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
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
i) Policies and practices of the facility about relating to parents. See Parent Relationships, STANDARD 2.044 through
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,
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
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(
2).
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
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 (
1). 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 (
3). 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
topics covered in first aid training
Management of a blocked airway and rescue breathing comprise two of the core elements of pediatric first aid training. In addition, the course must present an overview of the Emergency
Medical Services (EMS), accessing EMS, safety at the scene, and isolation of body substances, and the first aid instruction that is offered shall include, but not be limited to, recognition and first response of pediatric emergency management in a child care setting of the following situations:
a) Abrasions and lacerations;
b) Bleeding, including nosebleeds;
e) Poisoning, including swallowed, contact, and inhaled;
f) Puncture wounds, including splinters;
g) Injuries, including insect, animal, and human bites;
i) Convulsions or nonconvulsive seizures;
j) Musculoskeletal injury (such as sprains, fractures);
k) Dental and mouth injuries;
m) Allergic reactions, including information about when auto-injected epinephrine might be required;
o) Loss of consciousness;
r) Heat-related injuries, including heat exhaustion/heat stroke;
t) Moving and positioning injured/ill persons;
u) Management of a blocked airway and rescue breathing for infants and children with return demonstration by the learner;
v) Illness-related emergencies (such as stiff neck, inexplicable confusion, sudden onset of blood-red or purple rash, severe pain, temperature of 105 degrees F or higher, or looking/acting severely ill);Standard Precautions;
w) Organizing and implementing a plan to meet an emergency for any child with a special health care need;
x) Addressing the needs of the other children in the group while managing emergencies in a child care setting.
RATIONALE: First aid for children in the child care setting requires a more child-specific approach than standard adult-oriented first aid offers.
To ensure the health and safety of children in a child care setting, someone who is qualified to respond to common injuries and life-threatening emergencies must be in attendance at all times. A staff trained in pediatric first aid, including 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 reduce the potential for death and disability. 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.
Small family child care home providers often work alone and are solely responsible for the health and safety of children in care. Such providers must have pediatric first aid competence.
COMMENTS: Usually, other children will have to be supervised while the injury is managed. Parental notification and communication with emergency medical services must be carefully planned. First aid information can be obtained from the American Academy of Pediatrics (AAP) and the American Heart Association (AHA). Contact information for the AAP and the AHA is located in Appendix BB.
For discussion of the need for training in CPR, see STANDARD 1.026.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The facility shall maintain at least one readily available first aid kit wherever children are in care, including one for field trips and outings away from the facility and one to remain at the facility if all the children do not attend the field trip. In addition, a first aid kit shall be in each vehicle that is used to transport children to and from a child care center. Each kit shall be a closed container for storing first aid supplies, accessible to child care staff members at all times but out of reach of children. First aid kits shall be restocked after use, and an inventory shall be conducted at least monthly. The first aid kit shall contain at least the following items:
a) Disposable nonporous gloves;
d) A non-glass thermometer to measure a child's temperature;
g) Flexible roller gauze;
k) Pen/pencil and note pad;
l) Syrup of ipecac (use only if recommended by the Poison Control Center);
n) Current American Academy of Pediatrics (AAP) standard first aid chart or equivalent first aid guide;
o) Coins for use in a pay phone;
q) Small plastic or metal splints;
s) Adhesive strip bandages, plastic bags for cloths, gauze, and other materials used in handling blood;
t) Any emergency medication needed for child with special needs;
u) List of emergency phone numbers, parents' home and work phone numbers, and the Poison Control Center phone number.
RATIONALE: Facilities must place emphasis on safeguarding each child and ensuring that the staff members are able to handle emergencies. In a study that reviewed 423 injuries, first aid was sufficient treatment for 84.4% of the injuries (
125). The supplies needed for pediatric first aid, including rescue breathing and management of a blocked airway must be available for use where the injury occurs.
COMMENTS: Many centers simply leave a first aid kit in all vehicles used to transport children, regardless of whether the vehicle is used to take a child to or from a center, or for outings. Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
training of staff who handle food
All staff members with food handling responsibilities shall obtain training in food service. The director of a center or a large family child care home or the designated supervisor for food service shall obtain certification equivalent to the Food Service Manager's Protection (Sanitation) certificate.
RATIONALE: Outbreaks of foodborne illness have occurred in many settings, including child care facilities. Some of these outbreaks have led to fatalities and severe disabilities. Young children are particularly susceptible to foodborne illness. Because large centers serve more meals daily than many restaurants do, the supervisors of food handlers in these settings should have successfully completed food service certification, and the food handlers in these settings should have successfully completed courses on appropriate food handling.
COMMENTS: Sponsors of the Child and Adult Care Food Program provide this training for some small family child care home providers. For training in food handling, contact the regional office of the Food and Drug Administration, health departments, or the delegate agencies that handle nutrition and environmental health inspection programs. Contact information is located in located in Appendix BB. Other sources are US Department of Agriculture (USDA) publications, family child care associations, resource and referrals, and licensing agencies.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Caregivers shall use child abuse prevention education materials provided by the licensing agency, state and national organizations, or from other community agencies such as local branches of the National Committee to Prevent Child Abuse, to educate and establish child abuse prevention and recognition measures for the children, caregivers, and parents. The education and prevention shall address physical, sexual, and psychological or emotional abuse, injury prevention, the dangers of shaking infants and toddlers, as well as signs and symptoms of sexually transmitted diseases. Child care directors and head teachers shall participate in training to recognize visible signs of child abuse, including pattern marks, bruises in unusual locations, pattern or immersion burns, shaken baby syndrome, and behaviors suggesting sexual abuse. They shall know how to refer children with vaginal, penile, or rectal discharge or bleeding to their health provider. A child care provider shall refer the child to the local child protection agency for any reasonable suspicion of child abuse or neglect.
Caregivers shall be trained in compliance with their state's child abuse reporting laws.
RATIONALE: Centers and large and small family child care homes are strategic locations in which to distribute materials for the prevention of abuse and also for indicators of sexually transmitted diseases. The medical diagnosis of child physical and sexual abuse is complex. However, education about the physical manifestations of abuse can increase the number of appropriate referrals to physicians and child protection agencies.
COMMENTS: All caregivers should learn about the mandated reporting requirements for caregivers, the process for follow-up after making a report, and the protection and exposure of mandated reporters under the state's child abuse law. States and child care providers will select appropriate material from the many available media that can be used in child abuse prevention activities.
Child abuse materials designed for medical audiences may not be suitable for child care training because the photographs in them contain shocking images. Selective use of photographs that help caregivers recognize signs of physical abuse, however, is appropriate.
Resources are available from the American Academy of Pediatrics, the National Clearinghouse on Child Abuse and Neglect Information, and the National Committee for Prevention of Child Abuse. Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
training on occupational risk related to handling body fluids
The director of a center or a large family child care home caregiver shall ensure that all staff members who are at risk of occupational exposure to blood or other blood-containing body fluids will be offered hepatitis B immunizations and will receive annual training in Standard Precautions. Training shall be consistent with applicable standards of the Occupational Safety and Health Administration (OSHA Standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens") and local occupational health requirements and shall include, but not be limited to:
a) Modes of transmission of bloodborne pathogens;
c) Hepatitis B vaccine, pre-exposure, or post-exposure within 24 hours;
d) Program policies and procedures regarding exposure to blood/body fluid;
e) Reporting procedures under the exposure control plan to ensure that all first-aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs.
RATIONALE: Providing first aid in situations where blood is present is an intrinsic part of a caregiver's job. Split lips, scraped knees and other minor injuries associated with bleeding are common in child care. Regarding the applicability of the OSHA standard to child care, Patricia K. Clark, Director of the Directorate of Compliance Assistance stated:
"One of the central provisions of the OSHA standard on bloodborne pathogens is that employers are responsible for determining which job classifications or specific tasks and procedures are reasonably anticipated to result in worker contact with blood or other potentially infectious materials (OPIM). The standard relates coverage to occupational exposure, regardless of where that exposure may occur, since the risk of infection with bloodborne pathogens is dependent on the likelihood of exposure to blood or OPIM regardless of the particular job title or place of employment. If it is determined that a child care worker has occupational exposure, as defined by the standard, then that employee is covered by all sections of the standard including training, vaccination, personal protective equipment, and so forth."
Child care workers who are designated as responsible for rendering first aid or medical assistance as part of their job duties are covered by the scope of this standard.
COMMENTS: OSHA has model exposure control plan materials for use by child care facilities. Using the model exposure control plan materials, child care providers can prepare a plan to comply with the OSHA requirements. The model plan materials are available from regional offices of OSHA. Contact information for OSHA is located in Appendix BB.
TYPE OF FACILITY:
Center; Large 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
staff modeling of healthy behavior
The facility shall require all staff members to model healthy behaviors and attitudes in their contact with children in the facility, including eating nutritious foods, complying with no tobacco use policies, and handwashing protocols.
RATIONALE: Modeling is an effective way of con-firming that a behavior is one to be imitated.
COMMENTS: Modeling healthy behavior and attitudes can be specified in the plan as compliance with no tobacco use policies, handwashing protocols, and so forth.
See Policy on Smoking, Tobacco Use, Prohibited Substances, and Firearms, STANDARD 8.038 and STANDARD 8.039. See also Hygiene, STANDARD 3.012 through STANDARD 3.019, on handwashing protocols.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Situations That Require Handwashing
All staff, volunteers, and children shall follow the procedure in
STANDARD 3.021 for handwashing at the following times:
a) Upon arrival for the day or when moving from one child care group to another;
Eating, handling food, or feeding a child;
Playing in water that is used by more than one person.
Using the toilet or helping a child use a toilet;
Handling bodily fluid (mucus, blood, vomit), from sneezing, wiping and blowing noses, from mouths, or from sores;
Handling uncooked food, especially raw meat and poultry;
Handling pets and other animals;
Cleaning or handling the garbage.
RATIONALE: Handwashing is the most important way to reduce the spread of infection. Many studies have shown that unwashed or improperly washed hands are the primary carriers of infections. Deficiencies in handwashing have contributed to many outbreaks of diarrhea among children and caregivers in child care centers (
126).
In child care centers that have implemented a hand-washing training program, the incidence of diarrheal illness has decreased by 50% (
127). One study found that handwashing helped to reduce colds when frequent and proper handwashing practices were incorporated into a child care center's curriculum (
127,
128,
129).
Good handwashing after playing in sandboxes will help prevent ingesting zoonotic parasites that could be present in contaminated sand and soil (
131).
Thorough handwashing with soap for at least 10 seconds using comfortably warm, running water, (no less than 60 degrees F and no more than 120 degrees F) removes organisms from the skin and allows them to be rinsed away (
130). Handwashing is effective in preventing transmission of disease.
Washing hands after eating is especially important for children who eat with their hands, to decrease the amount of saliva (which may contain organisms) on their hands. Illnesses may be spread in a variety of ways:
a) In human waste (urine, stool);
b) In body fluids (saliva, nasal discharge, secretions from open injuries; eye discharge, blood);
d) By direct skin-to-skin contact;
e) By touching an object that has germs on it;
f) In drops of water, such as those produced by sneezing and coughing, that travel through the air.
Since many infected people carry communicable diseases without having symptoms and many are contagious before they experience a symptom, staff members need to protect themselves and the children they serve by carrying out hygienic procedures on a routine basis (
129).
Animals, including pets, are a source of infection for people, and people may be a source of infection for animals (
132).
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Children and staff members shall wash their hands using the following method:
a) Check to be sure a clean, disposable paper (or single-use cloth) towel is available.
b) Turn on warm water, no less than 60 degrees F and no more than 120 degrees F, to a comfortable temperature.
c) Moisten hands with water and apply liquid soap to hands.
d) Rub hands together vigorously until a soapy lather appears, and continue for at least 10 seconds. Rub areas between fingers, around nailbeds, under fingernails, jewelry, and back of hands.
e) Rinse hands under running water, no less than 60 degrees F and no more than 120 degrees F, until they are free of soap and dirt. Leave the water running while drying hands.
f) Dry hands with the clean, disposable paper or single use cloth towel.
g) If taps do not shut off automatically, turn taps off with a disposable paper or single use cloth towel.
h) Throw the disposable paper towel into a lined trash container; or place single-use cloth towels in the laundry hamper; or hang individually labeled cloth towels to dry. Use hand lotion to prevent chapping of hands, if desired.
RATIONALE: Running water over the hands removes soil, including infection-causing organisms. Wetting the hands before applying soap helps to create a lather that can loosen soil. The soap lather loosens soil and brings it into solution on the surface of the skin. Rinsing the lather off into a sink removes the soil from the hands that the soap brought into solution. Warm water, no less than 60 degrees F and no more than 120 degrees F, is more comfortable than cold water; using warm water promotes adequate rinsing during handwashing (
130).
Children and staff members should use liquid soap. Although adequately drained bar soap has not been incriminated in transmission of bacteria; bar soaps sitting in water have been shown to be heavily contaminated with
Pseudomonas and other bacteria. Many children do not have the dexterity to handle a bar of soap. Many adults and children do not take the time to rinse the soil they have applied to the soap bar before putting down the soap bar.
By using a paper towel to turn off the water faucet, people who have just completed handwashing prevent recontamination of their hands.
COMMENTS: Premoistened cleansing towlettes do not effectively clean hands and should not be used as a substitute for washing hands with soap and running water. When running water is unavailable, such as during an outing, towlettes may be used as a temporary measure until hands can be washed under running water. Antibacterial soaps may be used but are not required.
Water basins should not be used as an alternative to running water. If running water from an approved central plumbing source is unavailable, the staff should use a large container fitted with a spigot and fill it daily with a supply of safe water to run water over the hands, which are held above a water basin as a temporary measure. Camp sinks and portable commercial sinks with foot or hand pumps dispense water as for a plumbed sink and are satisfactory if filled with fresh water daily. The staff should clean and disinfect the water reservoir container and water catch basin daily. Outbreaks of disease have been linked to shared wash water and wash basins.
Single-use towels can be used. Shared cloth towels can transmit infectious disease. Even though a child may use a cloth towel that is solely for that child's use, preventing shared use of towels is difficult. Disposable towels prevent this problem, but once used, must be discarded. Many communicable diseases can be prevented through appropriate hygiene and sanitation. Taps that turn off automatically or those that can be turned off without using hands avoid the recontamination problem.
The use of cloth roller towels is not recommended for the following reasons:
a) Children often use cloth roll dispensers improperly, resulting in more than one child using the same section of towel.
b) Incidents of accidental strangulation have been reported (oral communication, U.S. Consumer Product Safety Commission Data Office, September 2000).
For additional information, see
Keeping Healthy, available from the National Association for the Education of Young Children (NAEYC) and
The ABC's of Safe and Healthy Child Care available from the Centers for Disease Control and Prevention (CDC). Contact information located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
health education topics for staff
Health education for staff shall include physical, oral, mental/emotional, nutritional, and social health of children. At a minimum, the topics shall include those listed in STANDARD 2.061.
RATIONALE: Children learn about health and safety by experiencing risk taking and risk control, fostered and managed by adults. Whenever opportunities for learning arise, facilities should integrate health edu-ation to promote healthy behaviors. Health education should be seen not as a structured curriculum, but instead, as a daily component of the planned program that is part of child development.
COMMENTS: Community resources could provide written health-related materials. Consultation can be sought from a certified health education specialist.
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.
The American Association for Health Education (AAHE) and the National Commission for Health Education Credentialing, Inc. (NCCHEC) provide information on certified health education specialists. Contact information for the AAHE and NCCHEC is located in Appendix BB. For additional information on health education for staff, see also Training, STANDARD 1.023 through STANDARD 1.036, for a comprehensive description of staff training topics. See Health Education for Children for topics, STANDARD 2.061.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Prevention of Exposure to Blood and Bodily Fluids
Child care facilities shall adopt a modified version of Standard Precautions developed for use in hospitals by The Centers for Disease Control and Prevention as defined in this standard and as may be recommended by the Centers for Disease Control and Prevention for child care settings in the future. This modified version of Standard Precautions shall be used to handle potential exposure to blood, including the blood-containing body fluids and tissue discharges, and to handle other potentially infectious fluids.
In child care settings, exceptions to Standard Precautions as defined by the Centers for Disease Control and Prevention for hospital settings shall include:
a) Use of non-porous gloves is optional unless blood or blood containing body fluids may be involved. Gloves are not required for feeding human milk or cleaning up of spills of human milk.
b) Gowns and masks are not required.
c) Sufficient barriers include materials such as disposable diaper table paper that is moisture resistant, and non-porous gloves.
The staff shall be educated regarding routine
precautions to prevent transmission of bloodborne pathogens before beginning to work in the facility and at least annually thereafter. The staff training shall comply with requirements of the Occupational Safety and Health Administration (OSHA), where applicable.
Procedures for Standard Precautions shall include:
a) Surfaces that may come in contact with potentially infectious body fluids must be disposable or of a material that can be sanitized. Use of materials that can be sterilized is not required.
b) The staff shall use barriers and techniques that:
1) Minimize potential contact of mucous membranes or openings in skin to blood or other potentially infectious body fluids and tissue discharges and
2) Reduce the spread of infectious material within the child care facility.
Such techniques include avoiding touching surfaces with potentially contaminated materials unless those surfaces are sanitized before further contact occurs with them by other objects or individuals.
c) When spills of body fluids, urine, feces, blood, saliva, nasal discharge, eye discharge, injury or tissue discharges, and human milk occur, these spills shall be cleaned up immediately, and further managed as follows:
1) For spills of vomit, urine, human milk, and feces, all floors, walls, bathrooms, tabletops, toys, kitchen counter tops, and diaper-changing tables in contact shall be cleaned and sanitized as for the procedure for diaper changing tables in STANDARD 3.014,
2) For spills of blood or other potentially infectious body fluids, including injury and tissue discharges, the area shall be cleaned and sanitized. Care shall be taken to avoid splashing any contaminated materials onto any mucus membrane (eyes, nose, mouth);
3) Blood-contaminated material and diapers shall be disposed of in a plastic bag with a secure tie.
4) Floors, rugs and carpeting that have been contaminated by body fluids shall be cleaned by blotting to remove the fluid as quickly as possible, then sanitized by spot-cleaning with a detergent-disinfectant, and shampooing, or steam-cleaning the contaminated surface.
RATIONALE: Some children and adults may unknowingly be infected with HIV or other infectious agents, such as hepatitis B virus, as these agents may be present in blood or body fluids (
26,
28). Thus, the staff in all facilities should adopt Standard Precautions for all blood spills. Bacteria and viruses carried in the blood, such as hepatitis B, pose a small but specific risk in the child care setting (
25). Blood and body fluids containing blood (such as watery discharges from injuries) pose the highest potential risk, because bloody body fluids contain the highest concentration of viruses. In addition, hepatitis B virus can survive in dried state in the environment for at least a week and perhaps even longer. Some other body fluids such as saliva contaminated with blood or blood-associated fluids may contain live virus (such as hepatitis B virus) but at lower concentrations than are found in blood itself. Other body fluids, including urine and feces, do not pose a risk with these bloodborne diseases unless they are visibly contaminated with blood, although these fluids do pose a risk with other infectious diseases.
Gloves are used mainly when people knowingly contact or suspect they may contact blood or blood-containing body fluids, including blood-containing tissue or injury discharges. These fluids may contain the viruses that transmit HIV, hepatitis B, and hepatitis C. While human milk (breast milk) can be contaminated with blood from a cracked nipple, the risk of transmission of infection to caregivers who are feeding expressed human milk is very low. Wearing of gloves to feed or clean up spills of expressed human milk is unnecessary, but caregivers with open cuts on their hands should avoid getting expressed human milk on their hands, especially if they have any open skin or sores on their hands.
During the preparation of the 2
nd edition of Caring for Our Children, the Steering Committee consulted several experts on the issue of precautions required for handling of human milk. Published policies confirm a clear consensus that gloves are not required for feeding human milk. Although the issue of use of gloves for clean up of human milk spills has not been addressed in previously published policies or in peer-reviewed literature, the Steering Committee could find no persuasive evidence that the risk involved in cleaning up spills is sufficient to require the use of gloves for human milk spills in child care settings.
Touching a contaminated object or surface may spread illnesses. Many types of infectious germs may be contained in human waste (urine, feces) and body fluids (saliva, nasal discharge, tissue and injury discharges, eye discharges, blood). Because many infected people carry communicable diseases without having symptoms, and many are contagious before they experience a symptom, staff members need to protect themselves and the children they serve by carrying out sanitation procedures on a routine basis. Education of the staff regarding cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (
26,
28).
Prior to using a bleach solution to sanitize, clean any visible soil from the surface with a detergent and rinse well with water. By itself, bleach is not a good cleaning agent. Two minutes of contact with a solution of ¼ cup household liquid chlorine bleach in one gallon of tap water prepared fresh daily is an effective method of surface-sanitizing of environmental surfaces and other inanimate objects that have first been thoroughly cleaned of organic soil (
26,
27,
29). Domestic bleach is sold in the conventional strength of 5.25% hypochlorite and a more recently marketed "ultra" bleach product that contains 6% hypochlorite solution. The recommended 1:64 dilution of 1/4 cup of domestic bleach to 1 gallon of water (or 1 tablespoon to 1 quart of water) produces a solution that contains 500-800 parts per million of available chlorine. Unpublished tests by Chlorox shows 2 minutes of contact on a visibly clean surface that has been coated with a spray of a 1:64 dilution of household bleach, kills most disease-causing organisms on that surface. Air-drying is fine, since chlorine evaporates when the solution dries. If the surface is to be wiped dry, wait for the 2 minute contact time to elapse first. Industrially prepared detergent-sanitizer solutions or detergent cleaning, rinsing and application of a non-bleach sanitizer is acceptable as long as these products are non-toxic for children and are used according to the manufacturer's instructions.
Cleaning and sanitizing rugs and carpeting that have been contaminated by body fluids is challenging. Extracting as much of the contaminating material as possible before it penetrates the surface to lower layers helps to minimize this challenge. Cleaning and sanitizing the surface without damaging it requires use of special cleaning agents designed for use on rugs, or steam cleaning.
Requirements of the OSHA for a facility plan and annual training of staff members who may be exposed to blood as a condition of their employment apply to child care workers who are employees.
COMMENTS: The Region III office of OSHA developed a model plan for child care facilities. Filling in the blanks in this model plan is easier than starting from scratch to write a conforming plan. The sanctions for failing to comply with OSHA requirements can be costly, both in fines and in health
consequences. Child care providers should take the necessary steps to meet OSHA requirements. Regional offices of OSHA are listed with other federal agencies in the telephone directory.
Either single-use disposable gloves or utility gloves should be used. Single-use disposable gloves should be used only once and then discarded immediately without being handled. If utility gloves are used, they should be cleaned after every use with soap and water and then dipped in bleach solution up to the wrist. The gloves should then be taken off and hung to dry. The utility gloves should be worn, not handled, during this cleaning and sanitizing procedure.
Staff who wear gloves must be mindful that the wearing of gloves does not prevent contamination of their hands or of surfaces touched with contaminated gloved hands. Handwashing and sanitizing of contaminated surfaces is still required even when gloves are used.
For the proper technique for removing gloves, see Appendix D.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
STAFF EDUCATION AND POLICIES ON CYTOMEGALOVIRUS (CMV)
Facilities that employ women of childbearing age shall educate these workers with regard to the following:
a) The increased probability of exposure to cytomegalovirus (CMV)
in the child care setting;
b) The potential for fetal damage when CMV is acquired during pregnancy;
c) Hygiene measures (especially handwashing and avoiding contact with urine, saliva, and nasal secretions) aimed at reducing the acquisition of CMV;
d) The availability of counseling and testing for serum antibody to CMV to determine the child care provider's immune status.
Female employees of childbearing age shall be referred to their personal health care providers or to the health department authority for counseling about their risk of cytomegalovirus (CMV) infection. This counseling may include testing for serum antibodies to CMV to determine the employee's immunity against CMV infection.
RATIONALE: CMV is the leading cause of congenital infection in the United States, with approximately 1% of live born infants infected prenatally (
79). While most infected fetuses escape resulting illness or disability, 10 to 20 percent will have hearing loss, mental retardation, cerebral palsy, or vision disturbances. Although maternal immunity does not prevent congenital CMV infection, evidence indicates that initial acquisition of CMV during pregnancy (primary maternal infection) carries the greatest risk for resulting illness or disability of the fetus (
79).
Children enrolled in child care facilities are more likely to acquire CMV than are children cared for at home. Epidemiologic data, as well as laboratory testing of viral strains, has provided evidence for child-to-child transmission of CMV in the child care setting (
79). Rates of CMV excretion have varied among facilities and even between class groups within a facility. Children between 1 and 3 years of age have the highest rates of excretion; published studies report rates between 20 to 80 percent in this age group. Children who acquire CMV from a maternal source or in a facility may continue to excrete the virus for years (
80). Thus, it is reasonable to conclude that child care staff members are more likely to come into contact with CMV-excreting children than are individuals in any other known situation or occupation.
Epidemiologic data and study of CMV strains have shown that premature newborn infants who acquire CMV in the nursery can transmit the virus to their parents (
81). Moreover, parents of children attending centers have a higher rate of development of antibodies to CMV than parents of children kept at home (
82). Parental infection with CMV is related to the child's CMV excretion (
81,
82,
83).
With regard to child-to-staff transmission, studies have shown a high rate of infection with CMV among child care workers with annual rates ranging from 14 to 20 percent (
84,
85,
86). Therefore, exposure to CMV with the higher rate of acquisition that occurs in child care staff will most likely lead to a higher rate of gestational CMV infection in staff members without antibodies to CMV and an increased rate of congenital CMV infection in their offspring (
79). Women who have antibodies to CMV can be reassured that their risk of having an infant damaged by congenital CMV infection is low.
With current knowledge on the risk of CMV infection in child care staff members and the potential consequences of gestational CMV infection, child care staff members should receive counseling in regard to the risks.
COMMENTS: Assays for measuring antibody to CMV are available commercially and seem to perform well when used by qualified laboratories. They are accepted for screening blood products, transfusion recipients, and organ donors and recipients.
For additional information regarding CMV, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
STAFF EDUCATION AND POLICIES ON ENTERIC (DIARRHEAL) AND HAV INFECTIONS
Facilities shall adhere to the following staff educational policies to prevent and control infections of the gastrointestinal tract (mainly diarrhea) or liver:
a) The facility shall conduct ongoing continuing education for staff members, to include the following:
1) Methods of transmission of pathogens that cause diarrhea and hepatitis A virus;
2) Recognition and prevention of diarrhea and disease associated with hepatitis A virus infection;
b) All caregivers, food handlers, and maintenance staff shall receive ongoing education and monitoring concerning handwashing and cleaning of environmental surfaces as specified in the facility's plan. See STANDARD 3.020 through STANDARD 3.023, on handwashing; and STANDARD 3.028 through STANDARD 3.040, on sanitation, disinfection, and maintenance;
c) At least annually, the director shall review all procedures related to preventing diarrhea and hepatitis A virus infections. Each caregiver, food handler, and maintenance person shall review a written copy of these procedures or view a video, which shall include age-specific criteria for inclusion and exclusion of children who have a diarrheal illness or hepatitis A virus infection and infection control procedures. See Child Inclusion/Exclusion/Dismissal, STANDARD 3.065 through STANDARD 3.068;
d) Guidelines for administration of immune globulin and immunization against hepatitis A virus shall be enforced to prevent infection in contacts of children with hepatitis A disease (
87,
99).
RATIONALE: Staff training in hygiene and monitoring of staff compliance have been shown to reduce the spread of diarrhea (
94,
97,
98,
100). These studies suggest that training combined with outside monitoring of child care practices can modify staff behavior as well as the occurrence of disease.
Child care providers should observe children for signs of disease to permit early detection and implementation of control measures. Facilities should consult the local health department to determine whether the increased frequency of diarrheal illness requires public health intervention.
COMMENTS: For additional information regarding enteric (diarrheal) and hepatitis A virus (HAV) infections, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Staff education on prevention of bloodborne diseases
All caregivers shall receive regular training on how to prevent transmission of bloodborne diseases, including hepatitis B virus (HBV).
RATIONALE: Efforts to reduce the risk of transmitting diseases in child care through hygienic and environmental standards in general should focus primarily on blood precautions and ensuring that children are appropriately immunized against hepatitis B virus.
COMMENTS: For additional information regarding HBV infections, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. also Continuing Education, STANDARD 1.029 through STANDARD 1.033.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
STAFF education about preventing transmission of hiv infection
Caregivers shall be knowledgeable about routes of transmission and about prevention of transmission of bloodborne pathogens, including human immunodeficiency virus (HIV) and shall practice measures recommended by the U.S. Public Health Service for prevention of transmission of these infections.
RATIONALE: Unwarranted fear about HIV transmission in child care should be dispelled. Studies examining transmission of HIV support the concept that HIV is not a highly infectious agent (
107). The major routes of transmission are through sexual contact, through contact with blood or body fluids containing blood, and from mother to child during the birth process. Several studies have shown that HIV-infected persons do not spread the HIV virus to other members of their households except through sexual contact.
HIV has been isolated in low volumes in saliva, urine, and human milk. Transmission of HIV through saliva seems to be uncommon. Cases suggest that contact with blood from an HIV-infected individual is a possible mode of transmission through contact between broken skin and blood or blood-containing fluids. Theoretically, biting is a possible mode of transmission of bloodborne illness, such as HIV infection. However, the risk of such transmission is believed to be rare. If a bite results in blood exposure to either person involved, the U.S. Public Health Service recommends postexposure follow-up, including consideration of postexposure prophylaxis (
112).
COMMENTS: For additional information regarding HIV, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB. See STANDARD 1.029 through STANDARD 1.033, on Continuing Education and STANDARD 3.026 and STANDARD 3.027, on the prevention of exposure to blood.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
written plan and training for handling urgent medical care or threatening incidents
The facility shall have a written plan for reporting and managing any incident or unusual occurrence that is threatening to the health, safety, or welfare of the children, staff, or volunteers. The facility shall also include procedures of staff training on this plan.
The following incidents, at a minimum, shall be addressed in the plan:
a) Lost or missing child;
b) Suspected sexual, physical, or emotional abuse or neglect of a child (as mandated by state law);
c) Injuries requiring medical or dental care;
d) Serious illness requiring hospitalization, or the death of a child or caregiver, including deaths that occur outside of child care hours.
The following procedures, at a minimum, shall be addressed in the plan:
a) Provision for a caregiver to accompany a child to the source of urgent care and remain with the child until the parent or legal guardian assumes responsibility for the child;
b) Provision for a backup caregiver or substitute (see Substitutes, STANDARD 1.037 through STANDARD 1.039) for large and small family child care homes to make this feasible. Child:staff ratios must be maintained at the facility during the emergency;
c) The source of urgent medical and dental care (such as a hospital emergency room, medical or dental clinic, or other constantly staffed facility known to caregivers and acceptable to parents);
d) Assurance that the first aid kits are resupplied following each first aid incident, and that required contents are maintained in a serviceable condition, by a periodic review of the contents;
e) Policy for scheduled reviews of staff members' ability to perform first aid for averting the need for emergency medical services.
RATIONALE: Emergency situations are not conducive to calm and composed thinking. Drafting a written plan provides the opportunity to prepare and to prevent poor judgements made under the stress of an emergency.
An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided to children in child care. Such an approach requires written plans, policies, procedures, and record-keeping so that there is consistency over time and across staff and an understanding between parents and caregivers about concerns for, and attention to, the safety of children.
Routine restocking of first aid kits is necessary to ensure supplies are available at the time of an emergency.
Management within the first hour or so following a dental injury may save a tooth.
COMMENTS: Parents may also have on file their preferred dentists in case of emergency. Parents should be notified, if at all possible, before dental services are rendered, but emergency care should not be delayed because the child's own dentist is not immediately available.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The facility shall have a written plan for reporting and evacuating in case of fire, flood, tornado, earthquake, hurricane, blizzard, power failure, bomb threat, or other disaster that could create structural damages to the facility or pose health and safety hazards to the children and staff. The facility shall also include procedures for staff training on this emergency plan.
RATIONALE: Emergency situations are not conducive to calm and composed thinking. Drafting a written plan provides the opportunity to prepare and to prevent poor judgments made under the stress of an emergency. An organized, comprehensive approach to injury prevention and control is necessary to ensure that a safe environment is provided children in child care. Such an approach requires written plans, policies, procedures, rehearsals, and record-keeping so that there is consistency over time and across staff and an understanding between parents and caregivers about concerns for, and attention to, the safety of the children and staff.
COMMENTS: Diagrammed evacuation procedures are easiest to follow in an emergency. Floor plan layouts that show two alternate exit routes are best. Plans should be clear enough that a visitor to the facility could easily follow the instructions. A sample emergency evacuation plan is provided in
Healthy Young Children from the National Association for the Education of Young Children (NAEYC). Contact information for the NAEYC is located in Appendix BB. See Appendix Y, for a sample
Incident Report Form.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
USE OF HEALTH CONSULTANTS
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
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 (
134). 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 (
135).
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 (
134). 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 (
133).
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 (
136). 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
HEALTH APPRAISALS AND ASSESSMENTS
PREEMPLOYMENT AND ONGOING ADULT HEALTH APPRAISALS, INCLUDING IMMUNIZATION
All paid and volunteer
staff members who work more than 40 hours per month shall have a health appraisal before their first involvement in child care work. Health appraisals shall be required every 2 years thereafter, unless the staff member's health provider recommends that this be done more frequently. If a child care provider works also at a different child care facility, a new health appraisal shall be required if there is a question about the results of the previous health appraisal, 2 years have elapsed since the previous health appraisal, or signs of ill health appear. People who work less than 40 hours per month shall be encouraged to have a health appraisal. The appraisal shall identify any accommodations required of the facility for the staff person to function in his or her assigned position. A statement from the health care provider that an appraisal covering the listed areas was completed, and details about any findings that require accommodation shall be on file at the facility.
Health appraisals for paid and volunteer staff members who work more than 40 hours per month shall include at a minimum:
d) Vision and hearing screening;
e) The results and appropriate follow-up of a tuberculosis (Tb) screening using the Mantoux intradermal skin test, one-step procedure. See STANDARD 6.014;
f) A review and certification of up-to-date immune status (measles, mumps, rubella, diphtheria, tetanus, polio, varicella, influenza, pneumonia, hepatitis A, and hepatitis B) (
118). See Immunizations, STANDARD 3.005 through STANDARD 3.007;
g) A review of occupational health concerns based on the performance of the essential functions of the job.
See Occupational Hazards, STANDARD 1.048; and
Major Occupational Health Hazards, Appendix B;
h) Assessment of risk from exposure to common childhood infections, such as parvovirus, CMV, and chickenpox (
118,
119);
i) Assessment of orthopedic, psychological, neurological, or sensory limitations or communicable diseases that require accommodations or modifications for the person to perform tasks that typical adults can do.
All adults who reside in a family child care home who are considered to be at high risk for Tb, and all adults who work less than 40 hours in any month in child care shall have completed Tb screening as specified in STANDARD 6.014. Adults who are considered at high risk for Tb include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active Tb.
The Tb test of staff members with previously negative skin tests shall not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation shall be on file in the facility.
All adults who work in child care shall be encouraged to have a full health appraisal.
RATIONALE: Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis.
Since detection of Tuberculosis using screening of healthy individuals has a low yield compared with screening of contacts of known cases of tuberculosis, routine repeated screening of healthy individuals with previously negative skin tests is not a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be subject to modification by local or state health authorities.
Even for young, healthy adults, care of children increases the risk of developing medical problems that can affect the adult's ability to perform on the job. For the protection of the children and adult staff members, a 2-year health appraisal should be considered as minimal surveillance.
Dental decay is transmissible. Bacteria which contribute to dental decay can be transmitted from care - givers to infants. Individuals with active tooth decay are more likely to transmit this bacteria to the children in their care.
COMMENTS: To focus the evaluation by the health professional, child care facilities should provide the job description or list of activities that the staff person is expected to perform. Unless the job description defines the duties of the role specifically, under federal law the facility may be required to adjust the activities of that person. For example, child care facilities typically require the following activities of care-givers:
a) Moving quickly to supervise and assist young children;
b) Lifting children, equipment, and supplies;
c) Sitting on the floor and on child-sized furniture;
d) Washing hands frequently;
e) Eating the same food as that served to the children (unless the staff member has dietary restrictions);
f) Hearing and seeing at a distance required for playground supervision or driving;
g) Being absent from work for illness no more often than the typical adult, to provide continuity of caregiving relationships for children in child care.
NAEYC's
Healthy Young Children: A Manual for Programs provides models for an assessment by a health professional. See also
Model Child Care Health Policies, available from National Association for the Education of Young Children (NAEYC) and from the American Academy of Pediatrics (AAP). Contact information located in Appendix BB.
Concern about the cost of health exams (particularly when many caregivers do not receive health benefits and earn minimum wage) is a barrier to meeting this standard. When staff members need hepatitis B immunization to meet OSHA requirements, the cost of this immunization may or may not be covered under a managed care contract. If not, the cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee's preparation for work in the child care setting by the prospective employee or the employer. Child care workers are among those for whom annual influenza vaccination should be strongly considered.
Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers throughout the country. These centers can be reached by calling 1-800-949-4232 and callers are routed to the appropriate region.
Also see STANDARD 1.045, STANDARD 6.014 and STANDARD 6.015. For a sample child care staff health assessment form, see Appendix E.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
DAILY STAFF HEALTH Assessment
On a daily basis, the administrator of the facility or caregiver shall assess (visually and verbally) staff members, substitutes, and volunteers for obvious signs of ill health. Staff members, substitutes, and volunteers shall be responsible for reporting immediately to their supervisor any injuries or illnesses they experience at the facility or elsewhere, especially those that might affect their health or the health and safety of the children. It is the responsibility of the administration, not the ill or injured staff member, to arrange for a substitute provider.
RATIONALE: Sometimes adults report to work when feeling ill or become ill during the day but believe it is their responsibility to stay. The administrator's or care-giver's assessment may prevent the spread of illness.
COMMENTS: Administrators and caregivers need guidelines to ensure proper application of this standard. For a demonstration of how to implement this standard, see the video series,
Caring for Our Children, available from National Association for the Education of Young Children (NAEYC) and the American Academy of Pediatrics (AAP) (
120). Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
HEALTH LIMITATIONS OF STAFF
Staff and volunteers must have a health care provider's release to return to work in the following situations:
a) When they have experienced conditions that may affect their ability to do their job or require an accommodation to prevent illness or injury in child care work related to their conditions (such as pregnancy, specific injuries, or infectious diseases);
b) After serious or prolonged illness;
c) When their condition or health could affect promotion or reassignment to another role;
d) Before return from a job-related injury;
e) If there are workers' compensation issues or if the facility is at risk of liability related to the employee's or volunteer's health problem;
f) When there is suspicion of a communicable disease.
If a staff member is found to be unable to perform the activities required for the job because of health limitations, the staff person's duties shall be limited or modified until the health condition resolves or employment is terminated because the facility can prove that it would be an undue hardship to accommodate the staff member with the disability.
RATIONALE: Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis.
COMMENTS: Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers throughout the country. These centers can be reached by calling 1-800-949-4232 and callers are routed to the appropriate region.
For additional information on health limitations of staff members, see STANDARD 6.030, for staff with acute or chronic hepatitis B (HBV); and STANDARD 6.036,
for staff with asymptomatic HIV.
TYPE OF FACILITY:
Center; Large Family Child Care Home
Immunization of Child Care Providers
Child care providers shall be current for all immunizations routinely recommended for adults by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). All child care providers shall have:
a) Completed a primary series for tetanus and diphtheria, and shall receive boosters every 10 years;
b) Been immunized or certified immune by a health care provider against measles, mumps, rubella, poliomyelitis, varicella (chickenpox), and hepatitis B following guidelines of the ACIP (
22,
23).
Additionally, influenza immunization is recommended for people 50 years of age and older and pneumococcal polysaccharide vaccine is recommended for people 65 years of age or older.
If a staff member is not appropriately immunized for medical or religious reasons, the child care facility shall require documentation of the reason, in writing.
RATIONALE: Vaccine-preventable infections of adults represent a continuing cause of morbidity and mortality and source of transmission of infectious organisms. Vaccines, which are safe and effective in preventing these diseases, need to be used in adults to minimize disease and to eliminate potential sources of transmission (
23,
24)
COMMENTS: For additional information on adult immunization, contact the Centers for Disease Control and Prevention (CDC) or visit the CDC website at www.cdc.gov/. Contact information is located in Appendix BB.
For additional information on vaccine-preventable diseases, see Health Plan for Child Health Services, STANDARD 8.013 through STANDARD 8.017; for additional immunization standards, Pre-employment Staff Health Appraisal, STANDARD 1.045.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
PREEMPLOYMENT AND ONGOING ADULT HEALTH APPRAISALS, INCLUDING IMMUNIZATION
All paid and volunteer
staff members who work more than 40 hours per month shall have a health appraisal before their first involvement in child care work. Health appraisals shall be required every 2 years thereafter, unless the staff member's health provider recommends that this be done more frequently. If a child care provider works also at a different child care facility, a new health appraisal shall be required if there is a question about the results of the previous health appraisal, 2 years have elapsed since the previous health appraisal, or signs of ill health appear. People who work less than 40 hours per month shall be encouraged to have a health appraisal. The appraisal shall identify any accommodations required of the facility for the staff person to function in his or her assigned position. A statement from the health care provider that an appraisal covering the listed areas was completed, and details about any findings that require accommodation shall be on file at the facility.
Health appraisals for paid and volunteer staff members who work more than 40 hours per month shall include at a minimum:
d) Vision and hearing screening;
e) The results and appropriate follow-up of a tuberculosis (Tb) screening using the Mantoux intradermal skin test, one-step procedure. See STANDARD 6.014;
f) A review and certification of up-to-date immune status (measles, mumps, rubella, diphtheria, tetanus, polio, varicella, influenza, pneumonia, hepatitis A, and hepatitis B) (
118). See Immunizations, STANDARD 3.005 through STANDARD 3.007;
g) A review of occupational health concerns based on the performance of the essential functions of the job.
See Occupational Hazards, STANDARD 1.048; and
Major Occupational Health Hazards, Appendix B;
h) Assessment of risk from exposure to common childhood infections, such as parvovirus, CMV, and chickenpox (
118,
119);
i) Assessment of orthopedic, psychological, neurological, or sensory limitations or communicable diseases that require accommodations or modifications for the person to perform tasks that typical adults can do.
All adults who reside in a family child care home who are considered to be at high risk for Tb, and all adults who work less than 40 hours in any month in child care shall have completed Tb screening as specified in STANDARD 6.014. Adults who are considered at high risk for Tb include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active Tb.
The Tb test of staff members with previously negative skin tests shall not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation shall be on file in the facility.
All adults who work in child care shall be encouraged to have a full health appraisal.
RATIONALE: Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis.
Since detection of Tuberculosis using screening of healthy individuals has a low yield compared with screening of contacts of known cases of tuberculosis, routine repeated screening of healthy individuals with previously negative skin tests is not a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be subject to modification by local or state health authorities.
Even for young, healthy adults, care of children increases the risk of developing medical problems that can affect the adult's ability to perform on the job. For the protection of the children and adult staff members, a 2-year health appraisal should be considered as minimal surveillance.
Dental decay is transmissible. Bacteria which contribute to dental decay can be transmitted from care - givers to infants. Individuals with active tooth decay are more likely to transmit this bacteria to the children in their care.
COMMENTS: To focus the evaluation by the health professional, child care facilities should provide the job description or list of activities that the staff person is expected to perform. Unless the job description defines the duties of the role specifically, under federal law the facility may be required to adjust the activities of that person. For example, child care facilities typically require the following activities of care-givers:
a) Moving quickly to supervise and assist young children;
b) Lifting children, equipment, and supplies;
c) Sitting on the floor and on child-sized furniture;
d) Washing hands frequently;
e) Eating the same food as that served to the children (unless the staff member has dietary restrictions);
f) Hearing and seeing at a distance required for playground supervision or driving;
g) Being absent from work for illness no more often than the typical adult, to provide continuity of caregiving relationships for children in child care.
NAEYC's
Healthy Young Children: A Manual for Programs provides models for an assessment by a health professional. See also
Model Child Care Health Policies, available from National Association for the Education of Young Children (NAEYC) and from the American Academy of Pediatrics (AAP). Contact information located in Appendix BB.
Concern about the cost of health exams (particularly when many caregivers do not receive health benefits and earn minimum wage) is a barrier to meeting this standard. When staff members need hepatitis B immunization to meet OSHA requirements, the cost of this immunization may or may not be covered under a managed care contract. If not, the cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee's preparation for work in the child care setting by the prospective employee or the employer. Child care workers are among those for whom annual influenza vaccination should be strongly considered.
Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers throughout the country. These centers can be reached by calling 1-800-949-4232 and callers are routed to the appropriate region.
Also see STANDARD 1.045, STANDARD 6.014 and STANDARD 6.015. For a sample child care staff health assessment form, see Appendix E.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
The center's written personnel policies shall address the major occupational health hazards for workers in child care settings. Special health concerns of pregnant providers shall be carefully evaluated, and up-to-date information regarding occupational hazards for pregnant providers shall be made available to them and other workers. The occupational hazards including those regarding pregnant workers listed in Appendix B (
Major Occupational Health Hazards) shall be referenced and used in evaluations by providers and
RATIONALE: Employees must be aware of the risks to which they are exposed so they can weigh those risks and take countermeasures. As a workforce composed primarily of women of childbearing age, pregnancy is common among providers in child care settings. In a study of child care personnel, one quarter of the study's sample reported becoming pregnant since beginning work in child care, with higher pregnancy rates for directors (33%) and family home providers (36%) than for center staff (15%) (
121,
122).
TYPE OF FACILITY:
Center; Large Family Child Care Home
training on occupational risk related to handling body fluids
The director of a center or a large family child care home caregiver shall ensure that all staff members who are at risk of occupational exposure to blood or other blood-containing body fluids will be offered hepatitis B immunizations and will receive annual training in Standard Precautions. Training shall be consistent with applicable standards of the Occupational Safety and Health Administration (OSHA Standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens") and local occupational health requirements and shall include, but not be limited to:
a) Modes of transmission of bloodborne pathogens;
c) Hepatitis B vaccine, pre-exposure, or post-exposure within 24 hours;
d) Program policies and procedures regarding exposure to blood/body fluid;
e) Reporting procedures under the exposure control plan to ensure that all first-aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs.
RATIONALE: Providing first aid in situations where blood is present is an intrinsic part of a caregiver's job. Split lips, scraped knees and other minor injuries associated with bleeding are common in child care. Regarding the applicability of the OSHA standard to child care, Patricia K. Clark, Director of the Directorate of Compliance Assistance stated:
"One of the central provisions of the OSHA standard on bloodborne pathogens is that employers are responsible for determining which job classifications or specific tasks and procedures are reasonably anticipated to result in worker contact with blood or other potentially infectious materials (OPIM). The standard relates coverage to occupational exposure, regardless of where that exposure may occur, since the risk of infection with bloodborne pathogens is dependent on the likelihood of exposure to blood or OPIM regardless of the particular job title or place of employment. If it is determined that a child care worker has occupational exposure, as defined by the standard, then that employee is covered by all sections of the standard including training, vaccination, personal protective equipment, and so forth."
Child care workers who are designated as responsible for rendering first aid or medical assistance as part of their job duties are covered by the scope of this standard.
COMMENTS: OSHA has model exposure control plan materials for use by child care facilities. Using the model exposure control plan materials, child care providers can prepare a plan to comply with the OSHA requirements. The model plan materials are available from regional offices of OSHA. Contact information for OSHA is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home
Prevention of Exposure to Blood and Bodily Fluids
Child care facilities shall adopt a modified version of Standard Precautions developed for use in hospitals by The Centers for Disease Control and Prevention as defined in this standard and as may be recommended by the Centers for Disease Control and Prevention for child care settings in the future. This modified version of Standard Precautions shall be used to handle potential exposure to blood, including the blood-containing body fluids and tissue discharges, and to handle other potentially infectious fluids.
In child care settings, exceptions to Standard Precautions as defined by the Centers for Disease Control and Prevention for hospital settings shall include:
a) Use of non-porous gloves is optional unless blood or blood containing body fluids may be involved. Gloves are not required for feeding human milk or cleaning up of spills of human milk.
b) Gowns and masks are not required.
c) Sufficient barriers include materials such as disposable diaper table paper that is moisture resistant, and non-porous gloves.
The staff shall be educated regarding routine
precautions to prevent transmission of bloodborne pathogens before beginning to work in the facility and at least annually thereafter. The staff training shall comply with requirements of the Occupational Safety and Health Administration (OSHA), where applicable.
Procedures for Standard Precautions shall include:
a) Surfaces that may come in contact with potentially infectious body fluids must be disposable or of a material that can be sanitized. Use of materials that can be sterilized is not required.
b) The staff shall use barriers and techniques that:
1) Minimize potential contact of mucous membranes or openings in skin to blood or other potentially infectious body fluids and tissue discharges and
2) Reduce the spread of infectious material within the child care facility.
Such techniques include avoiding touching surfaces with potentially contaminated materials unless those surfaces are sanitized before further contact occurs with them by other objects or individuals.
c) When spills of body fluids, urine, feces, blood, saliva, nasal discharge, eye discharge, injury or tissue discharges, and human milk occur, these spills shall be cleaned up immediately, and further managed as follows:
1) For spills of vomit, urine, human milk, and feces, all floors, walls, bathrooms, tabletops, toys, kitchen counter tops, and diaper-changing tables in contact shall be cleaned and sanitized as for the procedure for diaper changing tables in STANDARD 3.014,
2) For spills of blood or other potentially infectious body fluids, including injury and tissue discharges, the area shall be cleaned and sanitized. Care shall be taken to avoid splashing any contaminated materials onto any mucus membrane (eyes, nose, mouth);
3) Blood-contaminated material and diapers shall be disposed of in a plastic bag with a secure tie.
4) Floors, rugs and carpeting that have been contaminated by body fluids shall be cleaned by blotting to remove the fluid as quickly as possible, then sanitized by spot-cleaning with a detergent-disinfectant, and shampooing, or steam-cleaning the contaminated surface.
RATIONALE: Some children and adults may unknowingly be infected with HIV or other infectious agents, such as hepatitis B virus, as these agents may be present in blood or body fluids (
26,
28). Thus, the staff in all facilities should adopt Standard Precautions for all blood spills. Bacteria and viruses carried in the blood, such as hepatitis B, pose a small but specific risk in the child care setting (
25). Blood and body fluids containing blood (such as watery discharges from injuries) pose the highest potential risk, because bloody body fluids contain the highest concentration of viruses. In addition, hepatitis B virus can survive in dried state in the environment for at least a week and perhaps even longer. Some other body fluids such as saliva contaminated with blood or blood-associated fluids may contain live virus (such as hepatitis B virus) but at lower concentrations than are found in blood itself. Other body fluids, including urine and feces, do not pose a risk with these bloodborne diseases unless they are visibly contaminated with blood, although these fluids do pose a risk with other infectious diseases.
Gloves are used mainly when people knowingly contact or suspect they may contact blood or blood-containing body fluids, including blood-containing tissue or injury discharges. These fluids may contain the viruses that transmit HIV, hepatitis B, and hepatitis C. While human milk (breast milk) can be contaminated with blood from a cracked nipple, the risk of transmission of infection to caregivers who are feeding expressed human milk is very low. Wearing of gloves to feed or clean up spills of expressed human milk is unnecessary, but caregivers with open cuts on their hands should avoid getting expressed human milk on their hands, especially if they have any open skin or sores on their hands.
During the preparation of the 2
nd edition of Caring for Our Children, the Steering Committee consulted several experts on the issue of precautions required for handling of human milk. Published policies confirm a clear consensus that gloves are not required for feeding human milk. Although the issue of use of gloves for clean up of human milk spills has not been addressed in previously published policies or in peer-reviewed literature, the Steering Committee could find no persuasive evidence that the risk involved in cleaning up spills is sufficient to require the use of gloves for human milk spills in child care settings.
Touching a contaminated object or surface may spread illnesses. Many types of infectious germs may be contained in human waste (urine, feces) and body fluids (saliva, nasal discharge, tissue and injury discharges, eye discharges, blood). Because many infected people carry communicable diseases without having symptoms, and many are contagious before they experience a symptom, staff members need to protect themselves and the children they serve by carrying out sanitation procedures on a routine basis. Education of the staff regarding cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (
26,
28).
Prior to using a bleach solution to sanitize, clean any visible soil from the surface with a detergent and rinse well with water. By itself, bleach is not a good cleaning agent. Two minutes of contact with a solution of ¼ cup household liquid chlorine bleach in one gallon of tap water prepared fresh daily is an effective method of surface-sanitizing of environmental surfaces and other inanimate objects that have first been thoroughly cleaned of organic soil (
26,
27,
29). Domestic bleach is sold in the conventional strength of 5.25% hypochlorite and a more recently marketed "ultra" bleach product that contains 6% hypochlorite solution. The recommended 1:64 dilution of 1/4 cup of domestic bleach to 1 gallon of water (or 1 tablespoon to 1 quart of water) produces a solution that contains 500-800 parts per million of available chlorine. Unpublished tests by Chlorox shows 2 minutes of contact on a visibly clean surface that has been coated with a spray of a 1:64 dilution of household bleach, kills most disease-causing organisms on that surface. Air-drying is fine, since chlorine evaporates when the solution dries. If the surface is to be wiped dry, wait for the 2 minute contact time to elapse first. Industrially prepared detergent-sanitizer solutions or detergent cleaning, rinsing and application of a non-bleach sanitizer is acceptable as long as these products are non-toxic for children and are used according to the manufacturer's instructions.
Cleaning and sanitizing rugs and carpeting that have been contaminated by body fluids is challenging. Extracting as much of the contaminating material as possible before it penetrates the surface to lower layers helps to minimize this challenge. Cleaning and sanitizing the surface without damaging it requires use of special cleaning agents designed for use on rugs, or steam cleaning.
Requirements of the OSHA for a facility plan and annual training of staff members who may be exposed to blood as a condition of their employment apply to child care workers who are employees.
COMMENTS: The Region III office of OSHA developed a model plan for child care facilities. Filling in the blanks in this model plan is easier than starting from scratch to write a conforming plan. The sanctions for failing to comply with OSHA requirements can be costly, both in fines and in health
consequences. Child care providers should take the necessary steps to meet OSHA requirements. Regional offices of OSHA are listed with other federal agencies in the telephone directory.
Either single-use disposable gloves or utility gloves should be used. Single-use disposable gloves should be used only once and then discarded immediately without being handled. If utility gloves are used, they should be cleaned after every use with soap and water and then dipped in bleach solution up to the wrist. The gloves should then be taken off and hung to dry. The utility gloves should be worn, not handled, during this cleaning and sanitizing procedure.
Staff who wear gloves must be mindful that the wearing of gloves does not prevent contamination of their hands or of surfaces touched with contaminated gloved hands. Handwashing and sanitizing of contaminated surfaces is still required even when gloves are used.
For the proper technique for removing gloves, see Appendix D.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Procedure For Nasal Secretions
Staff members and children shall blow or wipe their noses with disposable, one-use tissues and then discard them in a plastic-lined, covered, hands-free trash container. After blowing the nose, they shall wash their hands, as specified in
STANDARD 3.021 and STANDARD 3.022.
RATIONALE: Handwashing is the most important way to reduce the spread of infection. Many studies have shown that unwashed or improperly washed hands are the primary carriers of infections.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Cuts or sores that are leaking body fluids shall be covered with a dry dressing to avoid contamination of surfaces in child care. The caregiver shall wear gloves if there is to be any contact with a wound.
If an individual has a cut or sore that is leaking a body fluid that cannot be contained or cannot be covered with a dry dressing, that person shall be excluded from the facility until the cut or sore is scabbed over or healed.
RATIONALE: Touching a contaminated object or surface may spread infectious organisms. Body fluids may contain infectious organisms.
Gloves can provide a protective barrier against infectious diseases that may be carried in body fluids.
COMMENTS: Covering sores on lips and on eyes is difficult. Dry scabs are best left open to the air. See STANDARD 3.069, for information regarding staff herpes simplex (cold sores).
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
EXPOSURE TO TOXIC SUBSTANCES
type and use of pesticides and herbicides
If pesticides are used, natural pesticides that are non-toxic to humans shall be given first consideration.
If chemical pesticides are used, they shall be only those that are registered with the Environmental Protection Agency (EPA), of a type applied by a licensed exterminator, in a manner approved by the EPA. The facility shall have and consult a Material Safety Data Sheet (MSDS) for all toxic chemicals used, and shall be in compliance with the directions provided. General right-of-way pesticides or herbicides, sprayed in the community by others, shall be prohibited on the grounds of a child care facility.
Pesticides shall be stored in their original containers and in a locked room or cabinet accessible only to authorized staff. No restricted-use pesticides shall be stored or used on the premises except by properly licensed persons. Banned pesticides shall not be used.
Pesticides shall be applied in a manner that prevents skin contact and other exposure to children or staff members and minimizes odors in occupied areas.
Notification shall be given to parents and staff before using pesticides, to determine if any child or staff member is sensitive to the product. A member of the child care staff shall directly observe the application to be sure that toxic chemicals applied on surfaces do not constitute a hazard to the children or staff. Pesticides shall be used in strict compliance with the instructions on the label or as otherwise directed or approved by the regulatory authority. No pesticide shall be applied while children are present.
Following the use of pesticides, herbicides, fungicides, or other potentially toxic chemicals, the treated area shall be ventilated for the period re-commended on the product label or by a nationally certified regional poison control center before being reoccupied. Tests, recommended by a nationally certified regional poison control center, shall be taken to determine safe levels before reentering the facility.
RATIONALE: Children must be protected from exposure to poisons. To prevent contamination and poisoning, child care staff must be sure that these chemicals are applied by individuals who are certified to do so. Direct observation of pesticide application by child care staff is essential to guide the exterminator away from surfaces that children can touch or mouth and to monitor for drifting of pesticides into these areas. The time of toxic risk exposure is a function of skin contact, the efficiency of the ventilating system, and the volatility of the toxic substance. The long-term effects of toxic substances are unknown. Spraying the grounds of a child care facility exposes children to toxic chemicals.
COMMENTS: Manufacturers of pesticides usually provide product warnings that exposure to these chemicals can be poisonous. Material safety data sheets should be available from a licensed exterminator or the product manufacturer.
Child care staff should ask to see the license of the exterminator and should be certain that the individual who applies the toxic chemicals has personally been trained and preferably, individually licensed. In some states only the owner of an extermination company is required to have this training, and he/she may then employ unskilled workers. Child care staff should ensure that the exterminator is familiar with the pesticide he/she is applying.
Child care operators should contact their state pesticide office and request that their child care facility be added to the state pesticide sensitivity list. When a child care facility is placed on the state pesticide sensitivity list, the child care operator will be notified if there are plans for general pesticide application occurring near the child care facility.
Child care staff and children who have developed sensitivity to pesticides can ask their physician to place them on a state pesticide sensitivity list. The state pesticide sensitivity list is made available to exterminators so that they are aware of people working or being cared for in a geographical area who have sensitivity to pesticides.
For further information about pest control, contact the local health authority or the EPA. Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing staff regarding presence of toxic substances
Employers shall provide child care workers with hazard information, as required by the Occupational Safety and Health Administration (OSHA), about the presence of toxic substances such as asbestos, formaldehyde, or hazardous chemicals in use in the facility. This information shall include identification of the ingredients of art materials and sanitizing products. Where nontoxic substitutes are available, these nontoxic substitutes shall be used instead of toxic chemicals.
RATIONALE: These precautions are essential to the health and well-being of the staff and the children alike. Federal agencies have stated that the quality of indoor air is more of a problem than that of outdoor air. Indoor air pollution is thus a potential occupational health hazard for child care workers, particularly because of potential for exposure to infectious and chemical agents at the same time. In addition, many cleaning products and art materials contain ingredients that may be toxic. Regulations require employers to make the complete identity of these materials known to users. Because nontoxic substitutes are available for virtually all necessary products, exchanging them for toxic products is required.
COMMENTS: Employers may contact the local building safety inspection authority for information about toxic substances in the building. The U.S. Department of Labor, which oversees OSHA, is responsible for protection of workers and is listed in the phone book of all large cities. Because standards change frequently, the facility should seek the latest standards from the Environmental Protection Agency (EPA). Information on toxic substances in the environment is available from the EPA. Material Safety Data Sheets (MSDS) are a good source of information. For information on consumer products and art materials, contact the U.S. Consumer Product Safety Commission (CPSC). Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home
Radon concentrations inside a home or building used for child care shall be less than 4 picocuries per liter of air.
RATIONALE: Radon is a colorless, odorless, radioactive gas that occurs naturally. It can be found in soil, water, building materials, and natural gas. Radon from the soil is the main cause of radon problems. When radon gas is inhaled, it can damage lung tissue and lead to lung cancer. Radon levels can be easily measured to determine if acceptable levels have been exceeded. Various methods are available to reduce radon in a building.
COMMENTS: For material and information on radon, contact the Environmental Protection Agency (EPA). Contact information for the EPA is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
preventing exposure to asbestos or other friable materials
Any asbestos, fiberglass, or other friable material or any material that is in a dangerous condition found within a facility or on the grounds of the facility shall be removed. Asbestos removal shall be done by a contractor certified to remove, encapsulate, or enclose asbestos in accordance with existing regulations of the Environmental Protection Agency (EPA). No children shall be present until the removal and cleanup of the hazardous condition have been completed.
Pipe and boiler insulation shall be sampled and examined in an accredited laboratory for the presence of asbestos in a friable or potentially dangerous condition.
Nonfriable asbestos shall be identified to prevent disturbance and/or exposure during remodeling or future activities.
RATIONALE: Removal of significant hazards will protect the staff, children, and families who use the facility. Asbestos dust and fibers that are inhaled and reach the lungs can cause lung disease. The requirement for asbestos is based on the National Asbestos School Hazard Abatement Act of 1984 and U.S. Consumer Product Safety Commission (CPSC) guidelines.
COMMENTS: Asbestos that is in a friable condition means that it is easily crumbled. For more information regarding asbestos and applicable EPA regulations, contact regional offices of the EPA. Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
proper use of arts and crafts materials
Only arts and crafts materials that are labeled nontoxic in accordance with the Labeling of Hazardous Art Material Act (LHAMA), 15 U.S C. 1277 and the American Society for Testing and Materials (ASTM)
D4236-94 Standard Practice for Labeling Art Materials for Chronic Health Hazards shall be used in the child care facility. The facility shall prohibit use of old or donated materials with potentially harmful ingredients.
Caregivers shall closely supervise all children using art materials and shall make sure art materials are properly cleaned up and stored in original containers that are fully labeled. Caregivers shall have emergency protocols in place in the event of an injury, poisoning, or allergic reaction. When using these materials, children and staff shall not be eating or drinking.
RATIONALE: This standard prevents contamination and injury. Labels are required on art supplies to identify any hazardous ingredients, risks associated with their use, precautions, first aid, and sources of further information (
40).
COMMENTS. For information on safe art materials contact the Art and Creative Materials Institute, the ASTM, and the U.S. Consumer Product Safety Commission. Contact information is located in
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
prohibition of poisonous substances and plants
Poisonous or potentially harmful substances and plants shall be prohibited in any part of a child care facility that is accessible to children. All substances not known to be nontoxic shall be identified and checked by name with the local poison control center to determine safe use.
RATIONALE: Plants are among the most common household substances that children ingest. Contact dermatitis is also a concern. Determining the toxicity of every commercially available household plant is difficult. A more reasonable approach is to keep any unknown plant and other potentially poisonous substances out of the environment that children use. All outside plants and their leaves, fruit, and stems should also be considered potentially toxic (
41). Many plants are essentially nontoxic when ingested in small to modest quantities. These nontoxic plants are preferable for use in child care facilities.
COMMENTS: Plants can be placed behind a glass enclosure to keep children from touching the plant. Cuttings, trimmings, and leaves from potentially harmful plants must be disposed of safely so children do not have access to them.
For nontoxic, frequently ingested products and plants, see the American Academy of Pediatrics' (AAP)
Handbook of Common Poisonings in Children. Contact information for the AAP is located in Appendix BB. See Appendix U, for a list of poisonous and safe plants.
TYPE OF FACILITY:
Center; Large Family Child Care Home: Small Family Child Care Home
prohibition of specific chemicals
The use of the following shall be prohibited:
b) Moth crystals or moth balls;
c) Chemical air fresheners that:
1) Contain ingredients on the Environmental Protection Agency's (EPA) toxic chemicals lists;
2) Are not approved as safe by the regulatory health authority.
RATIONALE: Many chemicals are sold to cover up noxious odors or ward off pests. Many of these chemicals are hazardous. As an alternative, child care providers should dilute noxious odors through cleaning and ventilation, and control pests using nontoxic methods.
COMMENTS: Contact the EPA Regional offices listed in the federal agency section of the telephone directory for assistance, or contact any nationally certified regional poison control center. Contact information for the EPA is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
ventilation of recently carpeted or paneled areas
Doors and windows shall be opened for 48-72 hours in areas that have been recently carpeted or paneled using adhesives. Window fans, room air conditioners, or other means to exhaust emission to the outdoors shall be used.
RATIONALE: Adhesives that contain toxic materials can cause significant symptoms in occupants of buildings where these materials are used.
COMMENTS: Airing the room for 48-72 hours is a minimum recommended period of time. Depending on the degree of air circulation and the rate of introducing fresh air into the room, additional ventilation time may be required. For more information on "safe" levels of home indoor air pollutants, contact the Environmental Protection Agency (EPA) or the U.S. Consumer Product Safety Commission (CPSC). Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
prohibition of materials emitting toxic substances
Insulation or other materials that contain elements that may emit toxic substances over recommended levels in the child care environment shall not be used in facilities. If existing structures contain such materials, the facility shall be monitored regularly to ensure a safe environment as specified by the regulatory agency.
RATIONALE: Children and caregivers must not be exposed to toxic substances. Some insulation and building materials such as urea foam insulation and particle board can emit formaldehyde gas, a respiratory and eye irritant (
42).
COMMENTS: Regional offices of the Environmental Protection Agency (EPA) can be contacted for advice. Contact information is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Any surface and the grounds around and under surfaces that children use at a child care facility, including dirt and grassy areas shall be tested for excessive lead in a location designated by the health department. Painted play equipment and imported vinyl mini-blinds shall be evaluated for the presence of lead. If they are found to have toxic levels, corrective action shall be taken to prevent exposure to lead at this facility. Only nontoxic paints shall be used.
In all centers, both exterior and interior surfaces covered by paint with lead levels of 0.06% and above, and accessible to children, shall be removed by a safe chemical or physical means or made inaccessible to children, regardless of the condition of the surface.
In large and small family child care homes, flaking or deteriorating lead-based paint on interior or exterior surfaces, equipment, or toys accessible to preschool-age children shall be removed or abated according to health department regulations.
Where lead paint is removed, the surface shall be refinished with lead-free paint or nontoxic material. Sanding, scraping, or burning of high-lead surfaces shall be prohibited. Children and pregnant women shall not be present during abatement activities.
RATIONALE: Ingestion of lead paint can result in high levels of lead in the blood, which affects the central nervous system and can cause mental retardation (
42). Paint and other surface coating materials should comply with lead content provisions of the
Code of Federal Regulations, Title 16, Part 1303.
Some imported vinyl mini-blinds contain lead and can deteriorate from exposure to sunlight and heat and form lead dust on the surface of the blinds (
43). The U.S. Consumer Product Safety Commission (CPSC) recommends that consumers with children 6 years of age and younger remove old vinyl mini-blinds and replace them with new mini-blinds made without added lead or with alternative window coverings. For more information on mini-blinds, contact the CPSC. Contact information is located in Appendix BB.
Lead is a neurotoxicant. Even at low levels of exposure, lead can cause reduction in a child's IQ and attention span, and result in reading and learning disabilities, hyperactivity, and behavioral difficulties. Lead poisoning has no "cure." These effects cannot be reversed once the damage is done, affecting a child's ability to learn, succeed in school, and function later in life. Other symptoms of low levels of lead in a child's body are subtle behavioral changes, irritability, low appetite, weight loss, sleep disturbances, shortened attention span.
COMMENTS: Paints made before 1978 may contain lead. If there is any doubt about the presence of lead in existing paint, contact the health department for information regarding testing. Lead is used to make paint last longer. The amount of lead in paint was reduced in 1950 and further reduced again in 1978. Houses built before 1950 likely contain lead paint, and houses built after 1950 have less lead in the paint. House paint sold today has little or no lead. Lead is prohibited in contemporary paints. Lead-based paint is the most common source of lead poisoning in children.
In buildings where lead has been removed from the surfaces, lead paint may have contaminated surrounding soil. Therefore, the soil in play areas around these buildings should be tested. Outdoor play equipment was commonly painted with lead-based paints, too. These structures and the soil around them should be checked if they are not known to be lead-free.
The danger from lead paint depends on:
a) Amount of lead in the painted surface;
b) Condition of the paint;
c) Amount of paint that gets into the child.
Children 9 months through 5 years of age are at the greatest risk for lead poisoning. Most children with lead poisoning do not look or act sick. A blood lead test is the only way to know if children are being lead poisoned. Children should have a test result below 10 ug/dL.
A booklet called
Protect Your Family from Lead in Your Home is available from the Environmental Protection Agency (EPA), the U.S. CPSC, and U.S. Department of Housing and Urban Development (HUD). The EPA also has a pamphlet, called
Finding a Qualified Lead Professional for Your Home,
that provides information on how to identify qualified lead inspectors and risk assessors. For further information on lead poisoning, contact the EPA or the National Lead Information Center. Contact information is located in
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
HAEMOPHILUS INFLUENZAE TYPE B (Hib)
immunization for
haemophilus influenzae type b
All children in child care shall have received age-appropriate immunizations with an
H. influenzae type b (Hib) conjugate vaccine (
44).
Children in child care, who are not immunized or not age-appropriately immunized, shall be excluded from care immediately if the child care facility has been notified of a documented case of an invasive Hib infection. These children shall be allowed to return when the risk of infection is no longer present, as determined by the health department.
RATIONALE: Appropriate immunization of children with an
H. influenzae type b conjugate vaccine prevents the occurrence of disease and decreases the rate of carriage of this organism, thereby decreasing the risk of transmission to others (
45,
46).
COMMENTS: Transmission of
H. influenzae type b may occur among unimmunized young children in group child care, especially children younger than 24 months of age.
For additional regarding Hib disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing parents of hib exposure
If a child with invasive
H. influenzae type b (Hib) infection has been in care, the facility shall inform parents of other children who attend the facility, after consultation with the health department, that their children may have been exposed to the Hib bacteria and may have greater risk of developing serious Hib disease if their child is unimmunized or incompletely immunized. The facility shall recommend that parents contact their child's health care provider.
RATIONALE: The risk of secondary cases of Hib disease occurring among child care contacts does not seem to be uniform. Studies of child care contacts of children with Hib disease have varied in identification of an increased risk of Hib disease in this setting
In general, the risk of secondary Hib disease is probably lower for child care contacts than it is for household contacts. The risk of secondary cases of Hib disease occurring among child care attendees is greatest among, and may be limited to, children younger than 2 years of age who are not immunized (
49). In settings with more than one classroom, increased risk has been shown only for children in the classroom of the infected child (
49,
50).
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information is located in Appendix BB.
For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067.
For additional information regarding Hib disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing public health authorities of hib cases
Local and/or state public health authorities shall be notified immediately about cases of
H. influenzae type b (Hib) infections involving children or child care providers in the child care setting. Facilities shall cooperate with their health department in notifying parents of children who attend the facility about exposure to children with Hib disease. This may include providing local health officials with the names and telephone numbers of parents of children in classrooms or facilities involved.
The health department may recommend rifampin,
an antibiotic taken to prevent infection, for chil-dren in care and staff members, to prevent secondary spread of Hib disease in the facility. Antibiotic prophylaxis is not recommended for pregnant women because the effect of rifampin on the fetus has not been established.
RATIONALE: Because the risk of secondary cases of Hib disease seems to be variable among child care contacts of children with Hib disease, opinions differ as to the most appropriate guidelines for the use of rifampin to prevent infection in the child care setting. Rifampin treatment of children exposed to a child with Hib disease can reduce the prevalence of Hib respiratory tract colonization in treated children and reduce the subsequent risk of invasive Hib infection, particularly in children under 2 years of age (
49). Prophylaxis should be initiated as soon as possible, when 2 or more cases of invasive disease have occurred within 60 days and when unimmunized or incompletely immunized children attend the child care
In addition, children who are not immunized or are not age-appropriately immunized should receive a dose of vaccine and should be scheduled for completion of the
Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) (
44,
51). See Appendix G.
COMMENTS: For additional information regarding Hib disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
immunization with
s. pneumoniae conjugate vaccine
All children less than 23 months of age in child care shall have received age-appropriate immunizations with
S. pneumoniae conjugate vaccine. Children age 24 to 59 months of age at high risk of invasive disease caused by
S. pneumoniae (including sickle cell disease, asplenia, HIV, chronic illness or immunocompromised) shall be recommended to receive
S. pneumoniae conjugate vaccine. All other children 24-59 months of age shall be encouraged to be protected against invasive
S. pneumoniae disease through immunization, especially children who attend out-of-home child care and children of American Indian, Alaska Native, and African-American descent (
52,
53,
54).
RATIONALE: Pneumococcal disease among children in out-of-home child care has been reported more frequently over the last decade in the U.S. and other developed countries. In the U.S., the risk for contracting an invasive pneumococcal infection in out-of-home child care (as defined as child care greater than 4 hours/week outside the home) increases by 2 to 3 times in children less than 60 months of age. Appropriate immunization of children with
S. pneumoniae conjugate vaccine prevents the occurrence of disease and decreases transmission to others.
The risk for invasive disease is greatest in children who attend out-of-home child care and children of American Indian, Alaska Native, and African-American descent (
53,
54).
COMMENTS: For additional information regarding
S. pneumoniae disease, consult the
Red Book from the American Academy of Pediatrics (AAP). See also Appendix G. Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing public health authorities of invasive
S. pneumoniae
Local and/or state public health authorities shall be notified immediately about cases of invasive
S. pneumoniae infections involving children or child care providers in the child care setting. Facilities shall cooperate with their health department in notifying parents of children who attend the facility about exposure to children with invasive
S. pneumoniae disease. This may include providing local health officials with the names and telephone numbers of parents of children in classrooms or facilities involved.
RATIONALE: Secondary spread of
S. pneumoniae in child care has been reported, but the degree of risk of secondary spread in child care facilities is unknown (
55). Prophylaxis of contacts after the occurrence of a single case of invasive
S. pneumoniae disease is not recommended.
In addition, children who are not immunized or are not age-appropriately immunized should receive a dose of vaccine and should be scheduled for completion of the
Recommended Childhood Immunization Schedule from the American Academy of Pediatrics (AAP) (
52). See Appendix G.
COMMENTS: For additional information regarding
S. pneumoniae disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
NEISSERIA MENINGITIDIS (MENINGOCOCCUS)
informing public health authorities of meningococcal infections
Local and/or state public health authorities shall be notified immediately about cases of meningococcal infections involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children with meningococcal infections. This may include providing local health officials with the names and telephone numbers of parents of children in involved classrooms or
RATIONALE:
Neisseria meningitidis is an important cause of bacterial meningitis in childhood. The infection is spread from person to person by direct contact with respiratory tract secretions (including large droplets) that contain
N. meningiditis organisms.
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information is located in Appendix BB.
For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067.
For additional information regarding meningococcal disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
health department recommendations on antibiotics
When the health department recommends administering an antibiotic to prevent secondary infection of meningococcal disease within the facility, an antibiotic to prevent an infection shall be administered to staff members and children, with parental permission (
56,
57,
58).
RATIONALE: Children and staff exposed, by close contact for an extended period to the child first infected with meningococcal disease, are at risk for contracting invasive meningococcal disease (
56). The attack rate of meningococcal disease for this population is more than 300 times higher than rates in the general population (
57).
Because outbreaks may occur in child care settings, chemoprophylaxis with rifampin or ceftriaxone is indicated for exposed child care contacts. Children in child care who are exposed to a child or an adult with meningococcal infection should receive rifampin
or ceftriaxone
as soon as possible to prevent an infection, preferably within 24 hours of diagnosis of the primary case (
57,
58). In contacts over 18 years of age, ciprofloxacin is effective. Rifampin and ciprofloxacin are not recommended for pregnant women.
COMMENTS: For additional information regarding meningococcal disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
protective measures for meningococcal infection
When an antibiotic to prevent an infection with
Neisseria meningitidis (meningococcal infection) is indicated for child care contacts, all children and staff members, for whom prophylaxis has been recommended, shall be excluded from attending the facility until these measures have begun. Any exposed individual who develops a febrile illness (one accompanied by a fever) shall receive prompt medical evaluation.
New entry children shall not be enrolled in a child care facility in which a case of invasive
N. meningitidis has been documented until 2 months has elapsed since the diagnosis was made.
RATIONALE: Children and staff exposed, by close contact for an extended period to the child first infected with meningococcal disease, are at risk for contracting invasive meningococcal disease (
56). The attack rate of meningococcal disease for this population is more than 300 times higher than rates in the general population (
57).
Because outbreaks may occur in child care settings, chemoprophylaxis with rifampin or ceftriaxone is indicated for exposed child care contacts. Children in child care who are exposed to a child or an adult with meningococcal infection should receive rifampin
or ceftriaxone
as soon as possible to prevent an infection, preferably within 24 hours of diagnosis of the primary case (
57,
58). In contacts over 18 years of age, ciprofloxacin is effective. Rifampin and ciprofloxacin are not recommended for pregnant women.
COMMENTS: For additional information regarding meningococcal disease, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing public health authorities of pertussis cases
Local and/or state public health authorities shall be notified immediately about cases of pertussis involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children with pertussis. This may include providing the health department officials with the names and telephone numbers of parents of children in the classrooms or facilities involved.
Guidelines for use of antibiotics and immunization for prevention of pertussis in individuals who have been in contact with children who have pertussis shall be implemented in cooperation with officials of the health department. Children and staff who have been exposed to pertussis, especially those who are incompletely immunized, shall be observed for respiratory tract symptoms for 20 days after the last contact with the infected person.
RATIONALE: Notification of health department officials when pertussis occurs in a child or staff member in a child care center will help ensure the following (
59,
60):
a) All children have received age-appropriate immunization;
b) Erythromycin prophylaxis (or other recommended antibiotic therapy, if erythromycin is not tolerated) is provided to those exposed to the child first infected with pertussis;
c) Children and adults are observed for respiratory tract symptoms.
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information for the NAEYC is located in Appendix BB.
For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067.
For additional information regarding pertussis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
prophylactic treatment for pertussis
When there is a known or suspected occurrence of pertussis in a child care facility, all staff members and children in care shall initiate the appropriate prophylactic treatment (usually administration of erythromycin or another appropriate antibiotic) and any additional treatment deemed medically necessary by a health care provider before they are allowed to return to the facility.
Adults and children who have been in contact with a person infected with pertussis shall be monitored closely for respiratory tract symptoms for 20 days after the last contact with the infected person.
RATIONALE: Even if outbreaks of pertussis in child care facilities have not been reported, children and staff who attend out-of-home child care occasionally contract pertussis. The spread of infection to contacts who are incompletely immunized can be reduced by treating the primary case and susceptible contacts with prophylactic antibiotics, usually
COMMENTS: For additional information regarding pertussis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
Children and staff members with characteristic symptoms (primarily cough) of pertussis shall be excluded from child care pending evaluation by a health care provider. The child or staff member may not return to the facility until:
a) Five days after initiation of a 10-14 day course of erythromycin or other recommended antibiotic therapy;
b) Three to four weeks after the onset of the cough;
c) The medical condition allows.
RATIONALE: Even if outbreaks of pertussis in child care facilities have not been reported, children and staff who attend out-of-home child care occasionally contract pertussis. The spread of infection to contacts who are incompletely immunized can be reduced by treating the primary case and susceptible contacts with prophylactic antibiotics, usually
COMMENTS: For additional information regarding pertussis, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
GROUP A STREPTOCOCCAL (GAS) INFECTION
exclusion for group A streptococcal infections
Children with group A streptococcal (GAS) respiratory tract, skin, or ear infections shall be excluded from child care until 24 hours after antibiotic treatment has been initiated and until the child has no fever for 24 hours.
RATIONALE: Streptococcal respiratory tract infections and scarlet fever resulting from GAS have been reported in children in child care, but are not a major problem (
61,
62). Group A streptococcal respiratory tract infections may resolve without treatment; however, GAS respiratory tract infections can be complicated by pneumonia, arthritis, rheumatic fever, and glomerulonephritis (
63).
Early identification and treatment of GAS infection in children and adults are important in reducing transmission and subsequent occurrence of disease. Consultation with the health department is advised when high rates of streptococcal infection occur in child care facilities. Parents of children exposed to a child with documented GAS infection should be notified of the exposure.
COMMENTS: For additional information regarding group A streptococcal respiratory tract infection, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
informing caregivers of group A STREPTOCOCCAL infection
Parents who become aware that their child is infected with group A streptocci (GAS), has strep throat, or has scarlet fever, shall inform caregivers within 24 hours.
When exposure to GAS infection occurs, care-
givers, in cooperation with health department officials, shall inform the parents of other children who attend the facility, that their children may have been exposed.
RATIONALE:
Periodically, the incidence of rheumatic fever seems to increase (
63). Identification and treatment of streptococcal infections of the respiratory tract are central to preventing rheumatic fever. Therefore, awareness of the occurrence of streptococcal infection in child care is important. Adult child care staff members are not immune to streptococcal infections and may be carriers of organisms that cause disease in children. When outbreaks of streptococcal disease occur, interventions are available to limit transmission of streptococcal infection. Consultation with the health department is advised when high rates of streptococcal infection occur in child care facilities.
This information could be useful to the exposed child's health care provider if the exposed child deve-lops illness.
COMMENTS: Sample letters of notification to parents that their child may have been exposed to an infectious disease are contained in the (National Academy for the Education of Young Children (NAEYC) publication,
Healthy Young Children. Contact information is located in Appendix BB.
For information about health education for children, staff, and parents, see STANDARD 2.060 through STANDARD 2.067.
For additional information regarding group A streptococcal infections, consult the
Red Book from the American Academy of Pediatrics (AAP). Contact information for the AAP is located in Appendix BB.
TYPE OF FACILITY:
Center; Large Family Child Care Home; Small Family Child Care Home
MEASURES FOR DETECTION AND CONTROL OF tuberculosis
Local and/or state public health authorities shall be notified immediately about suspected cases of tuberculosis disease involving children or child care providers in the child care setting. Facilities shall cooperate with their local health department officials in notifying parents of children who attend the facility about exposures to children or staff with tuberculosis disease. This may include providing the health department officials with the names and telephone numbers of parents of children in the classrooms or facilities involved.
Tuberculosis transmission shall be controlled by requiring regular and substitute staff members and volunteers to have their tuberculosis status assessed with a one-step or two-step Mantoux intradermal skin test prior to beginning employment unless they produce documentation of the following:
a) A positive Mantoux intradermal skin test result in the past, or
b) Tuberculosis disease that has been treated appropriately in the past.
The one-step Mantoux intradermal tuberculin test shall suffice except that for individuals over 60 years of age or those who have a medical condition that reduces their immune response, the use of the two-step method is required. Individuals with a positive Mantoux intradermal skin test or tuberculosis disease in the past shall be evaluated with chest radiographs and shall be cleared for work by their physician or a health department official. Review of the health status of any staff member with a positive Mantoux intradermal skin test or tuberculosis disease in the past shall be part of the routine annual staff health
In large and small family child care homes, this requirement applies to all adolescents and adults who are present while the children are in care.
Tuberculosis screening by
Mantoux intradermal skin testing, using the one-step procedure, of staff members with previously negative skin tests shall not be repeated on a regular basis unless required by the local or state health department. Anyone who develops an illness consistent with tuberculosis shall be evaluated promptly by a physician. Staff members with previously positive skin tests shall be under the care of a physician who, annually, will document the risk of contagion related to the person's tuberculosis status by performing a symptom review including asking about chronic cough, unintentional weight, unexplained fever and other potential risk factors.
RATIONALE: Young children acquire tuberculosis infection from infected adults or occasionally, infected adolescents (
64). Tuberculosis organisms are spread by inhalation of a small particle aerosol produced by coughing or sneezing by an adult or adolescent with contagious (active) pulmonary tuberculosis. Transmission usually occurs in an indoor environment. Tuberculosis is not spread through objects such as clothes, dishes, floors, and furniture.
The one-step Mantoux method of intradermal PPD skin testing involves injecting the material known as PPD into the skin so that a bleb is raised as the material is injected. For most healthy individuals, the one-step test is sufficient to detect latent TB or active TB disease. TB testing depends on cell-mediated immunity and the anemnestic or memory response where the body recalls a previous encounter with the antigen and reacts to it. In older individuals and those who have one of a group of specific conditions that reduce immune response, the first Mantoux test can produce a false negative response to a first test. In these individuals, the two-step method is recommended, involving repeating the Mantoux test procedure with an interval of at least one week to get an accurate result. Anamestic memory for most antigens occurs within one week after stimulation with the substance -thus a second test may be positive when a first is negative and indicate that an individual has latent TB or TB disease. The need for a two-step test for individuals under 60 years of age should be determined by the clinician performing the test or by the local department of health.
COMMENTS: The two stages of tuberculosis are:
a) Latent tuberculosis infection, when the tuberculosis germ is in the body and causes a positive Mantoux intradermal skin test but does not cause sickness;
b) Active tuberculosis (tuberculosis disease), when the tuberculosis germ is in the body and causes sickness.
Virtually all tuberculosis is transmitted from adults and adolescents with tuberculosis disease. Infants and young children with tuberculosis are not likely to transmit the infection to other children or adults because they generally do not produce sputum and are unable to forcefully cough out large numbers of organisms into the air.
