3.1.1.1: Conduct of Daily Health Check

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

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

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

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

COVID-19 modification as of October 10, 2022:  Children who are experiencing any of the symptoms/exposures/testing listed below should not enter the program. COVID-19 symptoms most likely seen in children: Congestion, runny nose or other allergy like symptoms Sore throat Headache Fever (100.4o F/38o C or higher); feeling feverish (chills, sweating) Refer to the complete list Symptoms of COVID-19 | CDC Are waiting for results of a COVID-19 test Have been recently diagnosed with COVID-19 and not yet cleared to discontinue isolation If experiencing any of the COVID-19 symptoms above, get tested. Children or staff who arrive in the program with symptoms, or develop symptoms while in care should wear a well-fitting mask while in the building and be sent home and get tested. Children or staff expose to COVID-19 or develop symptoms, should be tested.  There is overlap between COVID-19 symptoms and other common infectious childhood illnesses. Therefore, follow the program illness exclusion guidelines and refer to COVID-19 modification for Standard 3.6.1.1 Inclusion/Exclusion/Dismissal of Children. Additional Resources: Centers for Disease Control and Prevention Operational Guidance for K-12 Schools and Early Care and Education Programs to Support Safe In-Person Learning A Child is Showing Signs of COVID-19 in my Child Care Program: What Should I Do? Quick Guide for Providers  Masks American Academy of Pediatrics  Fever and Your Child

 

RATIONALE

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

COMMENTS

The daily health check should be performed in a relaxed and comfortable manner that respects the family’s culture as well as the child’s body and feelings. The child care health consultant should train the caregiver/teacher(s) in conducting a health check. The items in the standard can serve as a checklist to guide learning the procedure until it becomes routine.

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
Appendix F: Enrollment/Attendance/Symptom Record

NOTES

COVID-19 modification as of October 10, 2022.

3.1.1.2: Documentation of the Daily Health Check

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

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

3.1.2.1: Routine Health Supervision and Growth Monitoring

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

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

RATIONALE

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Paige, D. M. 1988. Clinical nutrition. 2nd ed. St. Louis: Mosby.
2. Kleinman, R. E. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
4. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health.
5. Centers for Disease Control and Prevention. 2011. About BMI for children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.
6. Holt K, Wooldridge N, Story M, Sofka D. Growth/ In adolescence, in infancy. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 95-101, 21-26, 49

3.1.3.1: Active Opportunities for Physical Activity

The facility should promote all children’s active play every day. Children should have ample opportunity to do moderate to vigorous activities, such as running, climbing, dancing, skipping, and jumping, to the extent of their abilities.

All children, birth to 6 years of age, should participate daily in:

     a. Two to 3 occasions of active play outdoors, weather permitting (see Standard 3.1.3.2: Playing Outdoors for appropriate weather conditions)

     b. Two or more structured or caregiver/teacher/adult-led activities or games that promote movement over the course of the day—indoor or outdoor

     c. Continuous opportunities to develop and practice age-appropriate gross motor and movement skills

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

Outdoor play

     a. Infants (birth–12 months of age) should be taken outside 2 to 3 times per day, as tolerated. There is no recommended duration of infants’ outdoor play.

     b. Toddlers (12 – 35 months) and preschoolers (3–6 years) should be allowed 60 to 90 total minutes of outdoor play (1).

These outdoor times can be curtailed somewhat during adverse weather conditions in which children may still play safely outdoors for shorter periods, but the time of indoor activity should increase so the total amount of exercise remains the same.

Total time allotted for moderate to vigorous activities:

     a. Toddlers should be allowed 60 to 90 minutes per 8-hour day for moderate to vigorous physical activity, including running.

     b. Preschoolers should be allowed 90 to 120 minutes per 8-hour day for moderate to vigorous physical activity, including running (1,2).

Infants should have supervised tummy time every day when they are awake. Beginning on the first day at the early care and education program, caregivers/teachers should interact with an awake infant on his/her tummy for short periods (3–5 minutes), increasing the amount of time as the infant shows he/she enjoys the activity (3).

There are many ways to promote tummy time with infants:

     a. Place yourself or a toy just out of the infant’s reach during playtime to get him/her to reach for you or the toy.

     b. Place toys in a circle around the infant. Reaching to different points in the circle will allow him/her to develop the appropriate muscles to roll over, scoot on his/her belly, and crawl.

     c. Lie on your back and place the infant on your chest. The infant will lift his/her head and use his/her arms to try to see your face (3,4).

Structured activities have been shown to produce higher levels of physical activity in young children, therefore it is recommended that caregivers/teachers incorporate 2 or more short, structured activities or games daily that promote physical activity (5).

Opportunities to actively enjoy physical activity should be incorporated into part-time programs by prorating these recommendations accordingly (eg, 20 minutes of outdoor play for every 3 hours in the facility).

Active play should never be withheld from children who misbehave (eg, child is kept indoors to help another caregiver/teacher while the rest of the children go outside) (6). However, children with out-of-control behavior may need 5 minutes or fewer to calm themselves or settle down before resuming cooperative play or activities.

Infants should not be seated for more than 15 minutes at a time, except during meals or naps (5). Infant equipment, such as swings, stationary activity centers, infant seats (eg, bouncers), and molded seats, should only be used for short periods, if used at all. A least-restrictive environment should be encouraged at all times (7).

Children should have adequate space for indoor and outdoor play.

RATIONALE

Time spent outdoors has been found to be a strong, consistent predictor of children’s physical activity (8). Children can accumulate opportunities for activity over the course of several shorter segments of at least 10 minutes each (9).  Free play, active play, and outdoor play are essential components of young children’s development (10). Children learn through play, developing gross motor, socioemotional, and cognitive skills. During outdoor play, children learn about their environment, science, and nature (10).

Infants’ and young children’s participation in physical activity is critical to their overall health, development of motor skills, social skills, and maintenance of healthy weight (11). Daily physical activity promotes young children’s gross motor development and provides numerous health benefits, including improved fitness and cardiovascular health, healthy bone development, improved sleep, and improved mood and sense of well-being (12).

Toddlers and preschoolers generally accumulate moderate to vigorous physical activity over the course of the day in very short bursts (15–30 seconds) (5). Children may be able to learn better during or immediately after these types of short bursts of physical activity, due to improved attention and focus (13).
Tummy time prepares infants to be able to slide on their bellies and crawl. As infants grow older and stronger they will need more time on their tummies to build their own strength (3).

Childhood obesity prevalence, for children 2 to 5 years old, has steadily decreased from 13.9% in 2004 to 9.4% in 2014 (14). Incorporating government food programs, physical activities, and wellness education into child care centers has been associated with these decreases (15).

Establishing communication between caregivers/teachers and parents/guardians helps facilitate integration of classroom physical activities into the home, making it more likely that children will stay active outside of child care hours (16). Very young children and those not yet able to walk, are entirely dependent on their caregivers/teachers for opportunities to be active (17).

Especially for children in full-time care and for children who don’t have access to safe playgrounds, the early care and education facility may provide the child’s only daily opportunity for active play. Physical activity habits learned early in life may track into adolescence and adulthood, supporting the importance for children to learn lifelong healthy physical activity habits while in the early care and education program (18).

COMMENTS

Additional Resources

Choosy Kids (https://choosykids.com)

EatPlayGrow Early Childhood Health Curriculum, Children’s Museum of Manhattan (www.eatplaygrow.org)

Head Start Early Childhood Learning & Knowledge Center, US Department of Health and Human Services, Administration for Children & Families (https://eclkc.ohs.acf.hhs.gov/physical-health/article/little-voices-healthy-choices)

Healthy Kids, Healthy Future; The Nemours Foundation (https://healthykidshealthyfuture.org)

Nutrition and Physical Activity Self-Assessment for Child Care, Center for Health Promotion and Disease Prevention, University of North Carolina (http://healthyapple.arewehealthy.com/documents/PhysicalActivityStaffHandouts_NAPSACC.pdf)

Online Physical Education Network (http://openphysed.org)

Spark (www.sparkpe.org)

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
Appendix S: Physical Activity: How Much Is Needed?

REFERENCES

1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43

2. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889

3. American Academy of Pediatrics. Back to sleep, tummy to play. HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/Back-to-Sleep-Tummy-to-Play.aspx. Updated January 20, 2017. Accessed January 11, 2018

4. Zachry AH. Tummy time activities. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/The-Importance-of-Tummy-Time.aspx. Updated November 21, 2015. Accessed January 11, 2018

5. US Department of Agriculture, US Department of Health and Human Services. Provide opportunities for active play every day. Nutrition and wellness tips for young children: provider handbook for the Child and Adult Care Food Program. https://fns-prod.azureedge.net/sites/default/files/opportunities_play.pdf. Published June 2013. Accessed January 11, 2018

6. Centers for Disease Control and Prevention and SHAPE America-Society of Health and Physical Educators. Physical activity during school: Providing recess to all students. 2017. https://www.cdc.gov/healthyschools/physicalactivity/pdf/Recess_All_Students.pdf. Accessed January 11, 2018

7. Moir C, Meredith-Jones K, Taylor BJ, et al. Early intervention to encourage physical activity in infants and toddlers: a randomized controlled trial. Med Sci Sports Exerc. 2016;48(12):2446–2453

8. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889

9. Hnatiuk JA, Salmon J, Hinkley T, Okely AD, Trost S. A review of preschool children’s physical activity and sedentary time using objective measures. Am J Prev Med. 2014;47(4):487–497

10. Bento G, Dias G. The importance of outdoor play for young children’s healthy development. Porto Biomed J. 2017;2(5):157–160

11. Jayasuriya A, Williams M, Edwards T, Tandon P. Parents’ perceptions of preschool activities: exploring outdoor play. Early Educ Dev. 2016;27(7):1004–1017

12. Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Appl Physiol Nutr Metab. 2012;37(4):773–792

13. Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cognitive function, and academic achievement in children: a systematic review. Med Sci Sports Exerc. 2016;48(6):1197–1222

14. Centers for Disease Control and Prevention. Overweight & obesity. Childhood obesity facts. Prevalence of childhood obesity in the United States, 2011-2014. https://www.cdc.gov/obesity/data/childhood.html. Updated April 10, 2017. Accessed January 11, 2018

15. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292–2299

16. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272

17. Society of Health and Physical Educators. Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5. 2nd ed. Reston, VA: SHAPE America; 2009. https://www.shapeamerica.org/standards/guidelines/activestart.aspx. Accessed January 11, 2018

18. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta‐analysis. Obes Rev. 2016;17(2)95–107

NOTES

Content in the STANDARD was modified on 05/29/2018.

3.1.3.2: Playing Outdoors

Children should play outdoors when the conditions do not pose any concerns health and safety such as a significant risk of frostbite or heat-related illness. Caregivers/teachers must protect children from harm caused by adverse weather, ensuring that children wear appropriate clothing and/or appropriate shelter is provided for the weather conditions. Weather that poses a significant health risk includes wind chill factor below -15°F (-26°C) and heat index at or above 90°F (32°C), as identified by the National Weather Service (NWS) (1). Child Care Center Directors as well as caregivers/teachers directors should monitor weather-related conditions through several media outlets, including local e-mail and text messaging weather alerts.

Caregivers/teachers should also monitor the air quality for safety. Please reference Standard 3.1.3.3 for more information.

 

Sunny weather

1. Children should be protected from the sun between the hours of 10:00 am and 4:00 pm. Protective measures include using shade; sun-protective clothing such as hats and sunglasses; and sunscreen with UV-B and UV-A ray sun protection factor 15 or higher. Parental/guardian permission is required for the use of sunscreen.

Warm weather

1. Children should have access to clean, sanitary water at all times, including prolonged periods of physical activity, and be encouraged to drink water during periods of prolonged physical activity (2).
2. Caregivers/teachers should encourage parents/guardians to have children dress in clothing that is light-colored, lightweight, and limited to one layer of absorbent material that will maximize the evaporation of sweat.
3. On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first 6 months of life. Infants receiving formula and water can be given additional formula in a bottle.

Cold weather

1. Children should wear layers of loose-fitting, lightweight clothing. Outer garments, such as coats, should be tightly woven and be at least water repellent when rain or snow is present.
2. Children should wear a hat, coat, and gloves/mittens kept snug at the wrist. There should be no  hood and neck strings..
3. Caregivers/teachers should check children’s extremities for normal color and warmth at least every 15 minutes.
   
   

Caregivers/teachers should be aware of environmental hazards such as unsafe drinking water, loud noises, and lead in soil when selecting an area to play outdoors. Children should be observed closely when playing in dirt/soil so that no soil is ingested. Play areas should be fully enclosed and away from heavy traffic areas. In addition, outdoor play for infants may include riding in a carriage or stroller. Infants should be offered opportunities for gross motor play outdoors.

RATIONALE

Outdoor play is not only an opportunity for learning in a different environment; it also provides many health benefits. Outdoor play allows for physical activity that supports maintenance of a healthy weight (3) and better nighttime sleep (4). Short exposure of the skin to sunlight promotes the production of vitamin D that growing children require.

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

Children need protection from adverse weather and its effects. Heat-induced illness and cold injury are preventable. Weather alert services are beneficial to child care centers because they send out weather warnings, watches, and hurricane information. Alerts are sent to subscribers in the warned areas via text messages and e-mail. It is best practice to use these services but do not rely solely on this system. Weather radio or local news affiliates should also be monitored for weather warnings and advisories. Heat and humidity can pose a significant risk of heat-related illnesses, as defined by the NWS (5). Children have a greater surface area to body mass ratio than adults. Therefore, children do not adapt to extremes of temperature as effectively as adults when exposed to a high climatic heat stress or to cold. Children produce more metabolic heat per mass unit than adults when walking or running. They also have a lower sweating capacity and cannot dissipate body heat by evaporation as effectively (6).

Wind chill conditions can pose a risk of frostbite. Frostbite is an injury to the body caused by freezing body tissue. The most susceptible parts of the body are the extremities such as fingers, toes, earlobes, and the tip of the nose. Symptoms include a loss of feeling in the extremity and a white or pale appearance. Medical attention is needed immediately for frostbite. The affected area should be slowly rewarmed by immersing frozen areas in warm water (around 104°F [40°C]) or applying warm compresses for 30 minutes. If warm water is not available, wrap gently in warm blankets (7). Hypothermia is a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. An infant with hypothermia may have bright red, cold skin and very low energy. A child’s symptoms may include shivering, clumsiness, slurred speech, stumbling, confusion, poor decision-making, drowsiness or low energy, apathy, weak pulse, or shallow breathing (7,8). Call 911 or your local emergency number if a child has these symptoms. Both hypothermia and frostbite can be prevented by properly dressing a child. Dressing in several layers will trap air between layers and provide better insulation than a single thick layer of clothing.

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

COMMENTS

Additional Resources

• The National Weather Service (NWS) provides up-to-date weather information on all advisories and warnings. It also provides safety tips for caregivers/teachers to use as a tool in determining when weather conditions are comfortable for outdoor play (www.nws.noaa.gov/om/heat/index.shtml).
• The National Oceanic and Atmospheric Administration (NOAA) Weather Radio All Hazards (NWR) broadcasts continuous weather information 24 hours a day, 7 days a week, directly from the nearest NWR office. As an all-hazards radio network, it is a single source for comprehensive weather and emergency information. In conjunction with federal, state, and local emergency managers and other public officials, NWR also broadcasts warning and post-event information for all types of hazards, including natural (eg, earthquakes, avalanches), environmental (eg, chemical releases, oil spills), and public safety (eg, AMBER alerts, 911 telephone outages). A special radio receiver or scanner capable of picking up the signal is required to receive NWR. Such radios/receivers can usually be found in most electronic store chains across the country; you can also purchase NOAA weather radios online at www.noaaweatherradios.com.
• To access the latest local weather information and warnings, visit the NWS at www.weather.gov; for local air quality conditions, visit https://www.airnow.gov.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.3.1 Active Opportunities for Physical Activity
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.4.5.1 Sun Safety Including Sunscreen
Appendix S: Physical Activity: How Much Is Needed?

REFERENCES

1. National Weather Service, National Oceanic and Atmospheric Administration. Wind chill safety. https://www.weather.gov/bou/windchill. Accessed January 11, 2018

2. Centers for Disease Control and Prevention. Increasing Access to Drinking Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https://www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit-final-508reduced.pdf. Accessed January 11, 2018

3. Cleland V, Crawford D, Baur LA, Hume C, Timperio A, Salmon J. A prospective examination of children’s time spent outdoors, objectively measured physical activity and overweight. Int J Obes (Lond). 2008;32(11):1685–1693

4. Söderström M, Boldemann C, Sahlin U, Mårtensson F, Raustorp A, Blennow M. The quality of the outdoor environment influences children’s health—a cross-sectional study of preschoolers. Acta Paediatr. 2013;102(1):83–91

5. KidsHealth from Nemours. Heat illness. http://kidshealth.org/en/parents/heat.html. Reviewed February 2014. Accessed January 11, 2018

6. American Academy of Pediatrics. Children & disasters. Extreme temperatures: heat and cold. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Extreme-Temperatures-Heat-and-Cold.aspx. Accessed January 11, 2018

7. American Academy of Pediatrics. Winter safety tips from the American Academy of Pediatrics. https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/AAP-Winter-Safety-Tips.aspx. Published January 2018. Accessed January 11, 2018

8. American Academy of Pediatrics. Extreme temperature exposure. HealthyChildren.org Web site. https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Extreme-Temperature-Exposure.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 8/8/2013 and 05/29/2018.

3.1.3.3: Protection from Air Pollution While Children Are Outside

Supervising adults should check the air quality index (AQI) each day and use the information to determine whether it is safe for children to play outdoors.

RATIONALE

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

COMMENTS

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.3.2 Playing Outdoors

REFERENCES

1. Gehring, U., Gruzieva, O., Agius, R., Beelen, R., Custovic, A., Cyrys, J.,Von Berg. (2013). Air pollution exposure and lung function in children: The ESCAPE project. Environmental Health Perspectives: EHP. 121(11-12), 1357-1364.
   
2. Lerodiakonou, D. (2016). Ambient air pollution, lung function, and airway responsiveness in asthmatic children. The Journal of Allergy and Clinical Immunology. 137(2), 390.
   

NOTES

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

3.1.3.4: Caregivers’/Teachers’ Encouragement of Physical Activity

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

     a. Lead structured activities to promote children’s activities 2 or more times per day.

     b. Wear clothing and footwear that permits easy and safe movement (1). 

     c. Provide prompts for children to be active (2,3). (eg, “Good throw!”).

     d. Encourage children’s physical activities that are appropriate and safe in the setting (eg, do not prohibit running on the playground when it is safe to run).

     e.Have orientation and annual training opportunities to learn about age-appropriate gross motor activities and games that promote children’s physical activity (2,4).

     f. Not sit during active play.

     g. Limit screen time and other digital media as outlined in Standard 2.2.0.3.

Caregivers/teachers should consider incorporating structured activities into the curriculum indoors or after children have been on the playground for 10 to 15 minutes. Caregivers/teachers should communicate with parents/guards about their use of screen time/digital media in the home.

RATIONALE

Children learn from the adult modeling of healthy and safe behavior. Caregivers/teachers may not be comfortable promoting active play, perhaps due to inhibitions about their own physical activity skills or lack of training. Caregivers/teachers may also assume their sole role on the playground is to supervise and keep children safe, rather than to promote physical activity. Continuing education activities are useful in disseminating knowledge about effective games to promote physical activity in early care and education while keeping children safe (4).

Children exposed to less screen time/digital media in early care and education settings engage in more moderate-to-vigorous physical activity compared with children who are exposed to more screen time (5).  This gives caregivers/teachers the opportunity to model the limitation of screen time/digital media use and to educate parents/guardians about alternative activities that families can do with their children (2). 

Additional Resource:

American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
Appendix S: Physical Activity: How Much Is Needed?

REFERENCES

1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43

2. Tandon PS, Saelens BE, Copeland KA. A comparison of parent and childcare provider's attitudes and perceptions about preschoolers' physical activity and outdoor time. Child Care Health Dev. 2017;43(5):679–686

3. Tandon PS, Walters KM, Igoe BM, Payne EC, Johnson DB. Physical activity practices, policies and environments in Washington state child care settings: results of a statewide survey. Matern Child Health J. 2017;21(3):571–582

4. Copeland KA, Khoury JC, Kalkwarf HJ. Child care center characteristics associated with preschoolers’ physical activity. Am J Prev Med. 2016;50(4):470–479

5. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272

NOTES

Content in the STANDARD was modified on 05/29/2018.

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

1. Caregivers/teachers are unaware of the dangers or risks associated with prone or side infant sleep positioning, and many believe that they are using the safest practices possible, even when they are not;
2. Although training programs are effective in improving the knowledge of caregivers/teachers, these programs alone do not always lead to changes in caregiver/teacher practices, beliefs, or attitudes; and 
3. Caregivers/teachers report the following major barriers to implementing safe sleep practices:They have been misinformed about methods shown to reduce the risk of SUID;

COMMENTS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.2 Swaddling
3.1.4.3 Pacifier Use
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.6.1 Strangulation Hazards
3.6.4.5 Death

REFERENCES

1. U.S. Centers for Disease Control and Prevention. 2016. About SUID and SIDS. http://www.cdc.gov/sids/aboutsuidandsids.htm. 
   
2. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.2016;138(6):e20162938. 
   https://pediatrics.aappublications.org/content/138/5/e20162938.
   
3. U.S. Consumer Product Safety Commission (CPSC). 2012. Cribs. https://www.cpsc.gov/safety-education/safety-guides/kids-and-babies/cribs.
   
4. First Candle. 2016. SIDS and daycare: A fatal combination. http://www.firstcandle.org/sids-and-daycare-a-fatal-combination/. 
   
5. Healthy Child Care America. 2012. A child care provider’s guide to safe sleep. Helping you to reduce the risk of SIDS. http://www.healthychildcare.org/PDF/SIDSchildcaresafesleep.pdf. 
   
6. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
   
7. Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-79.
   
8. Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and Breastfeeding Trial Group. 2009. Does the recommendation to use a pacifier influence the prevalence of breastfeeding? Pediatrics 155:350-54.
   
9. UCSF California Childcare Health Program (CCHP). 2016. Safe sleep policy for infants in child care programs. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-Policy.
   
10. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep for Infants in Child Care Programs: Reducing the Risk of SIDS and SUID. UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/SIDS-Note. 
    
11. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep: Reducing the Risk of Sudden Infant Death Syndrome (SIDS). UCSF School of Nursing California Childcare Health Program, San Francisco, CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-FAM. 
    
12. Centers for Disease Control and Prevention. 2013. Sudden infant death syndrome (SIDS). http://www.cdc.gov/features/sidsawarenessmonth/.
    
13. Eunice Kennedy Shriver National Institute of Child Health and Human Development. Safe sleep ® campaign materials. 2014. https://www.nichd.nih.gov/sts/materials/Pages/default.aspx.
    

NOTES

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

3.1.4.2: Swaddling

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

RATIONALE

There is evidence that swaddling can increase the risk of serious health outcomes, especially in certain situations. The risk of sudden infant death is increased if an infant is swaddled and placed on his/her stomach to sleep (1,2) or if the infant can roll over from back to stomach. Loose blankets around the head can be a risk factor for sudden infant death syndrome (SIDS) (3). With swaddling, there is an increased risk of developmental dysplasia of the hip, a hip condition that can result in long-term disability (4,5). Hip dysplasia is felt to be more common with swaddling because infants’ legs can be forcibly extended. With excessive swaddling, infants may overheat (i.e., hyperthermia) (6).

COMMENTS

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

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

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

REFERENCES

1. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of sudden infant death syndrome: A Meta-analysis. Pediatrics;137(6):e20153275.
   
2. Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence of swaddling experience on spontaneous arousal patterns and autonomic control in sleeping infants. J Pediatrics 157:85-91.
   
3. Contemporary Pediatrics. 2004. Guide for parents: Swaddling 101. http://www.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module1/swadling.pdf.
   
4. Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, W. Kuis, T. W. J. Schulpen, M. P. L’Hoir. 2007. Swaddling: A systematic review. Pediatrics 120:e1097-e1106.
   
5. Mahan, S. T., Kasser J. R. 2008. Does swaddling influence developmental dysplasia of the Hip? Pediatrics 121:177-78.
   
6. Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, A. Kahn. 2005. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 115:1307-11.
   

3.1.4.3: Pacifier Use

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

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

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

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.3 Oral Health Education
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.4.6.1 Strangulation Hazards

REFERENCES

1. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.2016;138(6):e20162938. 
   https://pediatrics.aappublications.org/content/138/5/e20162938.
   
2. Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: What should we recommend? Pediatrics117:1811-12.
   
3. Mitchell, E. A., P. S. Blair, M. P. L’Hoir. 2006. Should pacifiers be recommended to prevent sudden infant death syndrome? Pediatrics 117:1755-58.
   
4. Reeves, D. L. 2006. Pacifier use in childcare settings. Healthy Child Care 9:12-13.
   
5. Cornelius, A. N., J. P. D’Auria, L. M. Wise. 2008. Pacifier use: A systematic review of selected parenting web sites. J Pediatric Health Care 22:159-65.
   
6. American Academy of Pediatrics, Back to Sleep, Healthy Child Care America, First Candle. 2008. Reducing the risk of SIDS in child care. http://www.healthychildcare.org/pdf/SIDSfinal.pdf.
   
7. Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they good for your baby? http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/pacifiers/art-20048140.
   

NOTES

Content in the STANDARD was modified on 12/5/2011. 

3.1.4.4: Scheduled Rest Periods and Sleep Arrangements

The facility should provide an opportunity for, but should not require, sleep and rest. The facility should make available a regular rest period for all children and age appropriate sleep/nap environment (See Standard 5.4.5.1). For children who are unable to sleep, the facility should provide time and space for quiet play. A facility that includes preschool-aged and school-aged children should make books, board games, and other forms of quiet play available.

Facilities that offer infant care should provide a safe sleep environment and use a written safe sleep policy that describes the practices they follow to reduce the risk of sudden infant death syndrome and other infant deaths. For example, when infants fall asleep, they must be put down to sleep on their back in a crib with a firm mattress and no blankets or soft objects.

RATIONALE

Conditions conducive to sleep and rest for younger children include a consistent caregiver, a routine quiet place, regular times for rest, and use of routines and safe practices. Most preschool-aged children in all-day care benefit from scheduled periods of rest. This rest may take the form of actual napping, a quiet time, or a change of pace between activities. The times and duration of naps will affect behavior at home (1).

Young children need to develop healthy sleep habits for optimal development. Yet, sleep problems, i.e. short sleep duration, behavioral sleep problems, and sleep-disordered breathing all peak during the preschool years. In 2016, the National Sleep Foundation issued recommended sleep durations for newborns (14–17 hours), infants (12–15 hours), toddlers (11–14 hours), and preschoolers (10–13 hours), which include both daytime and nighttime sleep (2,3).Getting sufficient sleep helps prevent pediatric obesity. In meta-analyses, short sleep duration before 5 years of age is associated with 30% to 90% increased odds of overweight/obesity at later ages (4,5). To prevent early childhood obesity, the Institute of Medicine recommends that child care providers be required to adopt practices that promote age-appropriate sleep duration and that staff be trained to counsel parents about recommended sleep durations (6). Behavioral sleep problems (i.e., difficulty getting to/falling asleep) at 18 months of age are associated with a 60% to 80% increased risk of emotional and behavioral problems at 5 years of age (7). Irregular bedtimes throughout early childhood are associated with reduced reading, math, and spatial ability scores (8). Sleep-disordered breathing (e.g., snoring, apnea) in early childhood is associated with a 60% to 80% increase in social and emotional difficulties at 7 years of age (9).

COMMENTS

In the young infant, favorable conditions for sleep and rest include being dry, well fed, and comfortable. Infants may need 1 or 2 (or sometimes more) naps during the time they are in child care. As infants age, they typically transition to 1 nap per day, and having 1 nap per day is consistent with the schedule that most facilities follow. Different practices, such as rocking, holding a child while swaying, singing, reading, or patting an arm or back, could be used to calm the child. Lighting does not need to be turned off during nap time.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

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

REFERENCES

1. National Sleep Foundation. How much sleep do we really need? https://sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need. Accessed November 14, 2017

2. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549–1561

3. Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149

4. Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a systematic review and meta-analysis of prospective cohort studies. J Paediatr Child Health. 2017;53(4):378–385

5. Institute of Medicine. Early Childhood Obesity Prevention Policies: Goals, Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention-Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017

6. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, Hysing M. Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study. JAMA Pediatr. 2015;169(6):575–582

7. Kelly, Y; Kelly, J; Sacker, A; (2013) Time for bed: associations with cognitive performance in 7-year-old children: a longitudinal population-based study. Journal of Epidemiology and Community Health , 67 (11) pp. 926-931.

8. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857–e865

NOTES

Content in the STANDARD was modified on 05/30/2018.

3.1.4.5: Unscheduled Access to Rest Areas

All children should have access to rest or nap areas whenever the child desires to rest. These rest or nap areas should be set up to reduce distraction or disturbance from other activities. All facilities should provide rest areas for children, including children who become ill (1,2), at least until the child leaves the facility for care elsewhere. Children need to be within sight and hearing of caregivers/teachers when resting.

RATIONALE

Any child, especially children who are ill (1,2), may need more opportunity for rest or quiet activities.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill
Appendix A: Signs and Symptoms Chart

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020:45-50.
2. American Academy of Pediatrics. Out-of-home child care, infection control and prevention In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 125-136, 122-125, 124t

3.1.5.1: Routine Oral Hygiene Activities

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

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

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

Children whose teeth are properly brushed with fluoride toothpaste at home twice a day and are at low risk for dental caries may be exempt since additional brushing with fluoride toothpaste may expose a child to excess fluoride toothpaste.

COVID-19 modification as of March 31, 2023 In response to the Centers for Disease Control and Prevention’s COVID-19 Guidance for Operating Early Care and Education/Child Care Programs, toothbrushing may resume if programs can implement strategies to reduce the possibility of transmitting the virus to others via salivary droplets during brushing. It is recommended that: Program staff who brush infants’ and children’s teeth or help children brush should be fully vaccinated against COVID-19. In addition, staff may wear a mask covering their nose and mouth and wear face and eye protection, such as a face shield, for additional protection. If toothbrushing at the classroom table, clean and disinfect the table after brushing. If toothbrushing at the classroom table is not possible, children can brush at the sink with staff supervising. The sink should be cleaned and sanitized after each child finishes brushing. Encourage children to avoid placing toothbrushes directly on the classroom table or other surfaces. Wash hands with soap and water for at least 20 seconds before and after brushing or helping infants and children brush their teeth. If soap and water are not available, staff can use hand sanitizer that contains at least 60% alcohol. After children brush, ensure that they wash their hands with soap and water for at least 20 seconds, or, for children over age 2, use hand sanitizer that contains at least 60% alcohol. Encourage children to drink water throughout the day and after eating as water rinses a child’s mouth with every sip. Refer to CFOC Standard 3.1.5.2: Toothbrushes and Toothpaste for additional information.   Additional Resources: Early Childhood Learning and Knowledge Center. Centers for Disease Control and Prevention. Toothbrushing in Head Start Programs During the COVID-19 Pandemic

RATIONALE

Regular tooth brushing with fluoride toothpaste is encouraged to reinforce oral health habits and prevent gingivitis and tooth decay. There is currently no (strong) evidence that shows any benefit to wiping the gums of a baby who has no teeth. However, before the first tooth erupts, wiping a baby’s gums with clean gauze or a soft wet washcloth as part of a daily routine may make the transition to tooth brushing easier. Good oral hygiene is as important for a six-month-old child with one tooth as it is for a six-year-old with many teeth (2). Tooth brushing with fluoride toothpaste at least once a day reduces build-up of decay-causing plaque (2,3). The development of tooth decay-producing plaque begins when an infant’s first tooth appears in his/her mouth (4). Tooth decay cannot develop without this plaque which contains the acid-producing bacteria in a child’s mouth. The ability to do a good job brushing the teeth is a learned skill, improved by practice and age. There is general consensus that children do not have the necessary hand eye coordination for independent brushing until around age seven or eight so either caregiver/teacher brushing or close supervision is necessary in the preschool child. Tooth brushing and activities at home may not suffice to develop this skill or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care.

COMMENTS

The caregiver/teacher should use a small smear (grain of rice) of fluoride toothpaste spread across the width of the toothbrush for children under three years of age and a pea-sized amount for children ages three years of age and older (1). Children should attempt to spit out excess toothpaste after brushing. Fluoride is the single most effective way to prevent tooth decay. Brushing teeth with fluoride toothpaste is the most efficient way to apply fluoride to the teeth. Young children may occasionally swallow a small amount of toothpaste and this is not a health risk. However, if children swallow more than recommended amounts of fluoride toothpaste on a consistent basis, they are at risk for fluorosis, a cosmetic condition (discoloration of the teeth) caused by over exposure to fluoride during the first eight years of life (5). Other products such as fluoride rinses can pose a poisoning hazard if ingested (6).

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

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

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

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

Fluoride varnish applied to all children every 3-6 months at primary care visits or at their dental home reduces tooth decay rates, and can lead to significant cost savings in restorative dental care and associated hospital costs. Coupled with parent/guardian and caregiver/teacher education, fluoride varnish is an important tool to improve children’s health (9-11).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education

REFERENCES

1. American Academy of Pediatrics, Section on Oral Health. 2014. Maintaining and improving the oral health of young children. http://pediatrics.aappublications.org/content/134/6/1224
2. American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.
   
3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry30:112-18.
4. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845.
   
5. Centers for Disease Control and Prevention, Fluoride Recommendations Work Group. 2001. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR50(RR14): 1-42.
6. Centers for Disease Control and Prevention. 2013. Community water fluoridation. http://www.cdc.gov/fluoridation/faqs/http://www.cdc.gov/fluoridation/faqs/
   
7. American Academy of Pediatric Dentistry. Early childhood caries. Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf.
   
8. American Dental Association. ADA positions and statements. ADA statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx.
   
9. Marinho, V.C., et al. 2002. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database System Rev 3, no.  CD002279. http://www.ncbi.nlm.nih.gov/pubmed/12137653
   
10. American Academy of Pediatric Dentistry. 2006. Talking points: AAPD perspective on physicians or other non-dental providers applying fluoride varnish. Dental Home Resource Center.http://www.aapd.org/dentalhome/1225.pdf.
    
11. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine.2016. Policy statement: 2016 Recommendations for preventive pediatric health care. http://pediatrics.aappublications.org/content/early/2015/12/07/peds.2015-3908  

NOTES

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

3.1.5.2: Toothbrushes and Toothpaste

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

In facilities where tooth brushing is an activity, each child should have a personally labeled, soft toothbrush of age-appropriate size. No sharing or borrowing of toothbrushes should be allowed. After use, toothbrushes should be stored on a clean surface with the bristle end of the toothbrush up to air dry in such a way that the toothbrushes cannot contact or drip on each other and the bristles are not in contact with any surface (1). Racks and devices used to hold toothbrushes for storage should be labeled and disinfected as needed. The toothbrushes should be replaced at least every three to four months, or sooner if the bristles become frayed (2-5). When a toothbrush becomes contaminated through contact with another brush or use by more than one child, it should be discarded and replaced with a new one.

Each child should have his/her own labeled toothpaste tube. Or if toothpaste from a single tube is shared among the children, it should be dispensed onto a clean piece of paper or paper cup for each child rather than directly on the toothbrush (1,6). Children under three years of age should have only a small smear of fluoride toothpaste (grain of rice) on the brush when brushing. Those three years of age and older should use a pea-sized amount of fluoride toothpaste (7). Toothpaste should be stored out of children’s reach.


                       
                     Small smear of fluoride toothpaste                  Pea-sized amount of fluoride toothpaste

                             Photo Credit: National Center on Early Childhood Health and Wellness

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

COVID-19 modification as of March 31, 2023 In response to the Centers for Disease Control and Prevention’s COVID-19 Guidance for Operating Early Care and Education/Child Care Programs, toothbrushing may resume if programs can implement strategies to reduce the possibility of transmitting the virus to others via salivary droplets during brushing. Refer to modifications in CFOC Standard 3.1.5.1 Routine Oral Health Activities for guidance on resuming tooth brushing in group care settings. Additional Resources: National Center on Health, Behavioral Health, and Safety. Toothbrushing in Head Start Programs During the COVID-19 Pandemic

RATIONALE

Toothbrushes and oral fluids that collect in the mouth during tooth brushing are contaminated with infectious agents and must not be allowed to serve as a conduit of infection from one individual to another (1). Individually labeling the toothbrushes will prevent different children from sharing the same toothbrush. As an alternative to racks, children can have individualized, labeled cups and their brush can be stored bristle-up in their cup. Some bleeding may occur during tooth brushing in children who have inflammation of the gums. The Occupational Safety and Health Administration (OSHA) regulations apply where there is potential exposure to blood. Saliva is considered an infectious vehicle whether or not it contains blood, so caregivers/teachers should protect themselves from saliva by implementing standard precautions.
 

COMMENTS

Children can use an individually labeled or disposable cup of water to brush their teeth (1).

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

Some risk of infection can occur when numerous children brush their teeth and spit into the sink that is not sanitized between uses.

Tooth brushing ability varies by age. Young children want to brush their own teeth, but they need help until about age seven or eight. Adults helping children brush their teeth not only help them learn how to brush, but also improve the removal of plaque and food debris from all teeth (5).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
3.6.1.5 Sharing of Personal Articles Prohibited

REFERENCES

1. Centers for Disease Control and Prevention. 2005. Infection control in dental settings: The use and handling of toothbrushes. http://www.cdc.gov/OralHealth/InfectionControl/factsheets/toothbrushes.htm
   
2. American Dental Association, Council on Scientific Affairs. 2005. ADA statement on toothbrush care: Cleaning, storage, and replacement. http://www.ada.org/1887.aspx.
   
3. American Academy of Pediatric Dentistry. 2004. Early childhood caries (ECC).http://www.aapd.org/assets/2/7/ECCstats.pdf.
4. American Dental Hygienists’ Association. Proper brushing. http://www.adha.org/oralhealth/brushing.htm.
5. 12345 First Smiles. 2006. Oral health considerations for children with special health care needs (CSHCN). http://www.first5oralhealth.org/page.asp?page_id=432.
   
6. Davies, R. M., G. M. Davies, R. P. Ellwood, E. J. Kay. 2003. Prevention. Part 4: Toothbrushing: What advice should be given to patients? Brit Dent Jour 195:135-41.
7. American Academy of Pediatrics, Section on Oral Health. 2014 Maintaining and improving the oral health of young children. http://pediatrics.aappublications.org/content/134/6/1224.

NOTES

Content in the STANDARD was modified on 2/6/2013, 04/22/2013, and 3/10/2016.

COVID-19 modification as of March 31, 2023.

3.1.5.3: Oral Health Education

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

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

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

School-age children should receive additional information including:

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

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

Caregivers/teachers and parents/guardians should be taught to not place a child’s pacifier in the adult’s mouth to clean or moisten it or share a toothbrush with a child due to the risk of promoting early colonization of the infant oral cavity with Streptococcus mutans (1).

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

RATIONALE

Studies have reported that the oral health of participants improved as a result of educational programs (2).

COMMENTS

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

        a.    Dental or primary care provider visits to evaluate the need for supplemental fluoride therapy (prescription pills or drops if tap water does not contain fluoride) starting at six months of age, and professionally applied topical fluoride treatments for all children every 3-6 months starting when teeth are present (3,4);
        b.    First dental visit within six months after the first tooth erupts or by one year of age, whichever is earlier and whenever there is a question of an oral health problem;
        c.    Dental sealants generally at six or seven years of age for first permanent molars and for primary molars if deep pits and grooves or other high risk factors are present (4,6).

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

For more resources on oral health education, see:

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

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.3 Pacifier Use
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste

REFERENCES

1. American Academy of Pediatrics, Oral Health Initiative. Protecting All Children's Teeth (PACT): A pediatric oral health training program. Factors in Development: Bacteria. http://www2.aap.org/oralhealth/pact/
2. Dye, B. A., J. D. Shenkin, C. L. Ogden, T. A. Marshould, S. M. Levy, M. J. Kanellis. 2004. The relationship between healthful eating practices and dental caries in children aged 2-5 years in the United States. J Am Dent Assoc 135:55-66.
   
3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Pediatric Dentistry30:112-18.
4. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine.2016. Policy statement: 2016 Recommendations for preventive pediatric health care. http://pediatrics.aappublications.org/content/early/2015/12/07/peds.2015-3908 
5. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845.
   
6. American Academy of Pediatrics, Section on Pediatric Dentistry.2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.

3.2.1.1: Type of Diapers Worn

Facilities should adhere to the procedures outlined in 3.2.1.2: Handling Cloth Diapers and 3.2.1.4: Diaper Changing Procedure to prevent and control infections caused by fecal contact:
 
Diapers worn by children should be able to contain urine and stool and minimize exposure to human waste in the child care setting. Children should use disposable diapers with absorbent material (e.g., polymers) or cloth diapers. Cloth diapers should have an absorbent inner layer that is completely covered with an outer waterproof layer that has a waist closure (i.e., not pull-on waterproof pants). The cloth diaper and waterproof later should be changed at the same time (1). Whichever diapering system is used in the facility, clothes should be worn over diapers while the child is in the facility.

No rinsing or dumping of the contents of cloth diapers should be performed at the child care facility. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child’s family, stored in a location inaccessible to children, and given directly to the parent/guardian daily upon discharge of the child. Children of all ages who are incontinent of urine or stool should wear a barrier method, such as a disposable diaper or a cloth diaper that is completely covered with an outer waterproof layer and a waist closure.

While single unit reusable diaper systems, with an inner cloth lining attached to an outer waterproof covering, and reusable cloth diapers, worn with a front closure waterproof cover, meet the physical criteria of this standard (if used as described), they have not been evaluated for their ability to reduce fecal contamination, or for their association with diaper dermatitis (rash). Moreover, it has not been demonstrated that the waterproof covering materials remain waterproof with repeated cleaning and disinfecting. Therefore, single-use disposable diapers should be encouraged for use in child care facilities.

RATIONALE

Procedures that reduce fecal contamination help control the spread of disease. Fecal contamination has been associated with increased diarrheal rates in child care facilities (1). Gastrointestinal tract disease, or diarrhea (caused by bacteria, viruses, and parasites) and hepatitis A virus infection are spread from infected persons through fecal contamination of hands and objects. Protective procedures includes minimal handling of soiled diapers and clothing, thorough hand hygiene, and containment of fecal matter.  Fecal contamination in child care settings may be reduced when single-use, disposable diapers are used compared to cloth diapers worn with pull-on waterproof pants (3). When clothes are worn over either disposable or cloth diapers with pull-on waterproof pants, there is a reduction in contamination of the environment (1, 3).

Diaper Rash
Diaper dermatitis (rash) occurs frequently in diapered children. Diapering practices that reduce the frequency and severity of diaper dermatitis will require less application of skin creams and ointments, thereby decreasing the likelihood for fecal contamination of caregivers/teachers’ hands. Most common diaper dermatitis is caused by prolonged contact of the skin with urine, feces, or both (1). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (1). Frequency and severity of diaper dermatitis are lower when diapers are changed more often, regardless of the diaper used (1). The use of disposable diapers with absorbent material has been associated with less frequent and less severe diaper dermatitis in some children than with the use of cloth diapers and pull-on pants made of a waterproof material (2, 3).

COMMENTS

Reusable cloth diapers worn either without a covering or with pull-on waterproof pants do not meet the physical requirements of the standard.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers

REFERENCES

1. American Academy of Pediatrics. Infections Spread by the Fecal-Oral Route In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 143
2. American Academy of Pediatrics. Healthychildren.org. 2015. Diaper rash. https://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/Diaper-Rash.aspx. 
3. Counts, J.L., Helmes, C.T., Kenneally, D., Otts, D.R. Modern disposable diaper constructions: Innovations in performance help maintain healthy diapered skin. 2014. Clinical Pediatrics. 53(9S):10S-13S. 

NOTES

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

3.2.1.2: Handling Cloth Diapers

If cloth diapers are used, soiled cloth diapers and/or soiled training pants should never be rinsed or carried through the child care area to place the fecal contents in a toilet. Reusable diapers should be laundered by a commercial diaper service. Soiled cloth diapers should be stored in a labeled container with a tight-fitting lid provided by an accredited commercial diaper service, or in a sealed plastic bag for removal from the facility by an individual child’s family. The sealed plastic bag should be sent home with the child at the end of the day. The containers or sealed diaper bags of soiled cloth diapers should not be accessible to any child.¹

RATIONALE

Containing and minimizing the handling of soiled diapers so they do not contaminate other surfaces is essential to prevent the spread of infectious disease. Putting stool into a toilet in the child care facility increases the likelihood that other surfaces will be contaminated during the disposal.¹ There is no reason to use the toilet for stool if disposable diapers are being used. Commercial diaper laundries use a procedure that separates solid components from the diapers and does not require prior dumping of feces into the toilet.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.1 Type of Diapers Worn
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.25.

3.2.1.3: Checking For the Need to Change Diapers

Diapers should be checked for wetness and feces at least hourly, visually inspected at least every two hours, and whenever the child indicates discomfort or exhibits behavior that suggests a soiled or wet diaper. Diapers should be changed when they are found to be wet or soiled.

RATIONALE

Frequency and severity of diaper dermatitis is lower when diapers are changed more often, regardless of the type of diaper used (1). Diaper dermatitis occurs frequently in diapered children. Most common diaper dermatitis represents an irritant contact dermatitis; the source of irritation is prolonged contact of the skin with urine, feces, or both (2). The action of fecal digestive enzymes on urinary urea and the resulting production of ammonia make the diapered area more alkaline, which has been shown to damage skin (1,2). Damaged skin is more susceptible to other biological, chemical, and physical insults that can cause or aggravate diaper dermatitis (2).

Modern disposable diapers can be checked for wetness by feeling the diaper through the clothing and fecal contents can be assessed by odor. Nonetheless, since these methods of checking may be inaccurate, the diaper should be opened and checked visually at least every two hours. Even though modern disposable diapers can continue to absorb moisture for an extended period of time when they are wet, they should be changed after two hours of wearing if they are found to be wet. This prevents rubbing of wet surfaces against the skin, a major cause of diaper dermatitis.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.2 Handling Cloth Diapers
3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene

REFERENCES

1. Healthy Children. 2010. Ages and stages: When diaper rash strikes. http://www.healthychildren.org/English/ages-stages/baby/diapers-clothing/Pages/When-Diaper-Rash-Strikes.aspx.
2. Shelov, S. P., T. R. Altmann, eds. 2009. Caring for your baby and young child: Birth to age 5. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics.

3.2.1.4: Diaper Changing Procedure

RATIONALE

The procedure for diaper changing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (4). Posting the multistep procedure may help caregivers/teachers maintain the routine.

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

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

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

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

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

Children’s hands often stray into the diaper area (the area of the child’s body covered by a diaper) during the diapering process and can then transfer fecal organisms to the environment. Washing the child’s hands will reduce the number of organisms carried into the environment in this way. Infectious organisms are present on the skin and diaper even though they are not seen. To reduce the contamination of clean surfaces, caregivers/teachers should use a fresh wipe to wipe their hands after removing the gloves (5) or, if no gloves were used, before proceeding to handle the clean diaper and clothing.

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

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

Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, application, and storage. If the disinfectant is applied using a spray bottle, always assume that the outside of the spray bottle could be contaminated. Therefore, the spray bottle should be put away before hand hygiene is performed (the last and essential part of every diaper change) (6).

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
Appendix D: Gloving
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Children’s Environmental Health Network. 2016. Household chemicals. https://sharemylesson.com/teaching-resource/household-chemicals-fact-sheet-298286.

2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.25.
3. National Association for the Education of Young Children. Healthy Young Children: A Manual for Programs. Aronson SS, ed. 5th ed. Washington, DC: National Association for the Education of Young Children; 2012
4. American Academy of Pediatrics. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018

5. Early Childhood Education Linkage System, Healthy Child Care Pennsylvania. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster. Reaffirmed April 2018. Accessed June 26, 2018

6. University of California, San Francisco School of Nursing Institute for Health and Aging; University of California, Berkeley Center for Environmental Research and Children’s Health; Informed Green Solutions. Green Cleaning, Sanitizing, and Disinfecting: A Checklist for Early Care and Education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf. Published 2013. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 10/16/2018.

3.2.1.5: Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing

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

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

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

Use a fragrance-free bleach that is US Environmental Protection Agency (EPA) registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA registered (2).

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

 

Step 1: Get organized and determine whether to change the child lying down or standing up. Before bringing the child to the changing area, perform hand hygiene if hands have been contaminated since the last time hand hygiene was performed (3), gather, and bring supplies to the changing area.

1. Nonabsorbent paper liner large enough to cover the changing surface
2. Unused disposable training pants, underwear, clean clothes (if you need them)
3. Readily available wipes, dampened cloths, or wet paper towels for cleaning the child’s genitalia and buttocks
4. A plastic bag for any soiled clothes, including underwear, or disposable training pants
5. Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or disposable training pants; remove them before handling clean disposable training pants, underwear and clothing)

Step 2: Avoid contact with soiled items.

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

Step 3: Clean the child’s skin and check for spills.

1. Lift the child’s legs as needed to use disposable wipes, a dampened cloth, or a wet paper towel to clean the skin on the child’s genitalia and buttocks. Remove stool and urine from front to back and use a fresh wipe, dampened cloth, or wet paper towel each time you swipe. Put the soiled wipes, cloth, or paper towels into the soiled disposable training pants or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm’s reach of changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.
1. Check for spills under the child. If there are any, use the corner of the paper that extends beyond or under the child’s feet to fold over the soiled area so a fresh, unsoiled paper surface is now under the child.
2. If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can.
3. Whether or not gloves were used, use a fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child’s hands. Put the wipes into the plastic-lined, hands-free covered can.

Step 4: Put on clean disposable training pants or clean underwear and clothing, if necessary.

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

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

Use soap and warm water, between 60°F and 120°F (16°C and 49°C), at a sink to wash the child’s hands, if you can.

Step 6: Clean and disinfect the changing surface.

Dispose of the disposable paper liner used on the changing surface in a plastic-lined, hands-free covered can.

If clothing was soiled, securely tie the plastic bag used to store the clothing and send the bag home.

Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, and then rinse.

Wet the entire changing surface with a disinfectant that is appropriate for the surface material you are treating. Follow the manufacturer’s instructions for use.

Put away the disinfectant. Some types of disinfectants may require rinsing the changing table surface with fresh water afterward.

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

In the daily log, record what was in the disposable training pants or underwear and any problems (e.g., a loose stool, an unusual odor, blood in the stool, any skin irritation) and report as necessary (4).

RATIONALE

Children who are learning to use the toilet may still wet/soil their disposable training pants,  underwear and clothing. Changing these undergarments can lead to risk for spreading infection due to the contamination of surfaces from urine or feces (1). The procedure for changing a child’s soiled undergarment and clothing is designed to reduce the contamination of surfaces that will later come in contact with uncontaminated surfaces such as hands, furnishings, and floors (5, 6). Posting the multistep procedure may help caregivers/teachers maintain the routine.

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

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

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

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

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

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

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

Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, application, and storage. If the disinfectant is applied using a spray bottle, always assume that the outside of the spray bottle could be contaminated. Therefore, the spray bottle should be put away before hand hygiene is performed (the last and essential part of every change) (7).

Changing areas should never be located in food preparation areas and should never be used for temporary placement of food, drinks, or eating utensils. Additionally, changing tables that are a comfortable height for caregivers help reduce the risk of back injury for the adults, which may occur from lifting the child onto the table (1).

COMMENTS

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.1 Type of Diapers Worn
3.2.1.2 Handling Cloth Diapers
3.2.1.3 Checking For the Need to Change Diapers
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
Appendix D: Gloving
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Early Childhood Education Linkage Systems, Healthy Child Care Pennsylvania. Changing soiled underwear. http://www.ecels-healthychildcarepa.org/publications/fact-sheets/item/116-changing-soiled-underwear?highlight=WyJzb2lsZWQiXQ. Published 2016. Accessed June 26, 2018

2. Children’s Environmental Health Network. 2016. Household chemicals. https://sharemylesson.com/teaching-resource/household-chemicals-fact-sheet-298286.

3. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.25.
4. National Association for the Education of Young Children. Healthy Young Children: A Manual for Programs. Aronson SS, ed. 5th ed. Washington, DC: National Association for the Education of Young Children; 2012
5. American Academy of Pediatrics. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018

6. University of California, San Francisco School of Nursing Institute for Health and Aging; University of California, Berkeley Center for Environmental Research and Children’s Health; Informed Green Solutions. Green Cleaning, Sanitizing, and Disinfecting: A Checklist for Early Care and Education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf. Published 2013. Accessed June 26, 2018

7. Early Childhood Education Linkage System, Healthy Child Care Pennsylvania. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster. Reaffirmed April 2018. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 1/2012, 7/13/2012, 1/5/2013, 8/23/2016 and 10/16/2018.

3.2.2.1: Situations that Require Hand Hygiene

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

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

a. On arrival for the day, after breaks, or when moving from one child care group to another

b. Before and after

1. Preparing food or beverages
2. Eating, handling food, or feeding a child
3. Giving medication or applying a medical ointment or cream in which a break in the skin (eg, sores, cuts, scrapes) may be encountered
4. Playing in water (including swimming) that is used by more than one person

c. After

1. Diapering^*
2. Using the toilet or helping a child use a toilet
3. Handling bodily fluid (mucus, blood, vomit) from sneezing, wiping and blowing noses, mouths, or sores
4. Handling animals or cleaning up animal waste
5. Playing in sand, on wooden play sets, or outdoors
6. Cleaning or handling the garbage
7. Applying sunscreen and/or insect repellent

d. When children require assistance with brushing, caregivers/teachers should wash their hands thoroughly between brushings for each child. 

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

^*Hand hygiene after diaper changing must always be performed. Hand hygiene before changing diapers is required only if the staff member’s hands have been contaminated since the last time the staff member practiced hand hygiene.²

COVID-19 modification as of August 10, 2022:   In response to the Centers for Disease Control and Prevention’s COVID-19 Guidance for Operating Early Care and Education/Child Care Programs, it is recommended that program staff, and children: Practice hand hygiene during key times in the day (for example, before/after eating, after recess and after touching or handling masks.) Provide adequate handwashing supplies, including soap and water. Provide hand sanitizer containing at least 60% alcohol if hand washing with soap and water is not available. Store hand sanitizers up, away, and out of sight of younger children and only with adult supervision for children ages 5 years and younger. Additional Resources: Centers for Disease Control and Prevention. Your Guide to Masks CFOC Standard 3.2.2.5 Hand Sanitizers

 

RATIONALE

Hand hygiene is the most important way to reduce the spread of infection. Many studies have shown that improperly cleansed hands are the primary carriers of infections. Deficiencies in hand hygiene have contributed to many outbreaks of diarrhea among children and caregivers/teachers in child care centers.³

Child care centers that have implemented good hand hygiene techniques have consistently demonstrated a reduction in diseases transmission.³ When frequent and proper hand hygiene practices are incorporated into a child care center’s curriculum, there is a decrease in the incidence of acute respiratory tract diseases.⁴

Hand hygiene after exposure to soil and sand will reduce opportunities for the ingestion of zoonotic parasites that could be present in contaminated sand and soil.⁵

Thorough handwashing with soap for at least twenty seconds using clean running water at a comfortable temperature removes organisms from the skin and allows them to be rinsed away.⁶ Hand hygiene with an alcohol-based sanitizer is an alternative to traditional handwashing with soap and water when visible soiling is not present.
 
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately.⁷

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount.⁷ As with any hand hygiene product, supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes.⁷
Infectious organisms may be spread in a variety of ways:

1. In human waste (urine, stool);
2. In body fluids (saliva, nasal discharge, secretions from open injuries; eye discharge, blood);
3. Cuts or skin sores;
4. By direct skin-to-skin contact;
5. By touching an object that has live organisms on it;
6. In droplets of body fluids, such as those produced by sneezing and coughing, that travel through the air.

Since many infected people carry infectious organisms without symptoms and many are contagious before they experience a symptom, caregivers/teachers routine hand hygiene is the safest practice.⁸

COMMENTS

While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms).⁸ These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene. 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.5.2 Toothbrushes and Toothpaste
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs

REFERENCES

1. Mayo Clinic. 2010. Secondhand smoke: Avoid dangers in the air. http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/secondhand-smoke/art-20043914.
2. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.26.
3. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.20.

4. American Academy of Pediatrics. Enterovirus D68 In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 331-334, 658, 692

5. Palmer, S. R., L. Soulsby, D. I. H. Simpson, eds. 1998. Zoonoses: Biology, clinical practice, and public health control. New York: Oxford University Press.
6. Centers for Disease Control and Prevention. 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
7. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5. 

8. American Academy of Pediatrics. Hand Hygiene In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 148-149, 154, 164

NOTES

Content in the STANDARD was modified on 8/23/2016, 8/9/2017, 10/18/2018 and 01/22/2019.

COVID-19 modification as of August 10, 2022. 

3.2.2.2: Handwashing Procedure

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

1. Check to be sure a clean, disposable paper (or single-use cloth) towel is available.
2. Turn on clean, running water to a comfortable temperature.¹
3. Moisten hands with water and apply liquid or powder soap to hands.
1. Antibacterial soap should not be used.
2. Bar soaps should not be used.
4. Rub hands together vigorously until a soapy lather appears (hands are out of the water stream) and continue for at least 20 seconds (sing “Happy Birthday to You” twice).² Rub areas between fingers, around nail beds, under fingernails and jewelry, and on back of hands. Nails should be kept short; acrylic nails should not be worn.³
5. Rinse hands under clean, running water that is at a comfortable temperature until they are free of soap and dirt. Leave the water running while drying hands.
6. Dry hands with the clean, disposable paper or single-use cloth towel.
7. If faucets do not shut off automatically, turn faucets off with a disposable paper or single-use cloth towel.
8. Throw disposable paper towels into a lined trash container; place single-use cloth towels in the laundry hamper. Use hand lotion to prevent chapping of hands, if desired.

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

Use of antimicrobial soap is not recommended in early care and education settings. There are no data to support use of antibacterial soaps over other liquid soaps. Premoistened cleansing towelettes do not effectively clean hands and should not be used as a substitute for washing hands with soap and running water.

When running water is unavailable or impractical, the use of alcohol-based hand sanitizer (Standard 3.2.2.5) is a suitable alternative. The use of alcohol-based hand sanitizers is an alternative to traditional handwashing (with soap and water) if

1. Soap and water are not available and hands are not visibly dirty.^4,5
2. Hands are rubbed together, distributing sanitizer to all hand and finger surfaces, and allowed to air-dry.

Alcohol-based hand sanitizers should contain at least 60% alcohol and be kept out of reach of children. Active supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with eyes and mucous membranes.^6,7

Single-use towels should be used unless an automatic electric hand dryer is available. The use of cloth roller towels is not recommended because children often use cloth roller towel dispensers improperly, resulting in more than one child using the same section of towel.

Washbasins should not be used as an alternative to running water. Camp sinks and portable commercial sinks with foot or hand pumps dispense water like plumbed sinks and are satisfactory if filled with fresh water daily. The staff should clean and disinfect the water reservoir container and washbasin daily.

RATIONALE

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

 

Outbreaks of disease have been linked to shared wash water and washbasins.⁸

COMMENTS

Current handwashing procedure states that water remains on throughout the handwashing process. However, there is little research to prove whether a significant number of germs are transferred between hands and the faucet while performing hand hygiene.⁸  Turning off the faucet after wetting and before drying hands saves water for those early care and education programs practicing water conservation.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. http://www.cdc.gov/handwashing. Reviewed October 9, 2018. Accessed January 28, 2019

2. American Academy of Pediatrics. Isolation precautions. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:148–157

3. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1–45

4. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017

5. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—situations where hand sanitizer can be effective & how to use it in community settings. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Reviewed October 15, 2018. Accessed January 28, 2019

6. Centers for Disease Control and Prevention. CDC features. Wash your hands. https://www.cdc.gov/features/handwashing/index.html. Updated December 6, 2018. Accessed January 28, 2019

7. Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers—United States, 2011–2014. MMWR Morb Mortal Wkly Rep. 2017;66(8):223–226

8. Ogunsola FT, Adesiji YO. Comparison of four methods of hand washing in situations of inadequate water supply. West Afr J Med. 2008;27(1):24–28

9. Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—how to wash your hands. https://www.cdc.gov/handwashing/show-me-the-science-handwashing.html. Reviewed October 2, 2018. Accessed January 28, 2019

NOTES

Content in the STANDARD was modified on 8/9/2017 and 5/17/19.

3.2.2.3: Assisting Children with Hand Hygiene

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

RATIONALE

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

For examples of handwashing posters, see:

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.5 Hand Sanitizers

REFERENCES

1. Centers for Disease Control and Prevention. 2013. Information for schools and childcare providers. http://www.cdc.gov/flu/school/index.htm

3.2.2.4: Training and Monitoring for Hand Hygiene

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

RATIONALE

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

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

COMMENTS

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure

REFERENCES

1. Hawks, D., J. Ascheim, G. S. Giebink, S. Graville, A. J. Solnit. 1994. Science, prevention, and practice VII: Improving child day care, a concurrent summary of the American Public Health Association/American Academy of Pediatrics national health and safety guidelines for child-care programs; featured standards and implementation. Pediatrics 95:1110-12.
2. Roberts, L., E. Mapp, W. Smith, L. Jorm, M. Pate, R. M. Douglas, C. McGilchrist. 2000. Effect of infection control measures on the frequency of upper respiratory infection in child care: A randomized, controlled trial. Pediatrics 105:738-42.
3. Black, R. E., A. C. Dykes, K. E. Anderson. 1981. Handwashing to prevent diarrhea in day care centers. Am J Epidemiol 113:445-51.
4. Roberts, L., L. Jorm, M. Patel, W. Smith, R. M. Douglas, C. McGilchrist. 2000. Effect of infection control measures on the frequency of diarrheal episodes in child care: A randomized, controlled trial. Pediatrics 105:743-46.
5. Carabin, H., T. W. Gyorkos, J. C. Soto, L. Joseph, P. Payment, J. P. Collet. 1999. Effectiveness of a training program in reducing infections in toddlers attending daycare centers. Epidemiol 10:219-27.
6. Bartlett, A. V., B. A. Jarvis, V. Ross, T. M. Katz, M. A. Dalia, S. J. Englender, L. J. Anderson. 1988. Diarrheal illness among infants and toddlers in day care centers: Effects of active surveillance and staff training without subsequent monitoring. Am J Epidemiol 127:808-17.
7. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.

3.2.2.5: Hand Sanitizers

The use of hand sanitizers by children and adults in child care programs is an appropriate alternative to the use of traditional handwashing if soap and water is not available and if hands are not visibly dirty (1,2). ECE programs should provide hand sanitizer containing at least 60% alcohol. Hand sanitizers should be stored up, away, and out of sight of younger children and should be used only with adult supervision for children ages 5 years and younger.
 
Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of hand sanitizers with eyes and mucous membranes (3).
The technique for using hand sanitizers is:

• For visibly dirty hands and soap is not available, rinsing under running water or wiping with a water-saturated towel should be used to remove as much dirt as possible before using a hand sanitizer.
• Apply the product to the palm of one hand (read the label to learn the correct amount);
• Rub hands together; and
• Rub the product over all surfaces of the hands and fingers until hands are dry (4).

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

1. The maximum individual dispenser fluid capacity should be as follows:
2. 0.32 gal (1.2 L) for dispensers in individual rooms, corridors, and areas open to corridors;
3. 0.53 gal (2.0 L) for dispensers in suites of rooms;
4. Where aerosol containers are used, the maximum capacity of the aerosol dispenser should be 18 oz. (0.51 kg) and should be limited to Level 1 aerosols as defined in NFPA 30B: Code for the Manufacture and Storage of Aerosol Products;
5. Wall mounted dispensers should be separated from each other by horizontal spacing of not less than 48 in. (1,220 mm);
6. Wall mounted dispensers should not be installed above or adjacent to ignition sources such as electrical outlets;
7. Wall mounted dispensers installed directly over carpeted floors should be permitted only in child care facilities protected by automatic sprinklers (5).

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

RATIONALE

Studies have demonstrated that using an alcohol-based hand sanitizer after washing hands with soap and water is effective in reducing illness transmission in the home, in child care centers and in health care settings (6-8).
Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately (5).

Alcohol-based hand sanitizers have the potential to be toxic due to the alcohol content if ingested in a significant amount (1,3,4). 

COMMENTS

Even in health care settings, the Centers for Disease Control and Prevention (CDC) guidelines recommend washing hands that are visibly soiled or contaminated with organic material with soap and water as an adjunct to the use of alcohol-based sanitizers (6).
 
While alcohol-based hand sanitizers are helpful in reducing the spread of disease when used correctly, there are some common diarrhea-causing germs that are not killed (e.g. norovirus, spore-forming organisms) (1). These germs are common in child care settings, and children less than 2 years are at the greatest risk of spreading diarrheal disease due to frequent diaper changing. Even though alcohol-based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and water is always the preferred method for hand hygiene.

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html.
   
3. Centers for Disease Control and Prevention. When & how to wash your hands. 2015. https://www.cdc.gov/handwashing/when-how-handwashing.html. 
   
4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5.
   
5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
   

6. American Academy of Pediatrics. Hand Hygiene In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 148-149, 154, 164

7. Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. Comparing hand washing to hand sanitizers in reducing elementary school students’ absenteeism. Pediatric Nurs 33:368-72.
8. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Handwashing: Clean hands save lives!  http://www.cdc.gov/handwashing/.
9. ADDITIONAL REFERENCE:
    
   American Association of Poison Control Centers. 2016. Hand sanitizer. http://www.aapcc.org/alerts/hand-sanitizer/. 
   

NOTES

Content in the STANDARD was modified on 4/5/2017 and 8/9/2017.

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

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

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

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

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

RATIONALE

Hand hygiene is the most effective way to reduce the spread of infection (1,2).

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.20.
2. American Academy of Pediatrics. Out-of-home child care, infection control and prevention In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 125-136, 122-125, 124t

3.2.3.2: Cough and Sneeze Etiquette

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.5 Hand Sanitizers

REFERENCES

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

3.2.3.3: Cuts and Scrapes

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

A child or caregiver/teacher with a cut or sore that is leaking a body fluid that cannot be contained or cannot be covered with a dressing, should be excluded from the facility until the cut or sore is scabbed over or healed.

RATIONALE

Touching a contaminated object or surface may spread infectious organisms (1,2). Body fluids may contain infectious organisms (1,2).

Gloves can provide a protective barrier against infectious organisms that may be present in body fluids (1,2).

COMMENTS

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
Appendix D: Gloving

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
2. American Academy of Pediatrics. Out-of-home child care, infection control and prevention In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 125-136, 122-125, 124t

3.2.3.4: Prevention of Exposure to Blood and Body Fluids

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

In child care settings:

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

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

Procedures for Standard Precautions should include:

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

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

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

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

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
Appendix D: Gloving
Appendix L: Cleaning Up Body Fluids

REFERENCES

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

3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting

Cleaning, sanitizing, and/or disinfecting surfaces are important steps in reducing the risk of spreading infectious diseases to children, staff, and visitors in early care and education programs. In most situations, routine cleaning with soap and water is enough to remove dirt and some germs from surfaces. Sanitizing and/or disinfecting may be needed after cleaning to further reduce the risk of spreading illness. Sanitizers and disinfectants need to be applied to a clean surface to work effectively at killing germs.  

Activity	Type of Product	Method	Comments
Clean	Soap/detergent and water, or all-purpose cleaners, to remove germs, dirt, oils, and sticky substances from surfaces or objects	Clean surfaces, preferably with a microfiber cloth/mop, rinse the surface thoroughly, and air dry. Or dry with a paper towel or a clean microfiber cloth.	If using a cleaner other than soap and water, choose a product that has safer chemical ingredients and is certified by a third party (Safer Choice, Green Seal, or UL Ecologo).
Sanitize	Chemical product that reduces the number of most germs on non-porous surfaces or objects to a safe level	Sanitize surfaces that touch food (dishes, cutting boards, or mixed-use tables), or objects that a child might place in their mouth (toys).	Choose an Environmental Protection Agency (EPA)-registered product with directions for food-contact surfaces on the label.
Disinfect	Chemical product to kill bacteria and viruses on surfaces or objects	Disinfect equipment and surfaces that are used in toileting or diapering and in cleaning body fluids.  Allow disinfectant to sit on the surface and be visibly wet for the number of minutes listed on the product label.  Follow the manufacturer’s instructions for use and safe handling of products.	Choose a disinfectant product certified by the EPA’s Design for the Environment program.

Detailed definitions of Clean, Sanitize, Disinfect, and Germ[s] (microbes such as bacteria, viruses, fungi) that can cause disease are in the CFOC Online Glossary.

Programs need to write up and follow a routine schedule of cleaning, sanitizing, and disinfecting. Refer to CFOC Appendix K: Routine Schedule for Cleaning, Sanitizing and Disinfecting.

• Always disinfect surfaces or objects soiled with blood, body fluids that are bloody, and other potentially infectious body fluids (such as vomit, pus, urine, and feces) by following Occupational Safety and Health Administration (OSHA) Standard Precautions. Refer to CFOC Standard 3.2.3.4 Prevention of Exposure to Blood and Body Fluids and Appendix L: Cleaning Up Body Fluids.

• During illness outbreaks, programs may need to sanitize or disinfect surfaces more often and should refer to state, local, tribal, or territorial health authorities and child care licensing for more information.

Only U.S. Environmental Protection Agency (EPA)-registered products that have an EPA registration number on the label can make public health claims that can be trusted to reduce or destroy germs. The EPA registration label will also describe the product as a sanitizer or disinfectant.

The EPA Design for the Environment (DfE) now certifies products that meet certain health and environmental standards. DfE-certified products do not have ingredients that may pose long-term health risks, such as the potential to cause cancer or negatively impact the health of young children. The EPA also added more information to reduce the environmental impact of products. This includes how quickly chemicals break down, and how they affect fish and other aquatic life.

Before choosing a cleaning or antimicrobial product, you will need to know whether the surface needs to be cleaned, sanitized, or disinfected. Cleaning products may have hazardous chemicals that should not be used near children. Always follow the manufacturer’s instructions (listed on the label) for safe use, storage, and disposal of products. 

To reduce exposure to cleaning product fumes, ventilate the space by opening windows or doors or by bringing in outside air with a heating, ventilation, and air conditioning (HVAC) system. If you do not have an HVAC system, use a portable, high-efficiency particulate air (HEPA) cleaner in individual rooms. Child-safe portable fans or ceiling fans increase the circulation of fresh air from open windows. Placing a fan by an open window to blow inside air out encourages airflow throughout the room. Refer to CFOC Standard 5.2.1.1 Ensuring Access to Fresh Air Indoors.

CFOC Appendix J: Selection and Use of a Cleaning, Sanitizing and Disinfecting Product lists specific information on the following topics:

• Products Registered with the Environmental Protection Agency (EPA)
• Choosing Safer Products: Safety Data Sheet (SDS) and Required Staff Training
• Product Labeling Requirements 
• Indoor Air Quality and Ventilation
• Protecting Staff and Children’s Health
• Safer Products Options and Third Party Certifications logos
• How to Safely Prepare and Use Bleach Solutions
• Tools and Tips for Cleaning, Sanitizing, and Disinfecting
• Resources on Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product

RATIONALE

Infectious illnesses easily spread in the early care and education programs, since there is close contact between children, staff, and families. Infants and young children in early care and education programs and family child care homes are more likely to get ear infections, upper respiratory infections, and stomach illnesses than when children are cared for primarily in their own homes. Illnesses may spread in a variety of ways, such as by coughing, sneezing, direct skin-to-skin contact, or touching a contaminated object or surface. Infants and young children freely explore their environment by touching items, hugging and kissing children and adults, and putting their hands in their mouths. Surfaces and objects can carry germs, including toys, tables, floors, sinks, doorknobs, sandboxes, water play tables, etc.^1-3

Safe practices need to be developed for each product that early care and education programs use to clean, sanitize, and disinfect. Each product has specific hazards, precautions, and directions for maximum safety and effectiveness. OSHA requires employers to give their staff information about hazards, including access to and review of the Safety Data Sheets (SDSs), if the facility uses toxic substances such as cleaning, sanitizing, and disinfecting supplies. The SDSs explain the risk of exposure to products so that staff can take necessary precautions.

ADDITIONAL RESOURCES

• Cleaning and Disinfecting Your Facility - CDC
• Green Cleaning, Sanitizing and Disinfecting: A Toolkit for Early Care and Education -Western States Pediatric Environmental Health Specialty Unit (PEHSU), University of California, San Francisco. A set of resources developed in 2021 in collaboration with the EPA.
• Protecting Workers Who Use Cleaning Chemicals – OSHA-NIOSH

POSTERS

UCSF (University of California, San Francisco) California Childcare Health Program Posters (available in English, Chinese and Spanish)

• Safer Cleaning, Sanitizing and Disinfecting: Choose Safer Products 
• Safer Cleaning, Sanitizing and Disinfecting: Use the Right Tool for the Job 
• Step by Step Cleaning for Child Care Programs 
• Step by Step Sanitizing for Child Care Programs 
• Step by Step Disinfecting for Child Care Programs

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix L: Cleaning Up Body Fluids
Appendix W: Sample Food Service Cleaning Schedule

REFERENCES

1. Ibfelt T, Engelund EH, Permin A, Madsen JS, Schultz AC, Andersen LP. Presence of pathogenic bacteria and viruses in the daycare environment. J Environ Health. 2015 Oct;78(3):2429. PMID: 26591334.

2. Martínez-Bastidas T, Castro-del Campo N, Mena KD, Castro-del Campo N, León-Félix J, Gerba CP, Chaidez C. Detection of pathogenic micro-organisms on children’s hands and toys during play. J Appl Microbiol. 2014 Jun;116(6):16681675. doi: 10.1111/jam.12473. Epub 2014 Mar 20. PMID: 24524673.
3. Bright KR, Boone SA, Gerba CP. Occurrence of bacteria and viruses on elementary classroom surfaces and the potential role of classroom hygiene in the spread of infectious diseases. J Sch Nurs. 2010 Feb;26(1):3341. doi: 10.1177/1059840509354383. Epub 2009 Nov 10. PMID: 19903773.

NOTES

Standard was last updated 09/26/2022 and 10/27/2022 (for formatting).

3.3.0.2: Cleaning and Sanitizing Toys

Cleaning and sanitizing toys are important steps to reduce the risk of spreading infectious diseases in early care and education programs. Toys that cannot be cleaned and sanitized should not be used. Toys that children have placed in their mouths or that are contaminated by bodily fluids (secretion or excretion) should be set aside and not used until they are cleaned and sanitized. Collecting toys as they become dirty throughout the day and sorting them into separate containers (one for cloth toys and one for hard toys) can make it easier to clean and sanitize at the end of the day.

The following methods for cleaning and sanitizing toys should be used:

• Washing toys by hand: Wash toys with fragrance-free soap or detergent and water, then rinse with water, sanitize, and air dry. It is important to clean toys before sanitizing them because the sanitizer works better on clean surfaces. It is important to follow the instructions for the sanitizer and allow the sanitizer to air dry for the recommended time. Wooden toys that cannot be submersed in water or put in a dishwasher should be cleaned with a soapy cloth, then rinsed with a damp cloth, and then sanitized by applying a solution. The wooden toys should then be wiped dry or allowed to air dry. Always check the manufacturer’s recommendations for cleaning wooden toys.
• Washing toys in a dishwasher: Some hard toys can be cleaned and sanitized in a dishwasher. Check the manufacturer’s instructions on the toy to make sure the toy is dishwasher safe. Use the correct amount of fragrance-free dishwashing detergent and run the complete wash cycle. Make sure the dishwasher has a “sanitizing cycle” or is set to heat dry. Use a dishwasher with a sanitizing cycle that is certified to meet the NSF/ANSI 184 standard. This standard helps confirm that a residential dishwasher can reduce bacteria by at least 99.999% when run on the sanitizing cycle.⁴ Do not wash toys with dirty dishes, utensils, etc. A small mesh laundry bag can be used to hold small toys.
• Washing toys in a washing machine: A washing machine can clean many soft toys (e.g., stuffed animals, puppets, play clothing). Check the manufacturer’s instructions on the toy to confirm that it can go in a washing machine. Wash in the warmest temperature, and dry completely. Use a dryer on a high heat setting when possible. Rotating soft toys, puppets, and dramatic play clothing can help reduce the need to wash the material often.

Children playing with plastic or play foods, dishes, and utensils should be closely supervised to prevent shared mouthing of these toys. Only 1 child at a time should use machine-washable cloth toys. These toys should be laundered before another child uses them. Indoor toys should not be shared between groups of infants or toddlers unless the toys are washed and sanitized before being moved from one group to the other. For more information on toys such as play dough and other manipulative sensory items, see CFOC Standard 5.2.9.8.

See the Comments section below for more resources on cleaning schedules, choosing the right cleaning product, important information about using bleach products, and safer choice products. Always follow the manufacturer’s instructions for all products.

RATIONALE

Infectious diseases spread easily in early care and education programs, since children, staff, and families are all in close contact. Surfaces and objects can carry germs and have spread diseases.^1–3 Toys can spread disease when children put the toys in their mouths, touch the toys after putting their hands in their mouths during play or eating, or after toileting with inadequate hand hygiene. Using a dishwasher that has a “sanitizing cycle” or is set to heat dry is an acceptable way to save time and work when sanitizing plastic toys, as long as it’s not washing dishes and cutlery at the same time. Developing effective cleaning strategies and policies are important steps to reduce the risk of illness in early care and education programs.

COMMENTS

Early care and education programs need to write up and follow a routine schedule of cleaning, sanitizing, and disinfecting. Refer to CFOC Appendix K: Routine Schedule for Cleaning, Sanitizing and Disinfecting.

For more information on choosing a cleaning, sanitizing, or disinfecting product, please refer to CFOC Appendix J: Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product. Appendix J also has important information about the use of bleach products, how to prepare bleach solutions, and health and safety precautions. Never mix bleach with other household cleaners, especially those that have ammonia.

The use of products that have safer (less toxic) chemicals helps reduce health and environmental concerns. Manufacturers may claim that their products are “green,” “natural,” or “earth friendly,” but these claims are often misleading and might not be about a chemical’s safety. Organizations now certify and label products that meet certain health and environmental standards. These certifications can help you find less hazardous cleaning, sanitizing, and disinfecting products. CFOC Appendix J has more information on Third Party Certifications logos and these safer (less toxic) chemicals. Safer disinfectant options can be found at https://www.epa.gov/pesticide-labels/dfe-certified-disinfectants. Using the least hazardous products available will help protect the health of children, and early care and education program staff and custodial personnel.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Ibfelt T, Engelund EH, Permin A, Madsen JS, Schultz AC, Andersen LP. Presence of pathogenic bacteria and viruses in the daycare environment. J Environ Health. 2015 Oct;78(3):24-29. PMID: 26591334

2. Gerba CP, Chaidez C. Detection of pathogenic micro-organisms on children’s hands and toys during play. J Appl Microbiol. 2014 Jun;116(6):1668-1675. doi: 10.1111/jam.12473. Epub 2014 Mar 20. PMID: 24524673

3. Bright KR, Boone SA, Gerba CP. Occurrence of bacteria and viruses on elementary classroom surfaces and the potential role of classroom hygiene in the spread of infectious diseases. J Sch Nurs. 2010 Feb;26(1):33-41. doi: 10.1177/1059840509354383. Epub 2009 Nov 10. PMID: 19903773

4. Western States Pediatric Environmental Health Specialty Unit. Green cleaning, sanitizing, and disinfecting: A tooklit for early care and education, 2nd ed. San Francisco, CA: University of California, San Francisco; 2021

NOTES

Content in the STANDARD was modified on 3/20/2023.

3.3.0.3: Cleaning and Sanitizing Objects Intended for the Mouth

Thermometers, pacifiers, teething toys, and similar objects that are intended for the mouth should be cleaned, and reusable parts should be sanitized between uses. For more information on how to clean and sanitize mouthed objects, see CFOC Standard 3.3.0.2. For thermometers, refer to the manufacturer’s instructions for cleaning.

Children should never share pacifiers. Pacifiers need to be sanitized if they look dirty or if another child has used them. Use a sanitizer safe for contact with food, or boil the pacifier for 1 minute in water that can be for drinking or meal preparation, and air-dry. Using a dishwasher to sanitize can also replace the need for chemical sanitizers. Using a dishwasher that has a “sanitizing cycle” or that is set to heat-dry is an acceptable way to save time and work when sanitizing pacifiers and objects that are dishwasher-safe ¾ as long as the dishwasher can wash and sanitize the surfaces, and it doesn’t wash dishes and cutlery at the same time. Use a dishwasher with a sanitizing cycle that is certified to meet the NSF/ANSI 184 standard. This standard helps confirm that a residential dishwasher can reduce bacteria by at least 99.999% when run on the sanitizing cycle.¹

After you clean a pacifier, water often stays in the nipple. Be sure to squeeze any water through the nipple hole of the pacifier to be sure it is clean. Program staff should ensure their hands are thoroughly washed before squeezing the pacifier nipple. Squeeze the pacifier away from you, as water may still be hot. If water drops remain in the nipple, let the pacifier air-dry. Make sure the pacifier has cooled completely before giving it to the child.

RATIONALE

Infectious diseases spread easily in early care and education programs, since children, staff, and families are all in close contact. Mouthed objects can carry germs and have spread diseases.^2–4 Developing effective cleaning strategies and policies are important steps to reduce the risk of illness in early care and education programs.

COMMENTS

Early care and education programs need to write up and follow a routine schedule of cleaning, sanitizing, and disinfecting. Refer to CFOC Appendix K: Routine Schedule for Cleaning, Sanitizing and Disinfecting.

For more information on selecting a cleaning, sanitizing, or disinfecting product, please refer to CFOC Appendix J: Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product. Appendix J also has important information about the use of bleach products, how to prepare bleach solutions, and health and safety precautions. Never mix bleach with other household cleaners, especially those that have ammonia.

The use of products that have safer (less toxic) chemicals helps reduce health and environmental concerns. Manufacturers may claim that their products are “green,” “natural,” or “earth friendly,” but these claims are often misleading and might not be about a chemical’s safety. Organizations now certify and label products that meet certain health and environmental standards. These certifications can help you find less hazardous cleaning, sanitizing, and disinfecting products. CFOC Appendix J has more information on Third Party Certifications logos and these safer (less toxic) chemicals. Safer disinfectant choices can be found at https://www.epa.gov/pesticide-labels/dfe-certified-disinfectants. Using the least hazardous products available will help protect the health of children, and early care and education program staff and custodial personnel.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.3 Pacifier Use
3.2.2.2 Handwashing Procedure
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.2 Cleaning and Sanitizing Toys
3.6.1.3 Guidelines for Taking Children’s Temperatures
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Western States Pediatric Environmental Health Specialty Unit. Green cleaning, sanitizing, and disinfecting: A tooklit for early care and education, 2nd ed. San Francisco, CA: University of California, San Francisco; 2021

2. Ibfelt T, Engelund EH, Permin A, Madsen JS, Schultz AC, Andersen LP. Presence of pathogenic bacteria and viruses in the daycare environment. J Environ Health. 2015 Oct;78(3):24-29. PMID: 26591334

3. Gerba CP, Chaidez C. Detection of pathogenic micro-organisms on children’s hands and toys during play. J Appl Microbiol. 2014 Jun;116(6):1668-1675. doi: 10.1111/jam.12473. Epub 2014 Mar 20. PMID: 24524673

4. Bright KR, Boone SA, Gerba CP. Occurrence of bacteria and viruses on elementary classroom surfaces and the potential role of classroom hygiene in the spread of infectious diseases. J Sch Nurs. 2010 Feb;26(1):33-41. doi: 10.1177/1059840509354383. Epub 2009 Nov 10. PMID: 19903773

NOTES

Content in the STANDARD was modified on 3/20/2023.

3.3.0.4: Cleaning Individual Bedding

Bedding (sheets, pillows, pillowcases, blankets, sleeping bags, sleep sacks) in early care and education programs should only be made of materials that are washable. Each child’s bedding should be kept separately from other children’s bedding, either on the bed or stored in individually labeled bins, cubbies, or bags. Bedding should be removed from individual sleep equipment (cots, mats) before they are stored or stacked. Bedding that touches a child’s skin should be cleaned weekly if only 1 child uses the bedding or before another child uses it.¹

When cleaning bedding, it is important to use these guidelines:

• Follow the instructions on the laundry detergent container.
• Wash the bedding at the warmest temperature, and dry completely. Use a dryer on a high heat setting when possible.
• If the bedding is soiled with body fluids, launder with a disinfectant ¾ for example, non-chlorine bleach (preferred) or bleach ¾ and dry completely.
  

Early care and education programs should have written policies and procedures for collecting, handling, and washing soiled bedding. Programs that have laundryequipment in the kitchen must also make sure not to do laundry at the same time as preparing food. Surfaces must be cleaned and disinfected before food preparation and after laundering.

See the Comments section below for more resources on cleaning schedules and choosing the right cleaning and disinfecting product.

RATIONALE

Infectious diseases spread easily in early care and education programs, since children, staff, and families are all in close contact. Surfaces and objects can carry germs and have spread diseases.^2–4 Children in early care and education programs often nap on mats or cots that are taken out of storage for nap time, and then placed back in storage. Improper cleaning of bedding materials may increase the risk of spreading disease. Bedding can collect germs and insects (e.g., lice) that grow well in a moist and warm environment. But, the spread of disease is rare if bedding is cleaned and dried properly.⁵ Having bedding for each child, and storing each set in individually labeled bins, cubbies, or bags ¾ that clearly separate each child’s personal bedding ¾ are proper hygienic practices.⁶ Developing effective cleaning strategies and policies are important steps to reduce the risk of illness in early care and education programs.

COMMENTS

Early care and education programs need to write up and follow a routine schedule of cleaning, sanitizing, and disinfecting. Refer to CFOC Appendix K: Routine Schedule for Cleaning, Sanitizing and Disinfecting.

 For more information on choosing a cleaning, sanitizing, or disinfecting product, please refer to CFOC Appendix J: Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product. Appendix J also has important information about the use of bleach products, how to prepare bleach solutions, and health and safety precautions. Never mix bleach with other household cleaners, especially those that have ammonia.

 The use of products that have safer (less toxic) chemicals helps reduce health and environmental concerns. Manufacturers may claim that their products are “green,” “natural,” or “earth friendly,” but these claims are often misleading and might not be about a chemical’s safety. Organizations now certify and label products that meet certain health and environmental standards. These certifications can help you find less hazardous cleaning, sanitizing, and disinfecting products. CFOC Appendix J has more information on Third Party Certifications logos and these safer (less toxic) chemicals. Safer disinfectant choices can be found at https://www.epa.gov/pesticide-labels/dfe-certified-disinfectants. Using the least hazardous products available will help protect the health of children, and early care and education program staff and custodial personnel.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
Appendix E: Child Care Staff Health Assessment
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020

2. Ibfelt T, Engelund EH, Permin A, Madsen JS, Schultz AC, Andersen LP. Presence of pathogenic bacteria and viruses in the daycare environment. J Environ Health. 2015 Oct;78(3):24-29. PMID: 26591334

3. Gerba CP, Chaidez C. Detection of pathogenic micro-organisms on children’s hands and toys during play. J Appl Microbiol. 2014 Jun;116(6):1668-1675. doi: 10.1111/jam.12473. Epub 2014 Mar 20. PMID: 24524673

4. Bright KR, Boone SA, Gerba CP. Occurrence of bacteria and viruses on elementary classroom surfaces and the potential role of classroom hygiene in the spread of infectious diseases. J Sch Nurs. 2010 Feb;26(1):33-41. doi: 10.1177/1059840509354383. Epub 2009 Nov 10. PMID: 19903773

5. Toronto Public Health. Infection prevention and control in child care centres. Requirements and best practices. Last updated 2019. Accessed November 3, 2022. https://www.toronto.ca/wp-content/uploads/2019/07/98cb-CCC-IPAC-RBP-Revised-2018-2019-AODA.pdf

6. American Academy of Pediatrics. Section 2: Recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:124-125 

NOTES

Content in the STANDARD was modified on 3/20/2023.

3.3.0.5: Cleaning Crib and Other Sleep Surfaces

Cribs, crib mattresses, cots, mats, and other sleep surfaces (e.g., portable cribs, playyard/pen cradleboards) should have a nonporous, easy-to-wipe surface. Crib surfaces and materials should be cleaned weekly using an appropriate cleaning product with a microfiber cloth or disposable paper towel if the same child use the surfaces and materials each day. If different children use the crib surface and materials each day, they must always be cleaned before another child uses them. The crib surface should be cleaned and disinfected if soiled with body fluids. Allow the crib surface to air dry before the next use. Visible dirt and debris should be vacuumed.¹ Always follow the manufacturer’s instructions for cleaning crib surfaces. See the Comments section below for more resources on cleaning schedules and choosing the right cleaning and disinfecting product.

RATIONALE

Infectious diseases spread easily in early care and education programs, since children, staff, and families are all in close contact. Surfaces and objects, including crib surfaces, can carry germs and have spread diseases.^2–4 Developing effective cleaning strategies and policies are important steps to reduce the risk of illness in early care and education programs.

COMMENTS

Early care and education programs need to write up and follow a routine schedule of cleaning, sanitizing, and disinfecting for all sleep surfaces and equipment. Refer to CFOC Appendix K: Routine Schedule for Cleaning, Sanitizing and Disinfecting.

For more information on choosing a cleaning, sanitizing, or disinfecting product, please refer to CFOC Appendix J: Selection and Use of a Cleaning, Sanitizing, or Disinfecting Product. Appendix J also has important information about the use of bleach products, how to prepare bleach solutions, and health and safety precautions. Never mix bleach with other household cleaners, especially those that have ammonia.

The use of products that have safer (less toxic) chemicals helps reduce health and environmental concerns. Manufacturers may claim that their products are “green,” “natural,” or “earth friendly,” but these claims are often misleading and might not be about a chemical’s safety. Organizations now certify and label products that meet certain health and environmental standards. These certifications can help you find less hazardous cleaning, sanitizing, and disinfecting products. CFOC Appendix J has more information on Third Party Certifications logos and these safer (less toxic) chemicals. Safer disinfectant choices can be found at https://www.epa.gov/pesticide-labels/dfe-certified-disinfectants. Using the least hazardous products available will help protect the health of children, and early care and educationprogram staff and custodial personnel.

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.3.0.4 Cleaning Individual Bedding
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

1. Children’s Environmental Health Network. Crib mattress/nap mat hygiene. CEHN.org Web  site. https://cehn.org/download/crib-mattress-nap-mats-hygiene/.Last updated August 18, 2021. Accessed February 1, 2023.

2. Ibfelt T, Engelund EH, Permin A, Madsen JS, Schultz AC, Andersen LP. Presence of pathogenic bacteria and viruses in the daycare environment. J Environ Health. 2015 Oct;78(3):24-29. PMID: 26591334

3. Gerba CP, Chaidez C. Detection of pathogenic micro-organisms on children’s hands and toys during play. J Appl Microbiol.2014 Jun;116(6):1668-1675. doi: 10.1111/jam.12473. Epub 2014 Mar 20. PMID: 24524673

4. Bright KR, Boone SA, Gerba CP. Occurrence of bacteria and viruses on elementary classroom surfaces and the potential role of classroom hygiene in the spread of infectious diseases. J Sch Nurs.2010 Feb;26(1):33-41. doi: 10.1177/1059840509354383. Epub 2009 Nov 10. PMID: 19903773

NOTES

Content in the STANDARD was modified on 3/20/2023.

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

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

RATIONALE

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

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

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

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

COMMENTS

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

As more states move toward legalizing marijuana use for recreational and/or medicinal purposes, it is important for caregivers/teachers to be aware of the impact marijuana used medicinally and/or recreationally has on their ability to provide safe care. Staff modeling of healthy and safe behavior at all times is essential to the care and education of young children. 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

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

NOTES

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

3.4.2.1: Animals that Might Have Contact with Children and Adults

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

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

Fish are permissible but must be inaccessible to children.

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

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals

REFERENCES

1. Gilchrist, J., J. J. Sacks, D. White, M. J. Kresnow. 2008. Dog bites: Still a problem? Injury Prevention 14:296-301.
2. Reisner, I. R., F. S. Shofer. 2008. Effects of gender and parental status on knowledge and attitudes of dog owners regarding dog aggression toward children. J Am Vet Med Assoc 233:1412-19.
3. Information from Your Family Doctor. 2004. Dog bites: Teaching your child to be safe. Am Family Physician 69:2653.
4. Bernardo, L. M., M. J. Gardner, R. L. Rosenfield, B. Cohen, R. Pitetti. 2002. A comparison of dog bite injuries in younger and older children treated in a pediatric emergency department. Pediatric Emergency Care 18:247-49.
5. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13.
6. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.
7. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2000. Compendium of measures to control Chlamydia psittaci infection among humans (psittacosis) and pet birds (avian chlamydiosis). MMWR 49:3-17.
8. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Pregnant women and Toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm.
9. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
   ab1007.pdf.
10. Massachusetts Department of Public Health Division of Epidemiology and Immunization. 2001. Recommendations for petting zoos, petting farms, animal fairs, and other events and exhibits where contact between animals and people is permitted. http://www.mass.gov/Eeohhs2/docs/dph/cdc/rabies/reduce_zoos
    _risk.pdf.
11. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to nontraditional pets at home and to animals in public settings: risks to children. Pediatrics 122:876-86.
12. Centers for Disease Control and Prevention. 2010. Lymphocytic choriomeningitis (LCMV). http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/lcmv.htm.
13. Hemsworth, S., B. Pizer. 2006. Pet ownership in immunocompromised children – A review of the literature and survey of existing guidelines. Eur J Oncol Nurs 10:117-27.

3.4.2.2: Prohibited Animals

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

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

RATIONALE

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.3 Care for Animals

REFERENCES

1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections transmitted from animals. Infect Dis Clin North Am 5:649-61.
2. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13.
3. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
   ab1007.pdf.
4. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.
5. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to nontraditional pets at home and to animals in public settings: risks to children. Pediatrics 122:876-86.
6. PETCO Animal Supplies. 2006. Hermit crab: Care sheet. http://www.petco.com/caresheets/invertebrates/HermitCrab.pdf.
7. Kahn, C. M., S. Line, eds. 2010. The Merck veterinary manual. 10th ed. Whitehouse Station, NJ: Merck.

3.4.2.3: Care for Animals

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

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

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

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

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

Live animals should be prohibited from:

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

COMMENTS

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.2 Prohibited Animals

REFERENCES

1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections transmitted from animals. Infect Dis Clin North Am 5:649-61.
2. National Association of State Public Health Veterinarians. 2007. Compendium of measures to prevent disease associated with animals in public settings. MMWR 56:1-13.
3. Centers for Disease Control and Prevention (CDC). Pregnant women and toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm.
4. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. http://www.kdheks.gov/pdf/hef/
   ab1007.pdf.
5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009. Appendix D: Guidelines for animals in school and child-care settings. MMWR 58:20-21.
6. American Veterinary Medical Association. Animal welfare principles. https://www.avma.org/public/animalwelfare/pages/default.aspx.

3.4.3.1: Medical Emergency Procedures

All medical emergency procedures should take into account the specific needs of children enrolled, including such factors as age, abilities, special health care needs, and special developmental needs.¹

 

In the event of an emergency, the following emergency procedures should be carried out:

1. First aid should begin, and contact should be made with an emergency medical response team, such as 911 and/or Poison Control (1-800-222-1222).
2. Plans to transport the ill or injured person(s) to a local emergency medical facility should be followed.
3. The parent/guardian or emergency contact person should be contacted immediately.
4. A staff member should accompany the child or adult to the hospital and stay with the individual until the parent/guardian or emergency contact person arrives. Child to staff ratio should be maintained, additional staff may be needed to maintain the required ratio.
5. Debriefing should occur after an incident or emergency. Staff should discuss procedures, how well they were followed, and any changes that may need to be made.

Children with known medical conditions that might involve emergent care require a care plan created with the child’s primary health care provider in collaboration with the child’s parents/guardians. All staff need to be trained to manage an emergency until emergency medical care becomes available. Staff training in carrying out emergency medical procedures and plans, as well as providing first aid, should be conducted, at a minimum, annually.

The written medical emergency procedures and policies should be reviewed and practiced regularly, as well as immediately following an emergency, if changes are made to the facility or equipment, or if the needs of the children change.^1,2

RATIONALE

When staff know how to carry out the emergency medical procedures and plans, they will be able to prevent or minimize serious injury of children enrolled in early care and education programs.

COMMENTS

Additional Resources

First aid training is available from:

The American Academy of Pediatrics - http://www.pedfactsonline.com/

The American Red Cross - https://www.redcross.org/take-a-class/first-aid/first-aid-training

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.5.0.1 Care Plan for Children with Special Health Care Needs
3.6.2.9 Information Required for Children Who Are Ill

REFERENCES

1. American Academy of Pediatrics, National Association of School Nurses. PedFACTs: Pediatric First Aid for Caregivers and Teachers. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2012

2. National Center on Early Childhood Health and Wellness, US Department of Health and Human Services Administration for Children and Families Office of Head Start. Emergency Preparedness Manual for Early Childhood Programs. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/emergency-preparedness-manual-early-childhood-programs.pdf. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 5/17/19.

3.4.3.2: Use of Fire Extinguishers

Staff should demonstrate the ability to locate and operate fire extinguishers. Facilities should develop a fire emergency action plan for responding in the event of a fire in or near the facility that includes staff responsibilities and protocols for evacuation, notifying emergency personnel, and using fire extinguishers. Staff should be trained that the first priority is to remove the children from the facility safely and quickly. Putting out the fire is secondary to the safe exit of children and staff.

Caregivers/teachers within early care and education programs should have access to and be trained on the use of a fire extinguisher.

Discharge the extinguisher within its effective range using the PASS technique (pull, aim, squeeze, and sweep).¹ Most fire extinguishers operate using this technique.

• Pull the pin; this will break the seal.
• Aim low, pointing the fire extinguisher nozzle at the base of the fire.
• Squeeze the handle to release the extinguisher agent.
• Sweep from side to side at the base of the fire until it appears to be out.

Refer to Standard 5.2.5.2: Portable Fire Extinguishers for information on installation, inspection, maintenance, and record-keeping requirements.

RATIONALE

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.3.3 Response to Fire and Burns

REFERENCES

1. US Fire Administration. Choosing and using fire extinguishers. https://www.usfa.fema.gov/prevention/outreach/extinguishers.html. Reviewed December 12, 2017. Accessed August 21, 2019

NOTES

Content in the STANDARD was modified on 2/27/2020.

3.4.3.3: Response to Fire and Burns

Caregivers/teachers should participate in fire drills, at least annually, to practice and carry out the fire emergency action plan in the event of an actual fire. Staff should be trained that the first priority is to remove the children from the facility safely and quickly. Putting out the fire is secondary to the safe exit of children and staff.

 

Fire Emergency Action Plan

Early care and education programs should educate and train staff on the use of a fire extinguisher and develop a fire emergency action plan for responding in the event of a fire in or near the facility. Fire extinguishers are one component of a fire emergency action plan, but the primary outcome is a safe escape.¹ The fire emergency action plan and staff training should include the following action items, and staff should work together to evacuate children to safety and extinguish the fire, if possible. All efforts in the fire emergency action plan can take place simultaneously².

 

Plan	Action Items
Determine what is a fire emergency.	Declare the emergency, alert staff, pull fire alarm (if available), and call 9-1-1. When calling 9-1-1 remember3 If you do call 9-1-1, even by mistake, do not hang up the phone. Do your best to stay calm and answer all questions. Know the location of the emergency.
Identify a safe evacuation plan for all children and staff.	Evacuate children and staff. Children who can walk hold walking rope and follow teacher to evacuation site. Infants/toddlers and children with special health care needs are evacuated in evacuation cribs. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Take first aid kit and provide first aid and medications as needed.    Take a roster of all children present, and calm children. Scan and count to make sure all children are accounted for.    Have contact information and list of approved family/guardians authorized for pickup.
Select appropriate fire extinguisher.	Discharge the extinguisher within its effective range using the PASS technique (pull, aim, squeeze, and sweep). Most fire extinguishers operate using this technique.1 Pull the pin; this will break the seal. Aim low, pointing the fire extinguisher nozzle at the base of the fire. Squeeze the handle to release the extinguisher agent. Sweep from side to side at the base of the fire until it appears to be out.
Identify communication plan.	Communicate necessary information to parents/guardians. Communicate all clear to staff, children, and parents/guardians.

Staff should be taught and demonstrate the ability to recognize a fire too large to be fought with a portable fire extinguisher. Early care and education staff should remember to back away from an extinguished fire should it reignite and not reenter the building unless approved by the fire department.

 

Remembering and implementing all action items in the fire emergency action plan can be challenging; following the RACE acronym can help.

• Rescue: Evacuate all children, staff, and visitors.
• Alarm: Fire alarm should be pulled and local emergency services notified.
• Contain: Close doors and windows to contain the fire.
• Extinguish: Determine the location, size, and nature of the fire and attempt to extinguish it.

Children who are developmentally able should be instructed to stop, drop, and roll when garments catch fire.⁴

• Stop! Do not run.
• Drop! Drop to the ground right where you are.
• Roll! Roll repeatedly to put out the flames. Cover your face with your hands.

Children should be instructed to crawl on the floor under the smoke if necessary when they evacuate the building. This instruction is part of ongoing health and safety education and fire drills/exercise.

Should a child or staff member experience a burn, apply the cool/call method.

• Cool the burned area with water.
• Call for help.

Cool water should be applied to burns immediately. Ice should not be applied to skin, because of the potential for frostbite. The injury should be covered with a loose bandage or clean, dry cloth. Medical assessment/care should be immediate.

RATIONALE

Training all staff members and developing a fire emergency action plan can increase preparedness and help staff better understand what to do in the event of a fire. Caregivers/teachers that are trained and who participate in annual fire drills are better equipped to carry out the fire emergency action plan in the event of an actual fire.⁴

 

Injuries from inhaled debris, smoke, and toxins and excessive exposure to carbon monoxide, when paired with increased air temperatures during a fire, can post a risk to health; especially in young children.⁵

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.3.2 Use of Fire Extinguishers

REFERENCES

1. National Fire Protection Association. Fire extinguishers one element of fire response plan for students on college campuses. https://community.nfpa.org/community/safety-source/blog/2014/10/29/fire-extinguishers-one-element-of-fire-response-plan-for-students-on-college-campuses. Updated April 21, 2016. Accessed August 21, 2019

2. National Center on Early Childhood Health and Wellness, US Department of Health and Human Services Administration for Children and Families Office of Head Start. Emergency Preparedness Manual for Early Childhood Programs. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/emergency-preparedness-manual-early-childhood-programs.pdf. Accessed December 20, 2018

3. National Emergency Number Association. 9-1-1 tips & guidelines. https://www.nena.org/page/911tipsguidelines. Accessed August 21, 2019

4. American Academy of Pediatrics. Fire safety. HealthyChildren.org website. https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Fire-Safety.aspx. Updated February 29, 2012. Accessed August 21, 2019

5. Sheridan RL. Fire-related inhalation injury. N Engl J Med. 2016;375(19):1905

NOTES

Content in the STANDARD was modified on 02/27/2020.

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

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

The facility should report any instance in which there is reasonable cause to believe that child abuse and/or neglect has occurred to the child abuse reporting hotline, department of social services, child protective services, or police as required by state and local laws. Every staff member should be oriented to what and how to report. Phone numbers and reporting system, as required by state or local agencies, should be clearly posted in a location accessible to caregivers/teachers.

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

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

RATIONALE

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

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

COMMENTS

Child abuse includes physical, sexual, psychological, and emotional abuse. Other components of abuse include shaken baby syndrome/acute head trauma and repeated exposure to violence, including domestic violence. Neglect occurs when the parent/guardian/caregiver does not meet the child’s basic needs and includes physical, medical, educational, and emotional neglect (4). Caregivers/teachers and health professionals may contact individual state hotlines where available. While almost all states have hotlines, they may not operate 24 hours a day, and some toll-free numbers may only be accessible within that particular state. Childhelp provides a national hotline: 1-800-4-A-CHILD (800/422-4453).

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

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

For more information about specific state laws on mandated reporting, go to the Child Welfare Information Gateway Mandated Reporting Web site, https://www.childwelfare.gov/topics/responding/reporting/mandated.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect

REFERENCES

1. Rheingold AA, Zajac K, Chapman JE, et al. Child sexual abuse prevention training for childcare professionals: an independent multi-site randomized controlled trial of Stewards of Children. Prev Sci. 2015;16(3):374–385

2. Smith M, Robinson L, Segal J. Child abuse and neglect: how to spot the signs and make a difference. Helpguide.org Web site. https://www.helpguide.org/articles/abuse/child-abuse-and-neglect.htm. Updated October 2017. Accessed January 11, 2018

3. Darkness to Light. Reporting child sexual abuse. https://www.d2l.org/get-help/reporting. Accessed January 11, 2018

4. Child Welfare Information Gateway. What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms. Washington, DC: Child Welfare Information Gateway; 2013. https://www.childwelfare.gov/pubpdfs/whatiscan.pdf. Accessed January 11, 2018
   
   

NOTES

Content in the STANDARD was modified on 05/29/2018.

3.4.4.2: Immunity for Reporters of Child Abuse and Neglect

Caregivers/teachers who in good faith report suspected abuse and neglect should be protected from discharge, retaliation, or other disciplinary action. Immunity from civil or criminal liability should not be provided in those instances when the person making a report acted with malice or in “bad faith” or knowingly made a false report (1).

RATIONALE

Under the Child Abuse Prevention and Treatment Act, states are required to provide some form of immunity from liability for persons reporting suspected instances of child abuse or neglect. The term good faith encompasses an individual with a sincere belief and motives outside of malice or with intentions to defraud others (2). The reporter, to the best of his or her knowledge, has reason to believe that the child in question is being subjected to abuse or neglect (1). Unfortunately, many professionals, including caregivers/teachers, do not always report suspicions of child abuse and neglect, leading to underreporting of child abuse (3). These legislative acts are an effort to eliminate fears of repercussions in reporting suspected child abuse/neglect.

 

COMMENTS

To access the statutes for a specific state or territory, visit the State Statutes Search at https://www.childwelfare.gov/topics/systemwide/laws-policies/state/

 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect

REFERENCES

1. Child Welfare Information Gateway. Immunity for Reporters of Child Abuse and Neglect. Washington, DC: US Department of Health and Human Services, Children’s Bureau; 2016. https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/immunity. Accessed June 26, 2018

2. Brashler R, Finestone HM, Nevison C, et al. Time to make a call? The ethics of mandatory reporting. PM R. 2016;8(1):69–74

3. Walsh WA, Jones LM. Factors that Influence Child Abuse Reporting: A Survey of Child-Serving Professionals. Durham, NH: Crimes Against Children Research Center, University of New Hampshire; 2015

NOTES

Content in the STANDARD was modified on 8/28/2018

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

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

RATIONALE

Shaken baby syndrome/abusive head trauma is the occurrence of brain injury in newborns, infants, and children younger than 3 years caused by shaking a child. Even mild shaking can result in serious, permanent brain damage or death. The brain of the young child may bounce inside of the skull, resulting in brain damage, hemorrhaging, blindness, or other serious injuries or death. There have been several reported incidents in child care (1). 

Caregivers/teachers care for young children who may be fussy or constantly crying. It is important for caregivers/teachers to be educated about the risks of shaking and provided with strategies to cope if they are frustrated (2).  Many states have passed legislation requiring education and training for caregivers/teachers. Caregivers/teachers should check their individual state’s specific requirements (3). Staff should be knowledgeable about and be able to recognize the signs and symptoms of shaken baby syndrome/abusive head trauma in children in their care.

COMMENTS

Victims of shaken baby syndrome/abusive head trauma may exhibit one or more of the following symptoms (4):

1. Irritability
2. Trouble staying awake
3. Trouble breathing
4. Vomiting
5. Unable to be woken up

 

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

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

REFERENCES

1. Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: characteristic features, diagnosis, and management. Neurol Med Chir (Tokyo). 2017;57(2):82–93

2. Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical-Package.pdf. Accessed January 11, 2018

3. Child Care Aware. Health and safety training. http://childcareaware.org/providers/training-essentials/health-and-safety-training. Accessed January 11, 2018

4. American Academy of Pediatrics. Abusive head trauma: how to protect your baby. HeathyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Abusive-Head-Trauma-Shaken-Baby-Syndrome.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 05/30/2018.

3.4.4.4: Care for Children Who Have Experienced Abuse/Neglect

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

RATIONALE

All children who have experienced abuse or neglect have had their physical and emotional boundaries violated. With this violation often comes a breach of the child’s sense of security and trust. Children who have experienced abuse and neglect may come to believe that the world is not a safe place and that adults are not trustworthy. These children may have more emotional needs and may require more individual staff time and attention than children who have not experienced maltreatment.

Children who have experienced abuse or neglect may display varying levels of developmental delay, physical symptoms, or behavioral concerns such as avoidant or anxious behavior, fearfulness, sadness/depression, or impulsive, oppositional, aggressive, and sexualized behavior (1).

These problems may persist long after the maltreatment occurred and may have significant psychiatric and medical consequences into adulthood. In particular, children who have experienced abuse or neglect or have been exposed to violence, including domestic violence, often have excessive responses to environmental stress. Caregivers/teachers are better equipped in responding to a child’s behavior when provided with training and information about the dynamics of abuse, mental health consultation to explore trauma-informed strategies to support and keep the child safe, and data on long-term outcomes of child maltreatment (2). Child care staff may need to work closely with the child’s primary health care provider, therapist, social worker, and parents/guardians to formulate a more personalized behavior management plan.

COMMENTS

Centers serving children with a history of maltreatment-related behavior problems may require staff trained in trauma-informed practices and/or assistance from a child care mental health consultant. Care may be facilitated by having an intentional, written behavioral care plan. Resources on caring for a child who has experienced abuse or neglect are available from the following agencies:

• American Academy of Pediatrics. Managing Chronic Health Needs in Child Care and Schools: A Quick Reference Guide. Donoghue EA, Kraft CA, eds. 2nd ed. Itasca, IL: American Academy of Pediatrics; 2019
• Child Welfare Information Gateway. Trauma-informed practice. https://www.childwelfare.gov/topics/responding/trauma. Accessed June 26, 2018
• National Children’s Advocacy Center (www.nationalcac.org)
• Office of Juvenile Justice and Delinquency Prevention, Safe Start. Trauma-informed care for children exposed to violence: tips for teachers. https://www.justice.gov/sites/default/files/defendingchildhood/legacy/2011/09/19/tips-teachers.pdf. Accessed June 26, 2018
• Office of Head Start, Early Childhood Learning & Knowledge Center. Infant and early childhood mental health consultation and your program. https://eclkc.ohs.acf.hhs.gov/mental-health/article/infant-early-childhood-mental-health-consultation-your-program. Updated June 11, 2018. Accessed June 26, 2018

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Center for Early Childhood Mental Health Consultation, Georgetown University Center for Child and Human Development. Trauma signs and symptoms. https://www.ecmhc.org/tutorials/trauma/mod3_1.html. Accessed June 26, 2018

2. Van Toledo A, Seymour F. Caregiver needs following disclosure of child sexual abuse. J Child Sex Abus. 2016;25(4):403–414. http://www.tandfonline.com/doi/full/10.1080/10538712.2016.1156206. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 08/28/2018

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

All caregivers/teachers have a responsibility to supervise children at all times. The physical layout of child care facilities should be arranged to allow for a high level of visibility in all areas used by children, including diaper changing stations and toileting areas, while upholding children’s right to privacy. All areas should be within view by at least 1 adult in addition to the primary caregiver/teacher at all times.

For center-based programs, rooms should be designed so that there are windows to the hallways to keep classroom activities visible, or it should be ensured that inside doors to activity areas remain open during hours of operation. Home-based programs should ensure that activities are conducted in 1 or 2 primary rooms that are dedicated to child care programming. These arrangements reduce the risk of child abuse and neglect and the likelihood of extended periods in isolation for individual caregivers/teachers with children, especially in areas where children may be partially undressed or in the nude. For small family child care home caregivers/teachers, a plan should be intentionally made for how to ensure the most active supervision possible.

Caregivers/teachers should be educated and trained in child abuse prevention and remain aware of potential risks of abuse and neglect of a child when in care. Other facility staff should periodically walk into child care rooms to monitor/prevent potential instances of child abuse and neglect. Family home caregivers/teachers should not allow other adults in the household to be alone with children at any time.

 

 

RATIONALE

Despite the fact that most child abuse and neglect occur inside the home, children may also experience abuse by caregivers/teachers while in out-of-home care (1). While upholding a child’s right to privacy, centers can take action to prevent child abuse and neglect from occurring. For instance, the presence of multiple caregivers greatly reduces the risk of serious abusive injury. Child maltreatment tends to occur in privacy and isolation, especially in toileting areas and during diaper changing (2).

COMMENTS

Small family child care homes will need to be creative to ensure active supervision at all times, even when the children are toileting. This may include group potty time for toddlers or creating a very small play area in the hall outside the bathroom to which all the small children can be moved when each one in is the bathroom.

Additional information on preventing child abuse in out-of-home care can be found at:

• United States Department of Agriculture, National Institute of Food and Agriculture. Cooperative Extension. What child care providers need to know about preventing abuse and neglect. http://articles.extension.org/pages/25590/what-child-care-providers-need-to-know-about-preventing-abuse-and-neglect. Published September 4, 2015. Accessed June 26, 2018
• Karageorge K, Kendall R. The Role of Professional Child Care Providers in Preventing and Responding to Child Abuse and Neglect. Washington, DC: US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families Children’s Bureau, Office on Child Abuse and Neglect; 2008. https://www.childwelfare.gov/pubPDFs/childcare.pdf. Accessed June 26, 2018
• Office of Head Start, Early Childhood Learning & Knowledge Center. Active supervision toolkit. https://eclkc.ohs.acf.hhs.gov/publication/active-supervision-toolkit. Updated January 12, 2018. Accessed June 26, 2018
• Virtual Lab School. Child abuse prevention, identification, and reporting. https://www.virtuallabschool.org/preschool/safe-environments/lesson-7?module=426. Accessed June 26, 2018

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
3.2.2.1 Situations that Require Hand Hygiene

REFERENCES

1. American Academy of Pediatrics. Child abuse and neglect. HealthyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/What-to-Know-about-Child-Abuse.aspx. Updated April 13, 2018. Accessed June 26, 2018

2. United States Department of Agriculture, National Institute of Food and Agriculture. Cooperative Extension. Creating safe and appropriate diapering, toileting, and hand washing areas in child care. http://articles.extension.org/pages/63292/creating-safe-and-appropriate-diapering-toileting-and-hand-washing-areas-in-child-care. Published October 2, 2015. Accessed June 26, 2018

NOTES

Content in the STANDARD was modified on 08/28/2018

3.4.5.1: Sun Safety Including Sunscreen

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

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

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

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

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

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

RATIONALE

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

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

COMMENTS

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

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.3.1 Medication Administration

REFERENCES

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

NOTES

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

3.4.5.2: Insect Repellent and Protection from Vector-Borne Diseases

Most insects do not carry human disease and most insect bites only cause mild irritation. Insect repellents may be used with children older than 2 months in child care where there are specific disease outbreaks and alerts. As with all pesticides, care should be taken to limit children’s exposure to insect repellents (1). Caregivers/teachers should consult with a child care health consultant, the primary care provider, or the local health department about the appropriate use of repellents based on the likelihood that local insects are carrying potentially dangerous diseases (e.g., local cases of meningitis from mosquito bites). This information should be shared with parents/guardians, and collective decisions made about use.
Insect repellent requires the written permission of parents/guardians and label instructions must be followed. It does not require written permission from a primary care provider.

Repellents containing DEET
Repellents with 10%-30% DEET offer the broadest protection against mosquitoes, ticks, flies, chiggers, and fleas. Caregivers/teachers should read product labels and confirm that the product is 1) safe for children and 2) contains no more than 30% DEET. Most product labels for registrations containing DEET recommend consultation with a physician if applying to a child less than six months of age.
The use of DEET should reflect how much time the child will be exposed to biting insects (2):

• 10% DEET is generally effective for two hours.
• 24% DEET is generally effective for five hours.
• Products with more than 30% DEET should never be used on children.
• Do not use products that combine insect repellent and sunscreen. This is because sunscreen may need to be re-applied more often and in larger amounts than repellent.
• If sunscreen is also used, apply sunscreen FIRST. DEET may decrease the SPF of sunscreens by one-third. Sunscreens may increase absorption of DEET through the skin).

Other Types of Insect Repellents
Picaridin and IR3535 are other products registered at the Environmental Protection Agency (EPA) identified as providing repellent activity sufficient to help people avoid the bites of disease carrying mosquitoes (4). Para-menthane-diol (PMD) or pil of lemon eucalyptus products, according to their product labels, should NOT be used on children under three years of age (4,5).

General Guidelines for Use of Insect Repellents with Children
As noted above, insect repellents may be applied to children older than two months. In addition to consulting label instructions, teachers/caregivers may follow these guidelines: Protection from ticks
In places where ticks are likely to be found (6), caregivers/teachers should take the following steps to protect children in their care from ticks:
 
How to Remove a Tick (8):
It is important to remove the tick as soon as possible. Use the following steps:
Take care not to do the following:

RATIONALE

Mosquitoes and ticks can carry pathogens that may cause serious diseases (i.e., vector-borne diseases such as West Nile virus and Lyme disease) (7).
Zika is a mosquito-borne virus that usually causes mild illness that lasts from several days to a week. The mosquito that spreads Zika virus is found everywhere in the world including the United States. Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects (9). Information and recommendations regarding Zika are rapidly evolving. Please visit the Centers for Disease Control and Prevention (CDC) Zika updates page for the most recent information: http://www.cdc.gov/zika/index.html (9). 

COMMENTS

Insect repellents should be EPA-registered and labeled as approved for use in the child’s age range.
Aerosol sprays are not recommended. Pump sprays are a better choice. Regardless of the type of spray used, caregivers/teachers should spray the insect repellent into her/his hand and then apply to the child. It is not recommended to directly spray the child with the insect repellent to prevent unintentional injury to eyes and mouth. Preschool children, toddlers, and infants should not apply insect repellent to themselves. School age children can apply insect repellent to themselves if they are supervised to make sure that they are applying it correctly.
Parents/guardians should be notified when insect repellent is applied to their child since it is recommended that treated skin is washed with soap and water.
If a product gets in the eyes, flush with water and consult the poison center at 1-800-222-1222.
Several resources are available on reducing exposure to ticks and mosquitoes based on habits, protective attire, and insect repellent use. The following resources offer detailed information on preventing exposure to ticks and mosquitoes in early care and education settings:

• Preventing Tick Bites on People by the Centers for Disease Control and Prevention at http://www.cdc.gov/lyme/prev/on_people.html.
• UCSF California Childcare Health Program’s (CCHP) Health and Safety Note for child care centers:

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.4.5.1 Sun Safety Including Sunscreen

REFERENCES

1. National Pesticide Information Center. 2015. Pesticides and children. http://npic.orst.edu/health/child.html. 
   
2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
   
3. Center for Disease Control and Prevention. 2015. Chapter 2 - Protection against mosquitos, ticks, & other anthropods. https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/sun-exposure. 
   
4. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2015. West nile virus: Insect repellent use and safety. http://www.cdc.gov/westnile/faq/repellent.html.
   
5. Centers for Disease Control and Prevention. 2016. Avoid bug bites. https://wwwnc.cdc.gov/travel/page/avoid-bug-bites. 
   
6. Centers for Disease Control and Prevention. 2015. Geographic distribution of ticks that bite humans. https://www.cdc.gov/ticks/geographic_distribution.html. 
   
7. Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases. 2010. Lyme disease: Protect yourself from tick bites.http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ld_Prevention_Avoid.htm.
   
8. Centers for Disease Control and Prevention. 2015. Tick removal. https://www.cdc.gov/ticks/removing_a_tick.html. 
   
9. Centers for Disease Control and Prevention. 2016. About zika. https://www.cdc.gov/zika/about/index.html. 
   
10. ADDITIONAL REFERENCE:
    
    U.S. Environmental Protection Agency. 2016. Find the insect repellent that is right for you. https://www.epa.gov/insect-repellents/find-insect-repellent-right-you.
     
    

NOTES

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

3.4.6.1: Strangulation Hazards

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

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

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

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

RATIONALE

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

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

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

3.5.0.1: Care Plan for Children with Special Health Care Needs

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

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

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

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

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

RATIONALE

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

COMMENTS

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

1. McPherson, M., P. Arango, H. Fox, C. Lauver, M. McManus, P. Newacheck, J. Perrin, J. Shonkoff, B. Strickland. 1998. A new definition of children with special health care needs. Pediatrics 102:137-40.
2. U.S. Department of Health and Human Services, Health Resources and Services Administration. The national survey of children with special health care needs: Chartbook 2005-2006. http://mchb.hrsa.gov/cshcn05/.
3. American Association of Nurse Anesthetists. 2003. Creating a latex-safe school for latex-sensitive children. http://www
   .anesthesiapatientsafety.com/patients/latex/school.asp.
4. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.

3.5.0.2: Caring for Children Who Require Medical Procedures

Any child enrolled in an early care and education program who requires dietary, activity, environmental, or behavioral modifications or medication regularly or for emergencies should receive a written care plan from his or her primary health care provider or pediatric specialist. This is especially important for children with special health care needs who need procedures while in early care and education programs. Medical procedures requiring a written care plan can include, but are not limited to, instructions about¹

• Blood sugar regulations
• Postural drainage
• Supplemental oxygen
• Endotracheal suctioning
• Catheterization (unless the child requiring catheterization can perform this function on his or her own)
• Medication administration to control seizure activity
• Tube feedings
• Special medical procedures performed routinely or on an urgent basis

 

Early care and education staff should consider how the procedure aligns with the child’s daily schedule.

 

The child’s primary care provider, medical home (eg, pediatricians and other specialists), or pediatric specialist should provide all medical information, while parents/guardians are responsible for supplying the required equipment necessary to accommodate the child’s needs. This care plan should address any special preparation to perform routine and/or urgent procedures (other than those that might be required in an emergency for any typical child, such as cardiopulmonary resuscitation). This care plan should also include instructions for performing the procedure, a description of common and uncommon complications of the procedure, and what to do and who to notify if complications occur.

 

Caregivers/teachers should not assume care for a child with special health care needs who requires a procedure unless they are comfortable with training they have received and approved for that role by the child care health consultant or consulting primary care provider. Appropriate and sufficient training, consultation, and monitoring of early care and education staff should be provided by a qualified health care professional in accordance with all state practice acts and local, state, and other applicable laws. Facilities should follow state laws where such laws require registered nurses, or licensed practical nurses under supervision of a registered nurse, to perform certain medical procedures. Updated, written medical orders are required for these procedures.

 

If possible, parents/guardians should be present and take part in any training required for accommodating needs of their child in the early care and education program. Parents/guardians know their child best and should be encouraged to establish a relationship with their child’s caregivers/teachers and communicate information about the child’s tolerance of the procedures, normal reactions, and complications/issues they have encountered.

Communication among parents/guardians, the early care and education program, and the primary care provider (medical home) requires the free exchange of protected medical information.^1(p30–31) Confidentiality should be maintained at each step in compliance with any laws or regulations that are pertinent to all parties, such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Insurance Portability and Accountability Act (commonly known as HIPAA).^1(p23–24)

RATIONALE

Special health care needs that require specialized procedures are common among children, with their specific needs varying with age, abilities, and increasing independence.^1(p3) Children with special health care needs, and their families, require assistance to maintain health, well-being, and quality of life while in out-of-home care. Another goal of implementing these special health care procedures is to maximize the inclusion of children in all program- or school-related activities.

 

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.5.0.1 Care Plan for Children with Special Health Care Needs
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

1. American Academy of Pediatrics. Managing Chronic Health Needs in Child Care and Schools. Donoghue EA, Kraft CA, eds. 2nd ed. Itasca, IL: American Academy of Pediatrics; 2019

NOTES

Content in the STANDARD was modified on 02/27/2020.

3.6.1.1: Inclusion/Exclusion/Dismissal of Ill Children

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

 

Adapted from American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.

Children in early care and education programs can often become ill. Most illnesses are mild and do not require dismissal or temporary exclusion from programs. But some infectious diseases do require temporary exclusion to control the spread of illness in the program.

Staff should work with a child care health consultant, local public health authority, or other licensed health expert to:

• Develop policies and procedures for dismissal, temporary exclusion, and when to return to the program
• Tell staff and families they are responsible for promptly reporting illness when their child has symptoms
• Watch for and manage illnesses in the program
• Understand when to report infectious illnesses to local public health authorities

Programs should prepare to manage illnesses by:¹

• Working with a child care health consultant to develop procedures for handling illnesses, including care plans for ill children and an inclusion and exclusion policy
• Regularly reviewing the illness policy with staff and families; making it clear that the staff (not the families) will make the final decision about whether ill children may attend. The staff will decide based on the program’s illness guidelines, and their ability to care for the ill child¾while not taking away from the care of other children.
• Encouraging families to have a backup plan for child care when their child cannot attend the program.
• Doing daily health checks (see Standard 3.1.1.1) when children arrive and periodically through the day.
• Discussing the child’s behavior with the family to decide if the child can take part in the program, and if excluded, when the child is well enough to return.

When children are ill, staff should:

• Decide which children with mild illnesses can stay. For children whose symptoms do not need exclusion, verbal or written communication with the parent or guardian at the end of the day is fine.
• Tell parent or guardian when a child has new signs of illness. Contact the parent or guardian immediately for emergencies or urgent issues.
• Tell parents or guardians of children immediately if their child has symptoms that need temporary exclusion, so that they pick up their child as soon as possible.
• Only ask for a healthcare provider’s note to return to the program if their advice is needed to decide:
• If the child is a possible health risk to others
• Or if the program needs more information about special care the child needs

Conditions That Do Not Require Exclusion1–2
Conditions	Notes
Common cold, runny nose, and cough	No exclusion regardless of color or consistency of nasal discharge. For allergies that have similar symptoms to a common cold (e.g., runny nose, sneezing, cough), programs can encourage parents or guardians to get documentation from a healthcare provider to avoid unnecessary exclusions. During outbreaks such as COVID-19, follow recommendations from the Centers for Disease Control and Prevention (CDC) or the local health department.
Cytomegalovirus infection (CMV)	No exclusion required.
Diarrhea	No exclusion if stool is contained in the diaper, there are no toileting accidents, and there are no more than 2 stools per day above the normal for that child.
Eye drainage	No exclusion unless the child has watery discharge that is yellow or white; without fever, eye pain, or eyelid redness.
Fever	Temperature above 100.4° F (38° C) (axillary, temporal, or oral) is a fever. Children over 4 months old without signs of illness do not need to be excluded. Only take a child’s temperature if the child seems ill. (During outbreaks such as COVID-19, follow CDC or local health department recommendations.)
Fifth’s Disease (Parvovirus B19 or slapped cheek disease)	No exclusion for children who have normal immune systems and who don’t have an underlying blood disorder like sickle cell disease.
Hand, foot, and mouth (Coxsackie virus)	No exclusion unless the child has a fever with symptoms, mouth sores, and constant drooling, or if recommended by public health authorities to control an outbreak.3
Hepatitis B virus, chronic	No exclusion required.
HIV infection	No exclusion required.
Impetigo	Cover skin lesions until the end of the day if there is no fever or changes in behavior. If medical treatment starts before returning the next day, no exclusion is needed.
Lice or nits	Treatment may start at the end of the day. If treatment starts before returning the next day, no exclusion needed. “No-nit” policies are not effective in controlling spread of lice and are not recommended.2
Methicillin-resistant (MRSA) and methicillin-sensitive (MSSA) colonization	Colonization is the presence of bacteria on the body without illness. Active lesions or illness may require exclusion.
Molluscum contagiosum	No exclusion or covering of lesions is needed.
Pinkeye	No exclusion needed if pink or red on the white of the eye with or without drainage, without fever or behavioral change.2
Rash without fever or behavior changes	No exclusion necessary. Exception: Call EMS (911) for children who have a new rash with rapidly spreading bruising or small blood spots under the skin.
Ringworm	Cover skin lesions until the end of the day. If medical treatment starts before returning the next day, no exclusion is needed.
Roseola	No exclusion needed unless there is a fever and behavior changes.
Scabies	Treatment may be delayed until the end of the day. As long as treatment starts before returning the next day, no exclusion is needed.
Thrush	No exclusion needed. (The signs of thrush are white spots or patches in the mouth, cheeks, or gums.)

Conditions That Require Temporary Exclusion

Specific Conditions Requiring Temporary Exclusion1-2
Conditions	Notes
Abdominal pain	Exclude with persistent or intermittent pain with fever, dehydration, or other signs or symptoms.
Chickenpox	Exclude until all lesions have dried or crusted (usually 6 days after the start of the rash) and no new lesions have appeared for 24 hours.
COVID-19	Exclude according to current CDC guidelines.
Diarrhea	Exclusion is needed for: Diapered children whose stool is not contained in the diaper Toilet-trained children when diarrhea causes “accidents” or when increased number of bowel movements are a risk for accidents and soiling of toileting areas Children who have more than 2 stools per day above normal for that child while the child is in the program Children whose stool contains blood or mucus Children may return when the stool is contained in the diaper, or when toilet-trained children no longer have accidents or when they have no more than 2 stools above what is usual for the child. For some infectious diarrheal illnesses, exclusion is needed until additional guidelines have been met and programs communicate  with healthcare providers and health departments. Children who have germs in their stool but no symptoms do not need to be excluded, except when infected with Shiga toxin-producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi.
Fever	Exclude with behavior change or other symptoms. A temperature of 100.4° F (38° C) or above (from any site) in infants and children with behavior change. For infants younger than 2 months, a temperature of 100.4° F from any site) or above with or without a behavior change or other symptoms (e.g., sore throat, rash, vomiting, diarrhea) needs exclusion and immediate medical attention. (See Standard 3.6.1.3.)
Head lice	Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not had a medically approved treatment by the time they return.
Hepatitis A	Exclude for 1 week after onset of illness or as directed by the health department.
Impetigo	Exclusion is not needed before the end of the program day if impetigo lesions are covered, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Measles	Exclude until 4 days after onset of rash.
Mouth sores	Exclude children who have sores with drooling that a child is unable to control. Or exclude children who are unable to participate due to symptoms related to the mouth sores.
Mumps	Exclude until 5 days after onset of parotid (salivary) gland swelling.
Pertussis (whooping cough)	Exclude until treated with an appropriate antibiotic for 5 days, or 21 days from start of cough if untreated.
Rash with fever or behavior change	Exclude until a healthcare provider decides the illness is not a harmful contagious disease.
Ringworm	Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Rubella	Exclude until 7 days after onset of rash.
Scabies	Exclusion is not needed before the end of the program day, but let the parent or guardian know that day. Exclude only if the child has not been treated by the time they return.
Skin sores	Exclude if the child has sores on an exposed body surface that are leaking fluid and cannot be covered with a waterproof dressing.
Streptococcal pharyngitis (Strep throat, skin infections)	Exclude until treated with an appropriate antibiotic for 12 hours.
Tuberculosis (active)	Exclude until the healthcare provider or local health department decides the child is no longer infectious.
Vomiting	Exclude if the child vomits two or more times within 24 hours, unless vomiting is due to a noncontagious/noninfectious cause and the child can stay hydrated and take part in activities. If a child with a recent head injury vomits, get emergency medical care.

When children need temporary exclusion, staff should¹:

• Ask parents or guardians to pick the child up as soon as possible following the program’s illness exclusion policies.
• Let the child stay in the usual care setting/classroom (if symptoms allow) while waiting for pickup.
• Move the child to a familiar and comfortable place, supervised by someone who knows the child well and who will continue to watch the child for new or worsening symptoms. If the child is coughing or sneezing, separate the child from other children and staff by at least 3 feet to help decrease exposure to others who were not in close contact with the child before. 
• Make decisions on a case-by-case basis about giving care that is comfortable for the child while waiting for pickup. Consider the child’s age, surroundings, potential risk to others, and type and severity of symptoms. Staff should still appropriately tend to the child’s physical and emotional needs while waiting for pickup.
• If the child-to-staff ratio cannot be met while caring for the ill child, extra staff may be needed to care for the other children until the child is picked up. Putting the ill child in the care of an unfamiliar caregiver or in a different space may make it difficult to care for the child and can expose other people to infectious illnesses.
• Wash their hands, and continue to practice good hand hygiene if they (and other children) had contact with the ill child. Wash and sanitize toys, equipment, and surfaces used by the ill child after the child leaves.
• Discuss illness signs and symptoms with the parent or guardian who is picking up the child. Review illness guidelines for return to child care. If needed, give the family written information that may be shared with a healthcare provider. The information should include when symptoms started, observations about the child, if a temperature was taken (e.g., temperature of 101.5° F at 10:30 am), any actions taken, and the time actions were taken (e.g., ½ tsp children’s acetaminophen given orally at 11:00 am).
• Ask the parent or guardian to share written information from the child’s healthcare provider with staff. If more information is needed, ask for the parent’s or legal guardian’s written permission to contact the child’s doctor. Sharing health information with staff needs written consent from the parent or guardian.
• Follow the medical advice (if the child saw a healthcare provider) for return to child care. When needed, let staff and families know about a possible exposure to an infectious disease.
• Contact the local health department if a child or staff member might have a reportable or harmful infectious disease. If healthcare providers have different opinions about the care of a child with a reportable infectious disease, the health department has the legal authority to make a final decision.
• Document any care for an ill child in the child’s file with date, time, symptoms, and actions taken (and by whom); sign and date the document.

For programs that routinely offer care for ill children in a space designed for such care: Follow special procedures for giving this service, as defined in CFOC Standard 3.6.2.2 (http://nrckids.org/CFOC).

If the child seems well to the family and no longer meets criteria for exclusion, there is no need to ask for more information from the healthcare provider when the child returns to care. Children who have been sent home due to illness do not always need to see a healthcare provider.

Reportable/Notifiable Conditions¹

The CDC has a list of infectious diseases that must be reported to public health authorities in the United States at the national level (see https://ndc.services.cdc.gov/search-results-year/). Other conditions may need to be reported to local, state, tribal, or territorial public health authorities. Although laboratories and healthcare providers are expected to report these notifiable diseases, their reporting may not alert health authorities that the child attends an early care and education program or is enrolled in school and may have exposed others. Delayed notification may delay quick responses to prevent illness among those exposed to the child in the group setting. If in doubt about whether to report, contact the local, state, tribal, or territorial health department.

Staff should contact the local health department:

• When a child or staff member who is in contact with others has a reportable disease
• If staff, children, or families in the program have a reportable illness
• For help managing a suspected outbreak. An outbreak is 2 or more unrelated children (i.e., not siblings) with the same diagnosis or symptoms in the same group within 1 week. Clusters of mild respiratory illness, ear infections, and certain skin conditions are common and usually do not need to be reported.

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

COVID-19 modification as of March 20, 2023: Children who are experiencing any of the symptoms listed below should not enter the program and get tested: COVID-19 symptoms most likely seen in children: Congestion, runny nose or other allergy like symptoms Sore throat Headache Vomiting Diarrhea Fever (100.4o F/38o C or higher) Children who have been exposed and are waiting on the results of a COVID-19 test should: Stay home while waiting for the results if they have symptoms Children over two years of age should wear a well fitted mask for 10 days while attending the program if they do not have symptoms. If a child shows symptoms or becomes sick during the day, program staff should have the child wear a well fitted mask while in the building, send the child home, and encourage the child and any symptomatic parents/caregivers/family members to get tested. If a child in care is confirmed to have COVID-19: Follow the Cleaning and Disinfecting Your Facility Ensure families understand their child cannot return to in-person care until they have met CDC’s guidance, Maintain the sick child’s confidentiality, as required by the Americans with Disabilities Act (ADA), Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA). Additional Resources: Centers for Disease Control and Prevention Operational Guidance for K-12 Schools and Early Care and Education Programs to Support Safe In-Person Learning Masks

RATIONALE

Although young children often become ill, excluding children from early care and education programs can be stressful for families, and many exclusion decisions made by staff are not correct. Most infections in young children are mild and are spread by children who do not have symptoms. Excluding children with mild illnesses is unlikely to reduce the spread of most infections in early care and education settings. The most important reason for exclusion is if the child can’t take part in activities and the staff can’t care for the child. But exclusion is needed for some infectious diseases to control contamination and spread, and these diseases need criteria for a child’s return.²

COMMENTS

ADDITIONAL RESOURCES

For specific conditions, Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide, 5th Edition, has educational handouts that programs can copy and distribute to parents and guardians, healthcare providers, and staff. This publication is available from the American Academy of Pediatrics at https://shop.aap.org/managing-infectious-diseases-in-child-care-and-schools-5th-ed-paperback/  

 

State-specific guidelines for licensing and regulations on exclusion and return to care are at https://licensingregulations.acf.hhs.gov/

 

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.1.1 Conduct of Daily Health Check
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Guidelines for Taking Children’s Temperatures
3.6.1.4 Infectious Disease Outbreak Control
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix A: Signs and Symptoms Chart

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022

2. American Academy of Pediatrics, Section 2 recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:116-126

3. Centers for Disease Control and Prevention. Hand, foot, and mouth disease (HFMD) Causes & Transmission. CDC.gov Web site. Last reviewed February 2, 2021. Accessed August 8, 2022. https://www.cdc.gov/hand-foot-mouth/about/transmission.html

NOTES

Content in the STANDARD was modified 04/16/2015, 8/2015, 4/4/2017, 5/21/2019 and 10/25/2022.

COVID-19 modification as of March 20, 2023.

3.6.1.2: Staff Exclusion for Illness

After reading the CFOC standard, see COVID-19 modification below (Also consult applicable state licensure and public health requirements).

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

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

1. Influenza, until fever free for 24 hours. (Health care providers can use a test to determine whether an ill person has influenza rather than other symptoms. However, it is not practical to test all ill staff members to determine whether they have common cold viruses or influenza infection. Therefore, exclusion decisions are based on the symptoms of the staff member);
2. Chickenpox, until all lesions have dried and crusted, which usually occurs by six days;
3. Shingles, only if the lesions cannot be covered by clothing or a dressing until the lesions have crusted;
4. Rash with fever or joint pain, until diagnosed not to be measles or rubella;
5. Measles, until four days after onset of the rash (if the staff member or substitute has the capacity to develop an immune response following exposure);
6. Rubella, until six days after onset of rash;
7. Diarrheal illness, stool frequency exceeds two or more stools above normal for that individual or blood in stools, until diarrhea resolves, or until a primary care provider determines that the diarrhea is not caused by a germ that can be spread to others in the facility; For all cases of bloody diarrhea and diarrhea caused by Shiga toxin–producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi  I, exclusion must continue until the person is cleared to return by the primary health care provider. Exclusion is warranted for STEC, until results of 2 stool cultures are negative (at least 48 hours after antibiotic treatment is complete (if prescribed)); for Shigella species, until at least 1 stool culture is negative (varies by state); and for Salmonella serotype Typhi, until 3 stool cultures are negative. Stool samples need to be collected at least 48 hours after antibiotic treatment is complete. Other types of Salmonella do not require negative test results from stool cultures. Vomiting illness, two or more episodes of vomiting during the previous twenty-four hours, until vomiting resolves or is determined to result from non-infectious conditions;
8. Hepatitis A virus, until one week after symptom onset or as directed by the health department;
9. Pertussis, until after five days of appropriate antibiotic therapy or until 21 days after the onset of cough if the person is not treated with antibiotics;
10. Skin infection (such as impetigo), until treatment has been initiated; exclusion should continue if lesion is draining AND cannot be covered;
11. Tuberculosis, until noninfectious and cleared by a health department official or a primary care provider;
12. Strep throat or other streptococcal infection, until twenty-four hours after initial antibiotic treatment and end of fever;
13. Head lice, from the end of the day of discovery until after the first treatment;
14. Scabies, until after treatment has been completed;
15. Haemophilus influenzae type b (Hib), prophylaxis, until cleared by the primary health care provider;
16. Meningococcal infection, until cleared by the primary health care provider;
17. Other respiratory illness, if the illness limits the staff member’s ability to provide an acceptable level of child care and compromises the health and safety of the children. This includes a respiratory illness in which the staff member is unable to consistently manage respiratory secretions using proper cough and sneeze etiquette.

RATIONALE

Most infections are spread by children who do not have symptoms.
The terms contagious, infectious and communicable have similar meanings. A fully immunized child with a contagious, infectious or communicable condition will likely not have an illness that is harmful to the child or others. Children attending child care frequently carry contagious organisms that do not limit their activity nor pose a threat to their contacts.
Adults are as capable of spreading infectious disease as children (1,2). Hand and personal hygiene is paramount in preventing transmission of these organisms. 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.3.2 Cough and Sneeze Etiquette
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
   

2. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 138-146

   
   

NOTES

Content in the STANDARD was modified on 4/5/2017.
COVID-19 modification as of March 20, 2023.

3.6.1.3: Guidelines for Taking Children’s Temperatures

A normal body temperature is considered 98.6°F (37°C). A fever is a higher than normal body temperature. Body temperature increases in response to infection or other causes. In infants and children, a temperature of 100.4°F (38°C) or more from any area of the body is considered above normal.^1,2 A child with a fever may feel warm, look flushed, sweat more than usual, be less active. Getting a correct temperature can help guide staff to make decisions about inclusion, temporary exclusion, or dismissal of children with a fever.

 When early care and education program staff suspect that a child has a fever, they should take a temperature with a digital thermometer. A digital thermometer does not have mercury and is not made of glass. Different types of digital thermometers measure temperature at different areas of the body.³ It is important to use the correct method based on the child’s age and to document the temperature, time the temperature was taken, and type of thermometer used. Do not adjust the temperature reading for the location in which the temperature was taken. Whatever method you use, it is also important to follow the manufacturer’s cleaning instructions for the thermometer before and after each use. Thermometers may include:

• Tympanic (ear) thermometers. These may be used with children 6 months and older. Infants younger than 6 months have narrow ear canals, and tympanic thermometers can give inaccurate results. Tympanic thermometers need to be placed correctly in the child’s ear to be accurate. An accurate temperature depends on gently pulling the ear back before inserting the thermometer. A buildup of ear wax can make the temperature reading incorrect. Wait 15 minutes to take a temperature after being outside on a cold day, as that can cause an inaccurate low reading.

   

• Oral (under the tongue) thermometers. These can be used for children 4 years old and older. Use individual plastic covers each time, or clean and sanitize these thermometers each time according to the manufacturer’s instructions. Once the thermometer is turned on, place the tip under the tongue. Make sure the child’s lips are sealed until the thermometer beeps. Do not use teeth to keep the thermometer in place. If the child has had a hot or cold drink, wait 30 minutes after the drink to use an oral thermometer.

   

• Temporal artery (forehead) thermometers can be used for children of any age. This is the safest and most accurate way to get the temperature for a child under 6 months old in early care and education settings. Follow the manufacturer’s directions to know how and where to slide the thermometer across the forehead to make sure you get accurate results.

  
  

• Axillary (armpit) thermometers. These can be used for a child of any age. Temperatures are only accurate when the thermometer stays in the child’s closed armpit for the time recommended by the manufacturer. This method can be fast, but armpit temperatures are the least accurate.

   

• Rectal (in the bottom) thermometers. These are not recommended in early care and education programs due to health and safety concerns. A rectal thermometer could perforate (poke a hole) in the child’s rectum if not used properly. It could also pass germs from the stool, and if not properly cleaned, could spread illness among children and staff.

Armpit thermometers, pacifier thermometers, or fever strips are not accurate and not recommended. Glass or mercury thermometers should not be used in early care and education programs due to safety concerns.

 

RATIONALE

Taking an accurate temperature can guide staff as they make decisions about caring for children with a fever. If a child has a fever, early care and education program staff should prepare to manage the illness while keeping the child comfortable and safe. For more information, see 3.6.1.1 Inclusion/Exclusion/Dismissal of Children.

Safety and child abuse concerns may come up when using rectal thermometers. Early care and education program staff should be aware of these concerns. If rectal temperatures are taken, steps must be taken to make sure that all staff members are trained properly in this procedure and the opportunity for abuse is small  (e.g., make sure that more than one adult is present while taking the child’s temperature). Rectal temperatures should be taken only by staff with specific health training in performing this procedure, and parents/guardians must give permission.

Thermometers with mercury can easily break and release toxic levels of mercury fumes. To prevent mercury toxicity, the American Academy of Pediatrics (AAP) does not recommend using mercury or glass thermometers in early care and education programs.¹ Many state or local agencies operate facilities that collect used mercury thermometers. For more information on hazardous waste collections in your area, contact your state environmental protection agency or your local public health department.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.1.1 Conduct of Daily Health Check
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill

REFERENCES

1. American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022.

2. American Academy of Pediatrics. How to take a child’s temperature. Healthychildren.org Web site. Last reviewed October 12, 2020. Accessed April 27, 2022. https://www.healthychildren.org/English/health-issues/conditions/fever/pages/How-to-Take-a-Childs-Temperature.aspx

3. American Academy of Pediatrics. Signs and symptoms of fever. Healthychildren.org Web site. Last reviewed November 21, 2015. Accessed April 27, 2022. https://www.healthychildren.org/English/health-issues/conditions/fever/Pages/Signs-and-Symptoms-of-Fever.aspx

NOTES

Standard was last updated on September 13, 2022.

3.6.1.4: Infectious Disease Outbreak Control

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

RATIONALE

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness
3.6.4.1 Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease
3.6.4.2 Infectious Diseases That Require Parent/Guardian Notification

REFERENCES

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

3.6.1.5: Sharing of Personal Articles Prohibited

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

RATIONALE

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

3.6.2.1: Exclusion and Alternative Care for Children Who Are Ill

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

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

RATIONALE

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.2.3 Qualifications of Directors of Facilities That Care for Children Who Are Ill
3.6.2.4 Program Requirements for Facilities That Care for Children Who Are Ill
3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill
3.6.2.6 Child-Staff Ratios for Facilities That Care for Children Who Are Ill
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
3.6.2.8 Licensing of Facilities That Care for Children Who Are Ill
3.6.2.9 Information Required for Children Who Are Ill
3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill

REFERENCES

1. Crowley, A. 1994. Sick child care: A developmental perspective. J Pediatric Health Care. 8:261-67.
2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

3.6.2.2: Space Requirements for Care of Children Who Are Ill

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

1. Indoor space that the facility uses for children who are ill, including classrooms, hallways, bathrooms, and kitchens, should be separate from indoor space used with well children. This reduces the likelihood of mixing supplies, toys, and equipment. The facility may use a single kitchen for ill and well children if the kitchen is staffed by a cook who has no child care responsibilities other than food preparation and who does not handle soiled dishes and utensils until after food preparation and food service are completed for any meal;
2. If the program for children who are ill is in the same facility as the well-child program, well children should not use or share furniture, fixtures, equipment, or supplies designated for use with children who are ill unless they have been cleaned and sanitized before use by well children;
3. Children whose symptoms indicate infections of the gastrointestinal tract (often with diarrhea) should receive their care in a space separate from other children with other illnesses. Limiting child-to-child interaction, separating staff responsibilities, and not mixing supplies, toys, and equipment reduces the likelihood of disease being transmitted between children
4. Children with chickenpox, pertussis, measles, mumps, rubella, or diphtheria, require a room with separate ventilation including fresh outdoor air (1);
5. Each room/home that is designated for the care of children who are ill should have a handwashing sink that can provide a steady stream of clean, running water that is at a comfortable temperature at least for twenty seconds (2). Soap and disposable paper towels should be available at the handwashing sink at all times. A hand sanitizing dispenser is an alternative to traditional handwashing (3,4);
6. ach room/home that is designated for the care of children who are ill and are wearing diapers should have its own diaper changing area adjacent to a handwashing sink and/or hand sanitizer dispenser.

 

RATIONALE

Transmission of infectious diseases in early care and education settings are influenced by the environmental sanitation and physical space of the facilities (5).
 
Handwashing sinks should be stationed in each room that is designated for the care of ill children to promote hand hygiene and to give the caregivers/teachers an opportunity for continuous supervision of the other children in care when washing their hands. The sink must deliver a consistent flow of water for twenty seconds so that the user does not need to touch the faucet handles. Diaper changing areas should be adjacent to sinks to foster cleanliness and to enable caregivers/teachers to provide continuous supervision of other children in care. 

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.5 Hand Sanitizers
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition.Elk Grove Village, IL: American Academy of Pediatrics.
2. Centers for Disease Control and Prevention. 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html.
   
4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5
   

5. American Academy of Pediatrics. Enterovirus D68 In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 331-334, 658, 692

6. American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 122-123

NOTES

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

3.6.2.3: Qualifications of Directors of Facilities That Care for Children Who Are Ill

The director of a facility that cares for children who are ill should have the following minimum qualifications, in addition to the general qualifications described in Director’s Qualifications, Standards 1.3.1.1 and 1.3.1.2:

1. At least forty hours of training in prevention and control of infectious diseases and care of children who are ill, including subjects listed in Standard 3.6.2.5;
2. At least two prior years of satisfactory performance as a director of a regular facility;
3. At least twelve credit hours of college-level training in child development or early childhood education.

RATIONALE

The director should be college-prepared in early childhood education and have taken college-level courses in illness prevention and control, since the director is the person responsible for establishing the facility’s policies and procedures and for meeting the training needs of new staff members (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home

RELATED STANDARDS

3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill

REFERENCES

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

3.6.2.4: Program Requirements for Facilities That Care for Children Who Are Ill

Any facility that offers care for the child who is ill of any age should:

1. Provide a caregiver/teacher who is familiar to the child;
2. Provide care in a place with which the child is familiar and comfortable away from other children in care;
3. Involve a caregiver/teacher who has time to give individual care and emotional support, who knows of the child’s interests, and who knows of activities that appeal to the level of child development age group and to a sick child;
4. Offer a program with trained personnel planned in consultation with qualified health care personnel and with ongoing medical direction.

RATIONALE

When children are ill, they are stressed by the illness itself. Unfamiliar places and caregivers/teachers add to the stress of illness when a child is sick. Since illness tends to promote regression and dependency, children who are ill need a person who knows and can respond to the child’s cues appropriately.

COMMENTS

Because children are most comfortable in a familiar place with familiar people, the preferred arrangement for children who are ill will be the child’s home or the child’s regular child care arrangement, when the child care facility has the resources to adapt to the needs of such children.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.2.2 Space Requirements for Care of Children Who Are Ill
3.6.4.1 Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease
3.6.4.2 Infectious Diseases That Require Parent/Guardian Notification
3.6.4.3 Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
3.6.4.5 Death

3.6.2.5: Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill

Each caregiver/teacher in a facility that cares for children who are ill should have at least two years of successful work experience as a caregiver/teacher in a regular well-child facility prior to employment in the special facility. In addition, facilities should document, for each caregiver/teacher, twenty hours of pre-service orientation training on care of children who are ill beyond the orientation training specified in Standards 1.4.2.1 through Standard 1.4.2.3. This training should include the following subjects:

1. Pediatric first aid and CPR, and first aid for choking;
2. General infection-control procedures, including:
   1. Hand hygiene;
   2. Handling of contaminated items;
   3. Use of sanitizing chemicals;
   4. Food handling;
   5. Washing and sanitizing of toys;
   6. Education about methods of disease transmission.
3. Care of children with common mild childhood illnesses, including:
   1. Recognition and documentation of signs and symptoms of illness including body temperature;
   2. Administration and recording of medications;
   3. Nutrition of children who are ill;
   4. Communication with parents/guardians of children who are ill;
   5. Knowledge of immunization requirements;
   6. Recognition of need for medical assistance and how to access;
   7. Knowledge of reporting requirements for infectious diseases;
   8. Emergency procedures.
4. Child development activities for children who are ill;
5. Orientation to the facility and its policies.

This training should be documented in the staff personnel files, and compliance with the content of training routinely evaluated. Based on these evaluations, the training on care of children who are ill should be updated with a minimum of six hours of annual training for individuals who continue to provide care to children who are ill.

RATIONALE

Because meeting the physical and psychological needs of children who are ill requires a higher level of skill and understanding than caring for well children, a commitment to children and an understanding of their general needs is essential (1). Work experience in child care facilities will help the caregiver/teacher develop these skills. States that have developed rules regulating facilities have recognized the need for training in illness prevention and control and management of medical emergencies. Staff members caring for children who are ill in special facilities or in a get well room in a regular center should meet the staff qualifications that are applied to child care facilities generally.

Caregivers/teachers have to be prepared for handling illness and must understand their scope of work. Special training is required of caregivers/teachers who work in special facilities for children who are ill because the director and the caregivers/teachers are dealing with infectious diseases and need to know how to prevent the spread of infection. Each caregiver/teacher should have training to decrease the risk of transmitting disease (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Heymann, S. J., P. Hong Vo, C. A. Bergstrom. 2002. Child care providers’ experiences caring for sick children: Implications for public policy. Early Child Devel Care 172:1-8.

3.6.2.6: Child-Staff Ratios for Facilities That Care for Children Who Are Ill

Each facility for children who are ill should maintain a child-to-staff ratio no greater than the following:

Age of Children	Child to Staff Ratio
3-35 months	3 children to 1 staff member
36-71 months	4 children to 1 staff member
72 months and older	6 children to 1 staff member

RATIONALE

Some states stipulate the ratios for caring for children who are ill in their regulations. The expert consensus is based on theories of child development including attachment theory and recognition of children’s temporary emotional regression during times of illness (1-3); the lowest ratios used per age group seem appropriate.

COMMENTS

These ratios do not include other personnel, such as bus drivers, necessary for specialized functions such as transportation.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Davies, D. 1999. Child development: A practitioner’s guide. New York: The Guilford Press.
2. Schumacher, R. 2008. Charting progress for babies in child care: CLASP center ratios and group sizes – Research based rationale. http://www.clasp.org/admin/site/babies/make_the_case/files/cp_rationale6.pdf.
3. Crowley, A. A. 1994. Sick child care: A developmental perspective. J Pediatric Health Care 8:261-67.

3.6.2.7: Child Care Health Consultants for Facilities That Care for Children Who Are Ill

Each special facility that provides care for children who are ill should use the services of a child care health consultant for ongoing consultation on overall operation and development of written policies relating to health care. The child care health consultant should have the knowledge, skills and preparation as stated in Standard 1.6.0.1.

The facility should involve the child care health consultant in development and/or implementation, review, and sign-off of the written policies and procedures for managing specific illnesses. The facility staff and the child care health consultant should review and update the written policies annually.

The facility should assign the child care health consultant the responsibility for reviewing written policies and procedures for the following:

1. Admission and readmission after illness, including inclusion/exclusion criteria;
2. Health evaluation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance;
3. Plans for health care and for managing children with infectious diseases;
4. Plans for surveillance of illnesses that are admissible and problems that arise in the care of children with illness;
5. Plans for staff training and communication with parents/guardians and primary care providers;
6. Plans for injury prevention;
7. Situations that require medical care within an hour.

RATIONALE: Appropriate involvement of child care health consultants is especially important for facilities that care for children who are ill. Facilities should use the expertise of primary care providers to design and provide a child care environment with sufficient staff and facilities to meet the needs of children who are ill (2,3). The best interests of the child and family must be given primary consideration in the care of children who are ill. Consultation by primary care providers, especially those whose specialty is pediatrics, is critical in planning facilities for the care of children who are ill (1).

RATIONALE

Appropriate involvement of child care health consultants is especially important for facilities that care for children who are ill. Facilities should use the expertise of primary care providers to design and provide a child care environment with sufficient staff and facilities to meet the needs of children who are ill (2,3). The best interests of the child and family must be given primary consideration in the care of children who are ill. Consultation by primary care providers, especially those whose specialty is pediatrics, is critical in planning facilities for the care of children who are ill (1).

COMMENTS

Caregivers/teachers should seek the services of a child care health consultant through state and local professional organizations, such as:

1. Local chapters of the American Academy of Pediatrics (AAP);
2. Local Children’s hospital;
3. American Nurses Association (ANA);
4. Visiting Nurse Association (VNA);
5. American Academy of Family Physicians (AAFP);
6. National Association of Pediatric Nurse Practitioners (NAPNAP);
7. National Association for the Education of Young Children (NAEYC);
8. National Association for Family Child Care (NAFCC);
9. National Association of School Nurses (NASN);
10. Emergency Medical Services for Children (EMSC) National Resource Center;
11. State or local health department (especially public health nursing, infectious disease, and epidemiology departments).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Donowitz, L. G., ed. 1996. Infection control in the child care center and preschool, 18-19, 68. 2nd ed. Baltimore, MD: Williams and Wilkins.
2. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child care centers. Infect Dis Clin North Am 11:347-65.
3. Crowley A. A. 2000. Child care health consultation: The Connecticut experience. Matern Child Health J 4:67-75.

3.6.2.8: Licensing of Facilities That Care for Children Who Are Ill

A facility may care for children with symptoms requiring exclusion provided that the licensing authority has given approval of the facility, written plans describing symptoms and conditions that are admissible, and procedures for daily care. In jurisdictions that lack regulations and licensing capacity for facilities that care for children who are ill, the child care health consultant with the local health authority should review these plans and procedures annually in an advisory capacity.

RATIONALE

Facilities for children who are ill generally are required to meet the licensing requirements that apply to all facilities of a specific type, for example, small or large family child care homes or centers. Additional requirements should apply when children who are ill will be in care.

This standard ensures that child care facilities are continually reviewed by an appropriate state authority and that facilities maintain appropriate standards in caring for children who are ill.

COMMENTS

If a child care health consultant is not available, than the local health authority should review plans and procedures annually.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.2.10 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill

3.6.2.9: Information Required for Children Who Are Ill

For each day of care in a special facility that provides care for children who are ill, the caregiver/teacher should have the following information on each child:

1. The child’s specific diagnosis and the individual providing the diagnosis (primary care provider, parent/guardian);
2. Current status of the illness, including potential for contagion, diet, activity level, and duration of illness;
3. Health care, diet, allergies (particularly to foods or medication), and medication and treatment plan, including appropriate release forms to obtain emergency health care and administer medication;
4. Communication with the parent/guardian on the child’s progress;
5. Name, address, and telephone number of the child’s source of primary health care;
6. Communication with the child’s primary care provider.

Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information (2). Confidentiality should be maintained at each step in compliance with any laws or regulations that are pertinent to all parties such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/or the Health Insurance Portability and Accountability Act (commonly known as HIPAA) (2).

RATIONALE

The caregiver/teacher must have child-specific information to provide optimum care for each child who is ill and to make appropriate decisions regarding whether to include or exclude a given child. The caregiver/teacher must have contact information for the child’s source of primary health care or specialty health care (in the case of a child with asthma, diabetes, etc.) to assist with the management of any situation that arises.

COMMENTS

For school-age children, documentation of the care of the child during the illness should be provided to the parent to deliver to the school health program upon the child’s return to school. Coordination with the child’s source of health care and school health program facilitates the overall care of the child (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

1. Beierlein, J. G., J. E. Van Horn. 1995. Sick child care. National Network for Child Care. http://www.nncc.org/eo/emp.sick.child
   .care.html.
2. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics.

3.6.2.10: Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill

Facilities that care for children who are ill who have conditions that require additional attention from the caregiver/teacher, should arrange for a clinical health evaluation prior to admission, by a licensed primary care provider, for each child who is admitted to the facility. A child care health consultant can assist in arranging the evaluation. Facilities who serve children who are ill should include children with conditions listed in Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Children if their policies and plans address the management of these conditions, except for the following conditions which require exclusion from all types of child care facilities:

1. A severely ill appearance. This could include lethargy or lack of responsiveness, irritability, persistent crying, difficulty breathing, or having a quickly spreading rash;
2. Fever (temperature for an infant or child older than 2 months that is above 101° F [38.3° C] or, in infants younger than 2 months, a temperature above 100.4° F [38.0° F] by any method) and behavior change or other signs and symptoms;
3. Diarrhea (Defined by stool that is occurring with more frequency or is less formed in consistency than usual in the child and not associated with changes in diet.) Exclusion is required for all diapered children whose stool is not contained in the diaper. For toilet-trained children, exclusion is required when diarrhea is causing “accidents”. Exclude children whose stool frequency exceeds 2 stools above normal frequency) and one or more of the following:
   
   1. Signs of dehydration, such as dry mouth, no tears, lethargy, sunken fontanelle (soft spot on the head);
   2. Blood or mucus in the stool until it is evaluated for organisms that can cause dysentery;
   3. Diarrhea caused by Salmonella, Campylobacter, Giardia, Shigella or E.coli 0157:H7 until specific criteria for treatment and return to care are met.
4.  Vomiting 2 or more times in the previous 24 hours, unless vomiting is determined to be caused by a non-communicable or noninfectious condition and the child is not in danger of dehydration;
5. Contagious stages of pertussis, measles, mumps, chickenpox, rubella, or diphtheria, unless the child is appropriately isolated from children with other illnesses and cared for only with children having the same illness;
6. Untreated infestation of scabies or head lice; exclusion not necessary before the end of the program day;
7. Untreated infectious tuberculosis;
8. Undiagnosed rash WITH fever or behavior change;
9. Abdominal pain that is intermittent or persistent and is accompanied by fever, diarrhea, vomiting, or other signs and symptoms;
10. An acute change in behavior;
11. Undiagnosed jaundice (yellow skin and whites of eyes);
12. Upper or lower respiratory infection in which signs or symptoms require a higher level of care than can be appropriately provided; and
13. Severely immunocompromised children and other conditions as may be determined by the primary health care provider and/or child care health consultant (1,2).

RATIONALE

These signs and symptoms may indicate a significant systemic infection that requires professional medical management and parental care (1,2). Diarrheal illnesses that require an intensity of care that cannot be provided appropriately by a caregiver/teacher could result in temporary exclusion (1,2).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

2. American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 122-123

3. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 140-141

NOTES

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

3.6.3.1: Medication Administration

The administration of medicines at the facility should be limited to:

1. Prescription or non-prescription medication (over-the-counter [OTC]) ordered by the prescribing health professional for a specific child with written permission of the parent/guardian. Written orders from the prescribing health professional should specify medical need, medication, dosage, and length of time to give medication;
2. Labeled medications brought to the child care facility by the parent/guardian in the original container (with a label that includes the child’s name, date filled, prescribing clinician’s name, pharmacy name and phone number, dosage/instructions, and relevant warnings).

Facilities should not administer folk or homemade remedy medications or treatment. Facilities should not administer a medication that is prescribed for one child in the family to another child in the family.

No prescription or non-prescription medication (OTC) should be given to any child without written orders from a prescribing health professional and written permission from a parent/guardian. Exception: Non-prescription sunscreen and insect repellent always require parental consent but do not require instructions from each child’s prescribing health professional.

Documentation that the medicine/agent is administered to the child as prescribed is required.

“Standing orders” guidance should include directions for facilities to be equipped, staffed, and monitored by the primary care provider capable of having the special health care plan modified as needed. Standing orders for medication should only be allowed for individual children with a documented medical need if a special care plan is provided by the child’s primary care provider in conjunction with the standing order or for OTC medications for which a primary care provider has provided specific instructions that define the children, conditions and methods for administration of the medication. Signatures from the primary care provider and one of the child’s parents/guardians must be obtained on the special care plan. Care plans should be updated as needed, but at least yearly.

RATIONALE

Medicines can be crucial to the health and wellness of children. They can also be very dangerous if the wrong type or wrong amount is given to the wrong person or at the wrong time. Prevention is the key to prevent poisonings by making sure medications are inaccessible to children.

All medicines require clear, accurate instruction and medical confirmation of the need for the medication to be given while the child is in the facility. Prescription medications can often be timed to be given at home and this should be encouraged. Because of the potential for errors in medication administration in child care facilities, it may be safer for a parent/guardian to administer their child’s medicine at home.

Over the counter medications, such as acetaminophen and ibuprofen, can be just as dangerous as prescription medications and can result in illness or even death when these products are misused or unintentional poisoning occurs. Many children’s over the counter medications contain a combination of ingredients. It is important to make sure the child isn’t receiving the same medications in two different products which may result in an overdose. Facilities should not stock OTC medications (1).

Cough and cold medications are widely used for children to treat upper respiratory infections and allergy symptoms. Recently, concern has been raised that there is no proven benefit and some of these products may be dangerous (2,3,5). Leading organizations such as the Consumer Healthcare Products Association (CHPA) and the American Academy of Pediatrics (AAP) have recommended restrictions on these products for children under age six (4-7).

If a medication mistake or unintentional poisoning does occur, call your local poison center immediately at 1-800-222-1222.

Parents/guardians should always be notified in every instance when medication is used. Telephone instructions from a primary care provider are acceptable if the caregiver/teacher fully documents them and if the parent/guardian initiates the request for primary care provider or child care health consultant instruction. In the event medication for a child becomes necessary during the day or in the event of an emergency, administration instructions from a parent/ guardian and the child’s prescribing health professional are required before a caregiver/teacher may administer medication.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

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

REFERENCES

1. American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.
2. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medications in children. Pediatrics 121:783-87.
3. Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.
4. Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/10_11_07_OralInfantMedicines.aspx.
5. U.S. Department of Health and Human Services, Food and Drug Administration. 2008. Public Health advisory: FDA recomends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm051137.htm
   
6. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Slone Survey. Pediatrics 122: e323-29.
   
7. American Academy of Pediatrics. 2008. AAP Urges caution in use of over-the-counter cough and cold medicines. http://www.generaterecords.net/PicGallery/AAP_CC.pdf
   

3.6.3.2: Labeling, Storage, and Disposal of Medications

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

• The child’s first and last names;
• The date the prescription was filled;
• The name of the prescribing health professional who wrote the prescription, the medication’s expiration date;
• The manufacturer’s instructions or prescription label with specific, legible instructions for administration, storage, and disposal;
• The name and strength of the medication.

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

All medications, refrigerated or unrefrigerated, should:

• Have child-resistant caps;
• Be kept in an organized fashion;
• Be stored away from food;
• Be stored at the proper temperature;
• Be completely inaccessible to children.

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

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

RATIONALE

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

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

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.3 Training of Caregivers/Teachers to Administer Medication

REFERENCES

1. U.S. Food and Drug Administration. 2010. Disposal by flushing of certain unused medicines: What you should know. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
   EnsuringSafeUseofMedicine/SafeDisposalofMedicines/
   ucm186187.htm.
2. U.S. Environmental Protection Agency. 2009. Pharmaceuticals and personal care products as pollutants (PPCPs). http://www.epa
   .gov/ppcp/.
3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

3.6.3.3: Training of Caregivers/Teachers to Administer Medication

Any caregiver/teacher who administers medication should complete a standardized training course that includes skill and competency assessment in medication administration. The trainer in medication administration should be a licensed health professional. The course should be repeated according to state and/or local regulation. At a minimum, skill and competency should be monitored annually or whenever medication administration error occurs. In facilities with large numbers of children with special health care needs involving daily medication, best practice would indicate strong consideration to the hiring of a licensed health care professional. Lacking that, caregivers/teachers should be trained to:

1. Check that the name of the child on the medication and the child receiving the medication are the same;
2. Check that the name of the medication is the same as the name of the medication on the instructions to give the medication if the instructions are not on the medication container that is labeled with the child’s name;
3. Read and understand the label/prescription directions or the separate written instructions in relation to the measured dose, frequency, route of administration (ex. by mouth, ear canal, eye, etc.) and other special instructions relative to the medication;
4. Observe and report any side effects from medications;
5. Document the administration of each dose by the time and the amount given;
6. Document the person giving the administration and any side effects noted;
7. Handle and store all medications according to label instructions and regulations.

The trainer in medication administration should be a licensed health professional: Registered Nurse, Advanced Practice Registered Nurse (APRN), MD, Physician’s Assistant, or Pharmacist.

RATIONALE

Administration of medicines is unavoidable as increasing numbers of children entering child care take medications. National data indicate that at any one time, a significant portion of the pediatric population is taking medication, mostly vitamins, but between 16% and 40% are taking antipyretics/analgesics (5). Safe medication administration in child care is extremely important and training of caregivers/teachers is essential (1).

Caregivers/teachers need to know what medication the child is receiving, who prescribed the medicine and when, for what purpose the medicine has been prescribed and what the known reactions or side effects may be if a child has a negative reaction to the medicine (2,3). A child’s reaction to medication can be occasionally extreme enough to initiate the protocol developed for emergencies. The medication record is especially important if medications are frequently prescribed or if long-term medications are being used (4).

COMMENTS

Caregivers/teachers need to know the state laws and regulations on training requirements for the administration of medications in out-of-home child care settings. These laws may include requirements for delegation of medication administration from a primary care provider. Training on medication administration for caregivers/teachers is available in several states. Model Child Care Health Policies, 2nd Ed. from Healthy Child Care Pennsylvania is available at http://www.ecels-healthychildcarepa.org/publications/manuals-pamphlets-policies/item/248-model-child-care-health-policies and contains sample polices and forms related to medication administration.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
Appendix AA: Medication Administration Packet
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

1. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and administration in child care settings: A case study. Policy, Politics, and Nursing Practice 6:86-98.
2. Qualistar Early Learning. 2008. Colorado Medication Administration Curriculum. 5th ed. http://www.qualistar.org/medication-administration.html.
3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
4. Calder, J. 2004. Medication administration in child care programs. Health and Safety Notes. Berkeley, CA: California Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/medadminEN102004_adr.pdf.
5. Vernacchio, L., J. P. Kelly, D. W. Kaufman, A. A. Mitchell. 2009. Medication use among children <12 years of age in the United States: Results from the Slone Survey. Pediatrics 124:446-54.

3.6.4.1: Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease

Caregivers/teachers should work collaboratively with local and state health authorities to notify parents/guardians about potential or confirmed exposures of their child to a infectious disease. Notification should include the following information:

1. The names, both the common and the medical name, of the diagnosed disease to which the child was exposed, whether there is one case or an outbreak, and the nature of the exposure (such as a child or staff member in a shared room or facility);
2. Signs and symptoms of the disease for which the parent/guardian should observe;
3. Mode of transmission of the disease;
4. Period of communicability and how long to watch for signs and symptoms of the disease;
5. Disease-prevention measures recommended by the health department (if appropriate);
6. Control measures implemented at the facility;
7. Pictures of skin lesions or skin condition may be helpful to parents/guardians (i.e., chicken pox, spots on tonsils, etc.)

The notice should not identify the child who has the infectious disease.

RATIONALE

Effective control and prevention of infectious diseases in child care depends on affirmative relationships between parents/guardians, caregivers/teachers, public health authorities, and primary care providers.

COMMENTS

The child care health consultant can locate appropriate photographs of conditions for parent/guardian information use. Resources for fact sheets and photographs include the current edition of Managing Infectious Diseases in Child Care and Schools (1) and the Centers for Disease Control and Prevention Website on conditions and diseases. For a sample letter to parents notifying them of illness of their child or other enrolled children, see Healthy Young Children, available from the National Association for the Education of Young Children (NAEYC) at http://www.naeyc.org.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
   

3.6.4.2: Infectious Diseases That Require Parent/Guardian Notification

In cooperation with the child care regulatory authority and health department, the facility or the health department should inform parents/guardians if their child may have been exposed to the following diseases or conditions while attending the child care program, while retaining the confidentiality of the child who has the infectious disease:

1. Neisseria meningitidis (meningitis);
2. Pertussis;
3. Invasive infections;
4. Varicella-zoster (Chickenpox) virus;
5. Skin infections or infestations (head lice, scabies, and ringworm);
6. Infections of the gastrointestinal tract (often with diarrhea) and hepatitis A virus (HAV);
7. Haemophilus influenzae type B (Hib);
8. Parvovirus B19 (fifth disease);
9. Measles;
10. Tuberculosis;
11. Two or more affected unrelated persons affiliated with the facility with a vaccine-preventable or infectious disease.

RATIONALE

Early identification and treatment of infectious diseases are important in minimizing associated morbidity and mortality as well as further reducing transmission (1). Notification of parents/guardians will permit them to discuss with their child’s primary care provider the implications of the exposure and to closely observe their child for early signs and symptoms of illness.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

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

3.6.4.3: Notification of the Facility About Infectious Disease or Other Problems by Parents/Guardians

Upon registration of each child, the facility should inform parents/guardians that they must notify the facility within twenty-four hours after their child or any member of the immediate household has developed a known or suspected infectious or vaccine-preventable disease (1). When a child has a disease that may require exclusion, the parents/guardians should inform the facility of the diagnosis. 

The facility should encourage parents/guardians to inform the caregivers/teachers of any other problems which may affect the child’s behavior.

RATIONALE

This requirement will facilitate prompt reporting of disease and enable the caregiver/teacher to provide better care. Disease surveillance and reporting to local health authorities is crucial to preventing and controlling diseases in the child care setting (2,3). The major purpose of surveillance is to allow early detection of disease and prompt implementation of control measures. If it is known that the child attends another center or facility, all facilities should be informed (for example, if the child attends a Head Start program and a child care program that are separate–then both need to be notified and the notification of local health authority should name both facilities).

Ascertaining whether a child who is ill is attending a facility is important when evaluating childhood illnesses (2,3). Ascertaining whether an adult with illness is working in a facility or is a parent/guardian of a child attending a facility is important when considering infectious diseases that are more commonly manifest in adults. Cases of illness in family member such as infections of the gastrointestinal tract (with diarrhea), or infections of the liver may necessitate questioning about possible illness in the child attending child care. Information concerning infectious disease in a child care attendee, staff member, or household contact should be communicated to public health authorities, to the child care director, and to the child’s parents/guardians.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children

REFERENCES

1. Pennsylvania chapter of the American Academy of Pediatrics. Model Child Care Health Polices. Aronson SS, ed. 5^th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
   
2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Children in out-of-home child care. In: Red book: 2015 report to the committee of infectious diseases.  30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
   
3. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
   

3.6.4.4: List of Excludable and Reportable Conditions for Parents/Guardians

The facility should give to each parent/guardian a written list of conditions for which exclusion and dismissal may be indicated (1).

For the following symptoms, the caregiver/teacher should ask parents/guardians to have the child evaluated by a primary care provider. The advice of the primary care provider should be documented for the caregiver/teacher in the following situations:

1. The child has any of the following conditions: fever, lethargy, irritability, persistent crying, difficult breathing, or other manifestations of possible severe illness;
2. The child has a rash with fever and behavioral change;
3. The child has tuberculosis that has not been evaluated;
4. The child has scabies;
5. The child has a persistent cough with inability to practice respiratory etiquette.

The facility should have a list of reportable diseases provided by the health department and should provide a copy to each parent/guardian.

RATIONALE

Vomiting with symptoms such as lethargy and/or dry skin or mucous membranes or reduced urine output may indicate dehydration, and the child should be medically evaluated. Diarrhea with fever or other symptoms usually indicates infection. Blood and/or mucus may indicate shigellosis or infection with E. coli 0157:H7, which should be evaluated. Effective control and prevention of infectious diseases in child care depend on affirmative relationships between parents/guardians, caregivers, health departments, and primary care providers (2).

COMMENTS

 If there is more than one case of vomiting in the facility, it may indicate either contagious illness or food poisoning.

If a child with abdominal pain is drowsy, irritable, and unhappy, has no appetite, and is unwilling to participate in usual activities, the child should be seen by that child’s primary care provider. Abdominal pain may be associated with viral, bacterial, or parasitic gastrointestinal tract illness, which is contagious, or with food poisoning. It also may be a manifestation of another disease or illness such as kidney disease. If the pain is severe or persistent, the child should be referred for medical consultation (by telephone, if necessary).

If the caregiver/teacher is unable to contact the parent/guardian, medical advice should be sought until the parents can be located.

The facility should post the health department’s list of infectious diseases as a reference. The facility should inform parents/guardians that the program is required to report infectious diseases to the health department.

For information on assisting families in finding a medical home or primary care provider, consult the local chapter of the American Academy of Pediatrics (AAP), the facility’s child care health consultant, the local public health department, or the American Academy of Family Physicians (AAFP). For more information, see also the current edition of Managing Infectious Diseases in Child Care and Schools, available at here.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
   

2. American Academy of Pediatrics. Out-of-home child care In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 122-123

3. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 140-141

3.6.4.5: Death

Early care and education (ECE) programs should have a plan in place for responding to any death relevant to children enrolled in the program and their families. The plan should describe protocols the program will follow and resources available to children, families, and staff.¹

If an ECE program experiences the death of a child or adult, the following should be done, and these actions can take place simultaneously ²:

• When a child dies or collapses unexpectedly, ECE staff should notify emergency medical services/personnel promptly on discovering the child and begin to administer appropriate first aid and/or cardiopulmonary resuscitation as directed.²
• Caregivers/teachers responsible for any children who may have observed or were in the same room where the collapse or death occurred should take the children to a different room.
• Immediately notify the child’s parents/guardians or adult’s emergency contact; this can include information on what hospital the child/adult is being taken to.³
• Notify law enforcement immediately and follow all law enforcement protocols regarding the scene of the death.³

1. Do not disturb the scene.
2. Do not show the scene to others.
3. Reserve conversation about the event until having consulted with and completed all interviews with law enforcement.

• Notify the licensing agency the same day the death occurs.
• ECE programs should only release specific information about the circumstances of the child’s or adult’s death that the authorities and the deceased member’s family agree that the program may share.
• Supportive and reassuring comments should be provided to children directly affected. Provide age-appropriate information for children, parents/guardians, and staff.

Depending on the cause of death (including sudden unexpected infant deaths [SUIDs], sudden infant death syndrome [SIDS], suffocation, injury, maltreatment, etc), there may be a need for updated education on the subject for caregivers/teachers and/or children as well as implementation of improved health and safety practices.

Caregivers/teachers should be knowledgeable about safe sleep practices and implement them so that sleep-related deaths are not treated as possible maltreatment cases, resulting in false, inappropriate criminal and protective services investigations of the ECE program.⁵

 

If a child or adult known to the children enrolled in the ECE program dies while not at the ECE facility ^1,3

• Provide age-appropriate information for children, parents/guardians, and staff.
• Make resources for support available to staff, parents, and children.

If a death outside the ECE program might be due to suspected child maltreatment or neglect, the caregiver/teacher is mandated to report this to child protective services. Failing to consider or follow up on a suspected child abuse/neglect case can put other children (eg, siblings, children in the extended family, those enrolled in the program) at risk.⁴

RATIONALE

Proper management of unexpected deaths of children or adults by ECE staff allows families and staff who are affected the opportunity to react, grieve, assess, and communicate their needs.⁵ A parent’s experience following the death of a child varies enormously, and the way staff respond to and support families can make a considerable difference.²

 

COMMENTS

ADDITIONAL RESOURCES

 

The following resources can offer support and counseling to caregivers/teachers and families experiencing tragedy:

 

National Action Partnership to Promote Safe Sleep

http://nappss.org

First Candle

www.firstcandle.org

 

National Center for School Crisis and Bereavement
https://www.schoolcrisiscenter.org

 

“Supporting the Grieving Child and Family”

https://pediatrics.aappublications.org/content/138/3/e20162147

 

National Center for Education in Maternal and Child Health SUID/SIDS Gateway

https://www.ncemch.org/suid-sids

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect

REFERENCES

1. Association of SIDS and Infant Mortality Programs. The unexpected death of an infant or child: standards for services to families. http://www.stonybrookmedicine.edu/sites/default/files/asip_standards.pdf. Reviewed March 2001. Accessed May 18, 2020

2. Sidebotham P, Marshall D, Garstang J. Responding to unexpected child deaths. In: Duncan JR, Byard RW, eds. SIDS: Sudden Infant and Early Childhood Death; The Past, the Present and the Future. Adelaide, South Australia, Australia: University of Adelaide Press; 2018. https://www.ncbi.nlm.nih.gov/books/NBK513395. Accessed May 18, 2020

3. National SIDS/Infant Death Resource Center. Responding to a Sudden, Unexpected Infant Death: The Professional’s Role. Vienna, VA: National SIDS/Infant Death Resource Center; 2004. https://www.ncemch.org/suid-sids/documents/SIDRC/ProfessionalRole.pdf. Accessed May 18, 2020

4. Palusci VJ, American Academy of Pediatrics Council on Child Abuse and Neglect, Kay AJ, et al. Identifying child abuse fatalities during infancy. Pediatrics. 2019;144(3):e20192076 PMID: 31451610 https://doi.org/10.1542/peds.2019-2076

5. Palusci VJ. Pediatricians have critical role in identifying child abuse fatalities during infancy. AAP News. ttps://www.aappublications.org/news/2019/08/26/childabuse082619. Published August 26, 2019. Accessed May 18, 2020

NOTES

Content in the STANDARD was modified on 05/17/2016 and 8/25/2020.