning each other's beliefs and knowledge about how to deal with children. Reviewing the health record with parents ensures correct information and can be a valuable teaching and motivational tool (
45). It can also be a staff learning experience, through insight gained from parents on a child's special circumstances.
A health history is the basis for meeting the child's health, mental, and social needs in the child care setting (
45). Review of the health record can be a valuable educational tool for parents, through better understanding of the health report and immunization requirements (
45). A goal of out-of-home care of infants and children is to identify parents who are in need of instruction so they can provide preventive health/nutrition care at a critical time during the child's growth and development. It is in the child's best interest that the staff communicates with parents about the child's needs and progress. Parent support groups and parent involvement at every level of facility planning and delivery are usually beneficial to the children, parents, and staff. Communication among parents whose children attend the same facility helps the parents to share useful information and to be mutually supportive.
Both parents and caregivers have essential rights in helping to shape the kind of child care service their children receive.
COMMENTS: The need for follow-up on needed intervention increases when an understanding of the need and motivation for the intervention has been achieved through personal contact. A health history is most useful if the health advocate (see Qualifications of Health Advocates, STANDARD 1.021) personally reviews the records and updates the parents. A health history ensures that all information needed to care for the child is available to the appropriate staff member. Special instructions, such as diet, can be copied for everyday use. Compliance can be assessed by reviewing the records of these planned communi-
Parents who use child care services should be regarded as active participants and partners in facilities that meet their needs as well as their children's. Compliance can be measured by interviewing parents and staff.
See Plan for Child Health Services, STANDARD 8.013 through STANDARD 8.017, on health assessment; and STANDARD 3.004, on nutrition assessment and follow-up. See STANDARD 8.046 through STANDARD 8.051, for more information on health reports; and see STANDARD 8.051 and STANDARD 8.052, for more information on health records.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Each caregiver shall, at least twice a year, seek the views of parents about the strengths and needs of the facility. Caregivers shall honor parents' requests for more frequent reviews.
RATIONALE: This standard strengthens the recognition by parent and caregiver alike that parents have essential rights in helping to shape the kind of child care service their children receive.
COMMENTS: Small and large family child care homes should have group meetings of all parents once or twice a year. This standard avoids mention of procedures that are inappropriate to small family child care, as it does not require any explicit mechanism (such as a parent advisory council) for obtaining or offering parental input. Individual or group meetings with parents would suffice to meet this standard. Seeking consumer input is a cornerstone of facility planning and evaluation.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
support services for parents
Centers shall establish parent groups and parent support services. Centers shall document these
services and shall include intra-agency activities or other community support group offerings. The caregiver shall record parental participation in these on-site activities in the facility record.
RATIONALE: Parental involvement at every level of program planning and delivery and parent support groups are elements that are usually beneficial to the children, parents, and staff of the facility. The parent association group facilitates mutual understanding between the center and parents. Parental involvement also helps to broaden parents' knowledge of admini-stration of the facility and develops and enhances advocacy efforts.
COMMENTS: Parent meetings within a facility are useful means of communication that supplement mailings and indirect contacts.
The facility shall require parental consent and participation when significant decisions involving a child's services are made and during the process of formal evaluation of a child.
Parents shall be explicitly invited to:
a) Participate in discussions of the results of their child's evaluations and the relationship of their child's needs to the caregivers' ability to serve that child appropriately;
b) Give alternative perspectives;
c) Share their expectations and goals for their child and have these expectations and goals integrated with any plan for their child.
The facility shall document parents' presence at these meetings and invitations to attend.
If the parents do not attend the assessment, the caregiver shall inform the parents of the results, and offer an opportunity for discussion.
RATIONALE: To provide services effectively, facilities must recognize parents' observations and reports about the child and their expectations for the child, as well as the family's need of child care services. A marked discrepancy between professional and parental observations of, or expectations for, a child necessitates further discussion and development of a consensus on a plan of action.
Parents need to have accurate information about their children. An evaluation of a child is complete only when the facility has discussed the information with the parent. The caregiver should explain the results to parents honestly, but sensitively, without using technical jargon (
38).
COMMENTS: Parents need to be included in the process of shaping decisions about their children, e.g., adding, deleting, or changing a service.
Efforts should be made to provide notification of meetings in the primary language of the parents.
Efforts to schedule meetings at times convenient to parents should be encouraged. Those conducting an evaluation, and when subsequently discussing the findings with the family, should consider parents' input. Parents have both the motive and the legal right to be included in decision-making and to seek other opinions.
A second, independent opinion can be offered to the family to confirm the original evaluation, but extensive "shopping" for a more desirable or favorable opinion should be discouraged.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
enabling parents as child advocates
Child care providers shall inform parents about programs and sources of information that will improve parents' capability as advocates for the children's needs. When the facility does not directly offer applicable services, the child care provider shall refer parents to agencies with experience in working with the needs of their children. Facilities shall document any referrals in writing.
RATIONALE: Applicable referrals will make parents more effective advocates for their children's needs.
COMMENTS: Information should be shared with parents in the parents' primary language and with sensitivity to the parents' ethnic and cultural practices.
Advocacy training can be provided by a service provider or an outside agency.
In the case of a child with special needs, the family can be referred to agencies involved with special needs. For additional information on parental participation, see Parental Involvement, STANDARD 2.050through STANDARD 2.053, and Health Information Sharing, STANDARD 2.054.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
on-site services for children with special health needs
Child care providers shall be aware of all on-site services, including the following service providers, that may be of use for children in care:
a) Special clinics the child may attend, including sessions with medical specialists and registered dieticians;
b) Special therapists for the child (such as occupational, physical, speech, nutrition);
c) Counselors, therapists, or mental health service providers for parents (such as social workers, psychologists, psychiatrists).
All care providers shall provide written docu-mentation of the services rendered in the primary language of the parent. Information shall be exchanged only with the prior written, informed consent of the parent.
RATIONALE: Knowing who is treating the child and coordinating services with these individuals is vital to program implementation. There should be a liaison with special clinics for specific disabilities and illnesses when children are seen for consultation at these units. Services provided onsite at the facility should be coordinated with those offered at another site (
46,
47).
COMMENTS: Although information is best related in writing, telephone contacts are also helpful. Confi-dentiality should be respected both with written and verbal communication. Regular contacts between professionals working with the child and family served by the child care facility improve coordination of care, minimize confusion for the family and prevent dupli-cation. Caregivers, however, must strictly adhere to guidelines concerning confidentiality. Documentation of special therapy is necessary for monitoring purposes. These therapies may be provided by private therapists or by clinics or centers specializing in such services. Some social and psychological data may have to be exchanged within the limits of discretion and confidentiality.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care
communication from specialists
Providers who come into the facility to furnish special services to a child shall also communicate at each visit with the caregiver at the facility who is responsible for sharing information with the parent. These providers may include, but are not limited to, physicians, registered nurses, occu-pational therapists, physical therapists, speech therapists, educational therapists, and registered dietitians. The discussions shall be documented in the child's written record.
RATIONALE: Therapeutic services must be coordinated with the child's general education program and with the parents and caregivers so everyone understands the child's needs. To be most useful, the providers must share the therapeutic techniques with the caregivers and parents and integrate them into the child's daily routines, not just at therapy sessions. Parental consent to share some information may be necessary.
COMMENTS: See Child Records, 8.046 through 8.052, for information regarding child health records.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Health education for children and staff shall include physical, oral, mental/emotional, nutritional, and social health and shall be integrated daily in the program of activities, to include such topics as:
b) Families (including cultural heritage);
c) Personal/social skills;
d) Expression of feelings;
h) Safety (such as home, vehicular care seats and belts, playground, bicycle, fire, and firearms);
i) Conflict management and violence prevention;
m) Awareness of special needs;
n) Importance of rest and sleep;
q) Health risks of secondhand smoke;
s) Dialing 911 for emergencies.
RATIONALE: For young children, health and education are inseparable. Children learn about health and safety by experiencing risk taking and risk control, fostered by adults who are involved with them. Whenever opportunities for learning arise; facilities should integrate education to promote healthy behaviors. Health education should be seen not as a structured curriculum, but as a daily component of the planned program that is part of child development. Certified health education specialists are a good resource for this instruction. The American Association for Health Education (AAHE), the National Commission for Health Education Credentialing, Inc. (NCCHEC), and the State and Territorial Injury Prevention Directors' Association (STIPDA) provide information on this specialty. Contact information for the AAHE, NCCHEC, and STIPDA is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The content of a parent education plan shall be individualized to meet each family's needs and shall be sensitive to cultural values and beliefs. Written material, at a minimum, shall address the most important health and safety issues for all age groups served, shall be in a language understood by families, and may include the topics listed in STANDARD 2.061, with special emphasis on the following:
a) Safety (such as home, community, playground, firearm, vehicular, or bicycle);
b Oral health promotion and disease prevention;
c) Value of healthy lifestyle choices (such as exercise, nutrition, avoidance of substance abuse and tobacco use);
d) Importance of well child care (such as immunizations, hearing/vision screening, monitoring growth and development);
f) Parental health (such as pregnancy care, substance abuse prevention, smoking cessation, HIV/AIDS prevention, stress management, or subjects of concern to the parent);
h) Conflict management and violence prevention;
i) Prevention and management of infectious disease, including the need for parents of infants in child care to adopt some handwashing and diapering procedures (as done in child care) for the parents' protection as well as for the protection of the other children and adults in the family;
j) Child behavior (normal and problematic);
k) Handling emergencies/first aid;
l) Child advocacy skills;
Health education for parents shall utilize principles of adult learning to maximize the potential for parents to learn about key concepts. Facilities shall utilize opportunities for learning, such as the case of an illness present in the facility, to inform parents about illness and prevention strategies.
The staff shall introduce seasonal topics when they are relevant to the health and safety of parents and children.
RATIONALE: Adults learn best when they are motivated, comfortable, and respected, when they can immediately apply what they have learned, and when multiple learning strategies are used. Individualized content and approaches are needed for successful intervention. Parent attitudes, beliefs, fears, and educational and socioeconomic levels all should be given consideration in planning and conducting parent education (
48,
49). Parental behavior can be modified by education. Parents should be involved closely with the facility. If done well, didactic teaching can be effective for educating parents. If not done well, there is a danger of demeaning parents and making them feel less, rather than more, capable (
48,
49).
The concept of parent control and empowerment is key to successful parent education in the child care setting. Support and education for parents lead to better parenting abilities.
Knowing the family will help the health advocate. See Qualifications of Health Advocates, STANDARD 1.021, to determine content and method of the parent education plan. Specific attention should be paid to the parents' need for support and consultation or help with resources for their own problems. If the facility suggests a referral or resource, this should be documented in the child's record. Specifics of what the parent shared need not be recorded.
COMMENTS: Community resources could provide written health-related materials. Small and large family child care home providers can cover physical, oral, mental, and social health on an informal basis, as the small size of the homes and the varied ages of the enrollees preclude a "curriculum" per se. School-age child care facilities do not need to incorporate child health education into their programs, as enrollees receive this information in school.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
3. HEALTH PROMOTION AND PROTECTION
Written Plan For Medical Emergency
Facilities shall have a written plan for immediate management and rapid access to medical care as appropriate to the situation. This plan shall:
a) Describe for each child any special emergency procedures that will be used, if required, by the caregiver or by a physician or registered nurse available to the caregiver;
b) Note any special medical procedures, if required by the child's condition, that will be used or might be required for the child while he/she is in the facility's care, including the possibility of a need for cardiac resuscitation;
c) Include in a separate format, any information to be given to an emergency responder in the event that one must be called to the facility for the child. This information shall include:
1) Any special information needed by the emergency responder to respond appropriately to the child's condition;
2) A listing of the child's health care providers in the event of an emergency.
RATIONALE: The medical aspect of caring for children is likely to be the facet of care that caregivers are most poorly equipped to carry out, as their training is usually in early childhood education. The preparation of a written plan (a brief one would suffice) provides and opportunity for caregivers to work out how to deal with routine, urgent, and emergency medical needs.
Children with special needs may need an emergency responder whether it is for an asthma emergency, a cardiac emergency, or any of a number of conditions that put children at risk for emergency response and transport. An individual child's written plan for the first responders will save time and may be critical in the provision of appropriate care of a child in crisis.
COMMENTS: Training and other technical assistance for developing emergency plans can be obtained from the following:
a) American Academy of Pediatrics (AAP);
b) American Nurses' Association (ANA);
c) State and community nursing associations;
d) National therapy associations;
e) Local resource and referral agencies;
f) Federally funded, University Centers for Excellence in Developmental Disabilities Education, Research, and Service, programs for individuals with developmental disabilities;
g) Other colleges and universities with expertise in training others to work with children who have special needs;
h) Community-based organizations serving people with disabilities (Easter Seals, American Diabetes Association, American Lung Association, etc.).
i) Community sources of training in infant/child CPR (American Heart Association, American Red Cross, Emergency Medical Services for Children National Resource Center).
The State-designated lead agency responsible for implementing IDEA may provide additional help.
For additional information regarding emergency plans, see STANDARD 8.022 and STANDARD 8.023. For additional discussion about first aid and CPR, see STANDARD 1.026.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
SPECIAL MEDICAL CONDITIONS IN YOUNG CHILDREN
SEIZURES (INCLUDING EPILEPSY)
The child care facility shall have a seizure care plan and ensure that all caregivers receive training to successfully implement the plan. If a child in care has epilepsy or a history of febrile seizures that are not considered a form of epilepsy, the child's seizure care plan shall include the following:
a) Types of seizures the child has (such as partial, generalized, or unclassified), as well as a description of the manifestation of these types of seizures in this child;
b) The current treatment regimen for this child, including medications, doses, schedule of administration, guidelines, route of administration, and potential side effects for routine and as-needed medications;
c) Restrictions from activities that:
1) Could be dangerous if the child were to have a seizure during the activity;
2) Could precipitate a seizure (examples include swimming and falling from a height);
d) Recognizing and providing first aid for a seizure;
e) Guidelines on when emergency medical help should be sought for the child who has epilepsy, such as:
1) A major convulsive seizure lasting more than 5 minutes;
2) One seizure after another without waking up between seizures;
3) The child is completely unresponsive for 20 minutes after the seizure;
f) Documentation in the child's health report that indicates:
1) Whether the child has had a history of any type of
seizures;
2) Whether the child is currently taking medication to control the seizures;
3) What observations caregivers should make to help the child's clinician adjust the medication;
4) The type and frequency of reported seizures as well as seizures observed in the facility;
g) Plans for support of the child with epilepsy and the child's family.
RATIONALE: A child that has a seizure may not have epilepsy or even a history of seizures. Child care providers should be trained to care for any child who has a seizure. For children with epilepsy, the child care staff should have detailed information and skills to understand the child's health needs and how to meet these needs in the child care setting. Seizures are usually self-limited events. Prolonged seizures, sequential seizures without recovery to a normal status, or remaining unresponsive for 20 minutes after a seizure suggests that the child is in status epilepticus and requires emergency care. The staff must respond appropriately to self-limited seizures and situations that require emergency help.
Epilepsy can be overwhelming for the child and family. The child care staff must offer support in understanding the condition and contribute positively to management of the child.
The child's physician needs reliable information on the number and type of seizures as well as the symptoms that might be side effects of the child's medication so the physician can make appropriate adjustments in the child's therapy.
COMMENTS: This information should be provided by the child's physician. Although children may be sleepy for a period after having a generalized seizure, sending children home after they have recovered from a seizure is unnecessary and should be discouraged, unless specified in the health plan.
The classification system currently used for seizures replaces earlier terminology as follows:
Grand Mal is now referred to as Generalized Seizure.
Petit Mal is now referred to as Partial Seizure.
Children with febrile seizures (who are not diagnosed with any form of epilepsy) do not receive anticonvulsant medication. These children usually outgrow this condition.
If the child's parents consent, child care providers should establish a close and continuing liaison with the child's health care provider, especially if the seizures are not well controlled. Sometimes the child's clinicians will monitor the medication prescribed to control seizures by measuring blood samples and sometimes through observations by caregivers and parents. In either case, dosage may have to be adjusted to reduce side effects or provide better control.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Training For Staff To Handle Seizures
Staff members shall be trained in, and shall be prepared to follow, the prescribed procedure when a child has a seizure. These procedures include proper positioning, keeping the airway open, and knowing when and whom to call for medical assistance. All staff members shall be instructed about the relevant side effects of any anti-convulsant medications that children in the facility take and how to observe and report them.
Telephone numbers for emergency care shall be posted, as specified in Posting Documents, STANDARD 8.077.
RATIONALE: Without training, a staff member may panic when a child has a seizure. Without specific procedures, well-intended staff members may not take the steps required to avoid preventable injury during a seizure.
Anti-convulsant medication may affect a child's health and behavior. Observing and reporting these side effects contributes significantly to a health care provider's ability to recommend appropriate modifications in medication.
COMMENTS: The general guidelines for managing seizures apply to children with special needs. Staff members can be trained through initial and ongoing inservice efforts in specific procedures to follow with a child who has a seizure as well as appropriate supervision and movement of the other children present. See Continuing Education, STANDARD 1.029 through STANDARD 1.033.
Changes in health and behavior that may result from medication should be reported to the parent in the parent's native language and with sensitivity to the parent's ethnic and cultural practices. With written parental consent, the caregiver may also share this information with the child's primary health care provider. Useful references concerning seizures and side effects of medications used to control seizures, particularly if a child begins a new medicine while attending the facility, include the following:
b) The child's primary health care provider (if the parents consent to contact between the provider and the child care facility);
See also Medications, STANDARD 3.081 through STANDARD 3.083; and Medication Policy, STANDARD 8.021.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Management of Children With Asthma
When a child who has had a diagnosis of asthma by a health professional attends the child care facility, the following actions shall occur:
a) Each child with asthma shall have a special care plan prepared for the facility by the child's source of health care, to include:
1) Written instructions regarding how to avoid the conditions that are known to trigger asthma symptoms for the child;
2) Indications for treatment of the child's asthma in the child care facility;
3) Names, doses, and method of administration of any medications, e.g., inhalers, the child should receive for an acute episode and for ongoing prevention;
4) When the next update of the special care plan is due;
b) Based on the child's special care plan, the child's caregivers shall receive training, demonstrate competence in, and implement measures for:
1) Preventing exposure of the asthmatic child to conditions likely to trigger the child's asthma;
2) Recognizing the symptoms of asthma;
3) Treating acute episodes;
c) Parents and staff shall arrange for the facility to have necessary medications and equipment to manage the child's asthma while the child is at the child care facility;
d) Properly trained caregivers shall promptly and properly administer prescribed medications according to the training provided and in accordance with the special care plan;
e) The facility shall notify parents of any change in asthma symptoms when that change occurs. See the
Special Care Plan for a Child with Asthma, Appendix M;
f) The facility shall try to reduce these common asthma triggers by:
1) Encouraging the use of allergen impermeable nap mats or crib/mattress covers;
2) Prohibiting pets (particularly furred or feathered pets);
3) Prohibiting smoking inside the facility or on the playground;
4) Discouraging the use of perfumes, scented cleaning products, and other fumes;
5) Quickly fixing leaky plumbing or other sources of excess water;
6) Ensuring frequent vacuuming of carpet and upholstered furniture at times when the children are not present;
7) Storing all food in airtight containers, cleaning up all food crumbs or spilled liquids, and properly disposing of garbage and trash;
8) Using integrated pest management techniques to get rid of pests (using the least hazardous treatments first and progressing to more toxic treatments only as necessary);
9) Keeping children indoors when local weather forecasts predict unhealthy ozone levels or high pollen counts.
RATIONALE: Asthma is common, occurring in 7%-10% of all preschool and school-aged children. Asthma is a major cause of morbidity in childhood, resulting in sleep disturbance, limitations in exercise, absenteeism from child care and school, and hospitalization. Despite increased awareness and knowledge of the problem, asthma remains underdiagnosed and undertreated. Proper diagnosis, treatment, and prevention of exposure to environmental triggers can lessen complications and improve long term outcome. (
51)
Respiratory infections are the primary trigger of asthma (especially of severe episodes) in the young child. Because respiratory infections and asthma are common in early childhood, child care providers should expect to serve children with asthma. Respiratory irritants such as secondhand cigarette smoke, fumes, odors, chemicals, excess humidity, and very hot or cold air may also trigger asthma, so children with asthma should be protected from these irritants. In older preschoolers and school-age children, allergens (pets, mold, cockroaches, dust mites) in the child care setting or school may contribute as well. Reducing exposure to potential triggers is important to control symptoms and prevent attacks and also to improve the long-term prognosis.
Prompt and appropriate intervention during an acute episode of asthma is essential to prevent severe or prolonged effects. Many hospitalizations and most deaths from asthma are the result of delayed recognition of the symptoms or delayed and inadequate treatment. In general, when a child with known asthma has symptoms suggesting an acute asthma episode, treatment should begin promptly, according to instructions. In most instances, a delay in treatment is likely to have more negative effects than occasional overtreatment. Children should not have to wait to begin treatment until a parent can arrive to give it.
The physical assessment of some children with asthma can be augmented by use of a peak flow meter. Peak flow meters can only be used with children who are old enough to understand directions for use and able to cooperate. Peak flow readings can help to determine when treatment should be started, even for a child with no signs of distress, when treatment is helping, and when additional treatment or advice is needed. Staff members must receive training about the purpose, expected response, and possible side effects of medications they are expected to administer. They also must be trained in the proper use of equipment such as inhalers or nebulizers according to the guidelines for medication administration in that state's licensure regulations.
COMMENTS: Asthma is a chronic lung disease caused by an oversensitivity of the bronchial tubes to various stimuli or "triggers." In asthma, the lining of the tubes becomes inflamed and swollen and extra mucus is produced. Muscles surrounding the airways tighten so that the air passages become narrower. Typical symptoms of asthma include coughing, wheezing, tightness in chest, and shortness of breath. The symptoms of asthma can occur together or alone. Often, the only symptom of asthma is chronic or recurrent cough, particularly while sleeping, during activity, or with colds. Asthma is not the only condition that can cause these symptoms but is certainly the most common.
Symptoms can vary from very mild to severe and life threatening. They can be only occasional or continuous. Specific symptoms and warning signs can vary from child to child. Likewise, specific recommendations for treatment are likely to vary. Appropriate treatment depends on the frequency and severity of the symptoms. Accurate assessment by caregivers will aid in establishing the diagnosis and determining long-term management needs.
All of the symptoms of asthma need not be present at one time in any child. Asthma episodes can range from very mild to severe and life threatening. Not all children with asthma have allergies. Sensitivity to triggers may fluctuate over time, so exposure to one or more triggers may not always precipitate an attack. Also, triggers tend to be cumulative; the more a child is exposed to at one time, the more likely is an attack. Indications for notification of parents and physician will vary.
Notify parents if any one of the following is
present (
50):
a) Symptoms persist despite one dose of prescribed "rescue" medication (especially if symptoms are bad enough to interfere with sleep, eating, or activity);
b) Two or more doses of "rescue" medication have been needed during the course of a single day for recurrent symptoms;
c) Peak flow remains 50%-80% of normal despite one dose of the prescribed "rescue" medication;
d) Symptoms are severe (see below).
Notify physician/emergency services if any one of the following occurs (
50):
a) Child is struggling to breathe, hunches over, or sucks in chest and neck muscles in an attempt to breathe;
b) Child is having difficulty walking or talking because of shortness of breath;
c) Peak flow is less than 50% of normal;
d) Lips or fingernails turn gray or blue.
Additional resources on caring for children with asthma such as the
How Asthma-Friendly is Your Child-Care Setting? Checklist can be obtained from the National Heart, Lung, and Blood Institute and other useful materials from the Asthma and Allergy Foundation of America. Contact information for these organizations is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Caring for Children Who Require Medical Procedures
A facility that enrolls children who require tube feedings, endotrachial suctioning, oxygen, postural drainage, or catheterization daily (unless the child requiring catheterization can perform this function on his/her own) or any other special medical procedures performed routinely, or who might require special procedures on an urgent basis, shall receive a written report from the health care provider who prescribed the special treatment (such as a urologist for catheterization). A facility shall receive a written report from the child's clinician about any special preparation to perform urgent procedures other than those that might be required for a typical child, such as cardiac resuscitation. This report shall include instructions for performing the procedure, how to receive training in performing the procedure, and what to do and who to notify if complications occur. Training for the child care staff shall be provided by a qualified health care professional in accordance with state practice acts.
RATIONALE: The specialized skills required to implement these procedures are not traditionally taught to educators or educational assistants as part of their academic or practical experience.
COMMENTS: Parents 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 and consultation. Without these supports, facilities should not be expected to serve these children.
Before enrolling a child who will need this type of care, child care providers can request and review fact sheets and instructions, and training that includes a return demonstration of competence of caregivers for handling specific procedures. Often, the child's parents or clinicians have these materials and know where training is available. When the specifics are known, caregivers can make a more responsible decision about what would be required to serve the child.
See STANDARD 7.001, regarding facilities serving children with disabilities and other special needs. For additional discussion about first aid and CPR, see STANDARD 1.026.
TYPE OF FACILITY:
Center; Large Family Child Care; Small Family Child Care Home
4. GENERAL NUTRITION REQUIREMENTS
If dietary modifications are indicated based on a child's medical or special dietary needs, the caregiver shall modify or supplement the child's diet on a case-by-case basis, in consultation with the parents and the Nutrition Specialist, a trained nutrition expert, or the child's usual health care source.
Reasons for modification of the child's diet may be related to allergies, food idiosyncrasies, and other identified feeding issues.
For a child identified with medical special needs for dietary modification or special feeding techniques, written instructions from the child's parent or legal guardian and the child's health care provider shall be provided in the child's record and carried out accordingly. Dietary modifications shall be recorded, as specified in STANDARD 8.050.
These written instructions must identify:
a) The child's special needs;
b) Any dietary restrictions based on the special needs;
c) Any foods to be omitted from the diet and any foods to be substituted;
d) Limitations of life activities;
e) Any other pertinent special needs information.
The Nutrition Specialist shall approve menus that accommodate needed dietary modifications.
RATIONALE: Child care homes and facilities should have explicit and written procedures for dietary modifications or meal substitutes.
Dietary modifications for any child, including those with special health care needs, developmental problems of chewing and swallowing food, and food allergies, should be carefully monitored by a trained health professional, coordinated with the rest of the child's health care, and documented in the child's record. Periodic monitoring of dietary modifications or substitutions should provide opportunities to reevaluate the plan to ensure that the child's nutritional needs are met as the child grows and develops.
As a safety and health precaution, the staff should know in advance whether a child has food allergies, tongue thrust, special medical needs related to feeding, or requires nasogastric or gastric tube feedings or special positioning. These situations require individual planning prior to the child's entry into child care and on an ongoing basis (
58,
59).
Detailed information on a child's special needs is invaluable to the facility staff in meeting the nutritional needs of that child.
COMMENTS: Close collaboration between the home and the facility is needed for children on special diets Parents may have to provide food on a temporary or permanent basis if the facility, after exploring all community resources, is unable to provide the special diet.
For additional information on the Nutrition Specialist, see STANDARD 4.027.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Written Menus, Introduction of New Foods
Facilities shall develop, at least one month in advance, written menus showing all foods to be served during that month and shall make them available to parents. The facility shall date and retain these menus; amended to reflect any changes in the food actually served. Any substitutions shall be of equal nutrient value.
To avoid problems of food sensitivity in very young children, child care providers shall obtain from the child's parents, a list of foods that have already been introduced (without any reaction), and then serve some of these foods to the child. As new foods are introduced, child care providers shall share and discuss these foods with the parents prior to their introduction.
RATIONALE: Planning menus in advance helps to ensure that food will be on hand. Parents need to be informed about food served in the facility to know how to complement it with the food they serve at home. If a child has difficulty with any food served at the facility, parents can address this issue with appropriate staff members. Some regulatory agencies require menus as a part of the licensing and auditing process (
52,
56).
COMMENTS: Making the menus available to parents by posting them in a prominent area helps inform parents about proper nutrition. Sample menus and menu planning templates are available from most state health departments, the state extension service, and the Child and Adult Care Food Program. Contact information for the State Administrators of the Child and Adult Care Food Program is located in
For information on posting menus, see STANDARD 8.077.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Before any child enters a child care facility, the facility shall obtain a written history of any special nutrition or feeding needs the child has. The staff shall review this history with the child's parents. If further information is required, along with the parents' written consent, the program may consult with the child's primary health care provider.
The written history of special nutrition or feeding needs shall be used to develop individual feeding plans and, collectively, to develop facility menus. Disciplines related to special nutrition needs, including nursing, speech, and occupational and physical therapy, shall participate when needed and/or when they are available to the facility. With the exception of children on special diets, the general nutrition guidelines for facilities in General Requirements, STANDARD 4.001 through
STANDARD 4.010; Nutrition for Infants, STANDARD 4.011 through STANDARD 4.021; Nutrition for Toddlers and Preschoolers, STANDARD 4.022 through STANDARD 4.024; and Nutrition for School-age Children, STANDARD 4.025, shall be applied.
The feeding plan shall include steps to take when a situation arises that requires rapid response by the staff (such as a child's choking during mealtime or a child with a known history of food allergies demonstrating signs and symptoms of anaphylaxis). The completed plan shall be on file and accessible to the staff.
RATIONALE: Children with special needs may have individual requirements relating to diet, swallowing, and similar feeding needs that require the development of an individual plan prior to their entry into the facility.
Many children with special needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent feeding skills. Food, eating style, utensils, and equipment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (
63).
Staff members must know ahead of time what procedures to follow, as well as their designated roles during an emergency.
Anaphylaxis is a severe, rapid immune response in an allergic individual. This response manifests itself in a collection of symptoms affecting multiple organ systems in the body. The most dangerous symptoms include difficulty breathing and shock. Anaphylaxis is life-threatening and should be considered a medical emergency requiring immediate recognition and treatment (
57,
58,
63).
In children, foods are the most common cause of anaphylaxis. Nuts, eggs, milk, and seafood are the most common allergens for food-induced anaphylaxis in children.
COMMENTS: Close collaboration between the home and the facility is necessary for children on special diets. Parents may have to provide food on a temporary or permanent basis if the facility, after exploring all community resources, is unable to provide the special diet.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Care for Children With Food Allergies
When children with food allergies attend the child care facility, the following shall occur:
a) Each child with a food allergy shall have a special care plan prepared for the facility by the child's source of health care, to include:
1) Written instructions regarding the food(s) to which the child is allergic and steps that need to be taken to avoid that food;
2) A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan shall include specific symptoms that would indicate the need to administer one or more medications;
b) Based on the child's special care plan, the child's caregivers shall receive training, demonstrate competence in, and implement measures for:
1) Preventing exposure to the specific food(s) to which the child is allergic;
2) Recognizing the symptoms of an allergic reaction;
3) Treating allergic reactions;
c) Parents and staff shall arrange for the facility to have necessary medications, proper storage of such medications, and the equipment and training to manage the child's food allergy while the child is at the child care facility;
d) Caregivers shall promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the special care plan;
e) The facility shall notify the parents of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur;
f) The facility shall notify the child's physician if the child has required treatment by the facility for a food allergic reaction;
g) The facility shall contact the emergency medical services system immediately whenever epinephrine has been administered;
h) Parents of all children in the child's class shall be advised to avoid any known allergies in class treats or special foods brought into the child care setting.
i) Individual child's food allergies shall be posted prominently in the classroom and/or wherever food is served.
j) On field trips or transport out of the child care setting, the written child care plan for the child with allergies shall be routinely carried.
RATIONALE: Food allergy is common, occurring in between two and eight percent of infants and children (
64). Food allergic reactions can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Deaths from food allergy are being reported in increasing numbers. A major factor in these deaths has been a delay in the administration of life-saving emergency medication, particularly epinephrine. Intensive efforts to avoid exposure to the offending food(s) are therefore warranted. Detailed care plans and the ability to implement such plans for the treatment of reactions is essential for all food-allergic children (
52,
58,
63).
Successful food avoidance requires a cooperative effort that must include the parents, the child, the child's health care provider, and the child care staff. The parents, with the help of the child's health care provider, must provide detailed information on the specific foods to be avoided. In some cases, especially for children with multiple food allergies, the parents may need to take responsibility for providing all the child's food. In other cases, the child care staff may be able to provide safe foods as long as they have been fully educated about effective food avoidance.
Effective food avoidance has several facets. Foods can be listed on an ingredient list under a variety of names, such as milk being listed as casein, caseinate, whey, and lactoglobulin. Food sharing between children must be prevented by careful supervision and repeated instruction to the child about this issue. Accidental exposure may also occur through contact between children or by contact with contaminated surfaces, such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just from being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by washing children's hands and faces and all surfaces that were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the use of peanut butter to make a bird feeder or wheat to make play dough.
Some children with food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have an antihistamine or epinephrine available to be used in the event of a reaction. For all children with a history of anaphylaxis, or for those with peanut and/or tree nut allergy (whether or not they have had anaphylaxis), epinephrine should be readily available. This will usually be provided as a pre-measured dose in an auto-injector, such as the Epi-Pen or Epi-Pen Junior. Specific indications for administration of epinephrine should be provided in the detailed care plan. In virtually all cases, Emergency Medical Services (EMS) should be called immediately and children should be transported to the emergency room by ambulance after the administration of epinephrine (
58). A single dose of epinephrine wears off in 15 to 20 minutes.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
NUTRITION LEARNING EXPERIENCES AND EDUCATION
Nutrition Learning Experiences For Children
The facility shall have a nutrition plan (see
STANDARD 4.001 and STANDARD 8.035) that integrates the introduction of food and feeding experiences with facility activities and home feeding. The plan shall include opportunities for children to develop the knowledge and skills necessary to make appropriate food choices.
For centers, this plan shall be a written plan and shall be the shared responsibility of the entire staff, including directors, food service personnel, and parents. The nutrition plan shall be developed with guidance from, and shall be approved by, the Child Care Nutrition Specialist (see
Appendix C).
Caregivers shall teach children about the taste and smell of foods. The children shall feel the textures and learn the different colors and shapes of foods. The teaching shall be evident at mealtimes and during curricular activities, without interfering with the pleasure of eating.
RATIONALE: Nourishing and attractive food is a foundation for developmentally appropriate learning experiences and contributes to health and well-being (
52-
60,
65,
66,
67,
68). Coordinating the learning experiences with the food service staff maximizes effectiveness of the education. In addition to the nutritive value of food, infants and young children are helped, through the act of feeding, to establish warm human relationships. Eating should be an enjoyable experience in the facility and at home.
Nutrition is a vital component of good health. Enjoying and learning about food in childhood promotes good nutrition habits for a lifetime.
COMMENTS: Parents and caregivers should always be encouraged to sit at the table and eat the same food offered to young children as a way to strengthen family style eating which supports child's serving and feeding him or herself. Family style eating requires special training for the food service and child care staff since they need to monitor food served in a group setting. The use of serving utensils shall be encouraged to minimize food handling by children. The presence of an adult at the table with children while they are eating is a way to encourage social interaction and conversation about the food such as its name, color, texture, taste, and concepts such as number, size, and shape; as well as sharing events of the day. The parent or adult can help the slow eater, prevent behaviors that might increase risk of fighting, eating each others food and stuffing food in mouth which might cause choking.
Several community based nutrition resources can help child care providers with the nutrition and food service component of their programs. The key to identifying a qualified nutrition professional is training in pediatric nutrition (normal nutrition, nutrition for children with special needs, dietary modifications) and experience and competency in basic food service
Local resources for nutrition education include:
Local and state nutritionists in health department in maternal and child health programs and divisions of children with special health care needs;
Registered dietitians/nutritionists at hospitals;
WIC and cooperative extension nutritionists;
School food service personnel;
State administrators of Child and Adult Care Food Program;
National School Food Service Management Institute;
Child Care Nutrition Resource System of the Food and Nutrition Information System (National Agricultural Library, USDA);
Nutrition consultants with local affiliates of the following organizations:
American Dietetic Association;
American Public Health Association;
Society for Nutrition Education;
American Association of Family and Consumer Sciences;
American Heart Association;
