Caring for Our Children (CFOC)

Chapter 9: Administration

9.2 Policies

9.2.3 Health Policies

9.2.3.1: Policies and Practices that Promote Physical Activity

Content in the Standard was modified on 08/25/2016 and 05/30/2018.

The facility should have written policies for the promotion of indoor and outdoor physical activity and the removal of potential barriers to physical activity participation. Policies should cover the following areas:

     a. Benefits: benefits of physical activity and outdoor play.

     b. Duration: Children will spend 60 to 120 minutes each day outdoors depending on their age, weather permitting. Policies will describe what will be done to ensure physical activity

         and provisions for gross motor activities indoors on days with more extreme conditions (ie, very wet, very hot, or very cold).

     c. Type: Structured (caregiver/teacher-initiated) versus unstructured activity.

     d. Setting: provision of covered areas for shade and shelter on playgrounds, if feasible (1).

     e. Clothing: Clothing should protect children from sun exposure and permit easy movement (not too loose and not too tight) that enables full participation in active play; footwear

         should provide support for running and climbing. Hats and sunglasses should be worn to protect children from sun exposure. 

Examples of appropriate clothing/footwear include:

     a. Gym shoes or sturdy gym shoe equivalent.

     b. Clothes for the weather, including heavy coat, hat, and mittens in the winter/snow; raincoat and boots for the rain; and layered clothes for climates in which the temperature can

         vary dramatically on a daily basis. Lightweight, breathable clothing, without any hood and neck strings, should be worn when temperatures are hot to protect children from sun

         exposure. 

Examples of inappropriate clothing/footwear include:

     a. Footwear that can come off while running or that provides insufficient support for climbing (2)

     b. Clothing that can catch on playground equipment (eg, those with drawstrings or loops)

If children wear “dress clothes” or special outfits that cannot be easily laundered, caregivers/teachers should talk with the children’s parents/guardians about the program’s goals in providing physical activity during the program day and encourage them to provide a set of clothes that can be used during physical activities.

Facilities should discuss the importance of this policy with parents/guardians on enrollment and periodically thereafter.

RATIONALE

If appropriately dressed, children can safely play outdoors in most weather conditions. Children can learn math, science, and language concepts through games involving movement (3,4).

Having a policy on outdoor physical activity that will take place on days when there are adverse weather conditions informs all caregivers/teachers and families about the facility’s expectations. The policy can make clear that outdoor activity may require special clothing in colder weather or arrangements for cooling off when it is warm. By having such a policy, the facility encourages caregivers/teachers and families to anticipate and prepare for outdoor activity when cold, hot, or wet weather prevails.

The inappropriate dress of a child is often a barrier in reaching recommended amounts of physical activity in child care centers. Sometimes, children cannot participate in physical activity because of their inappropriate clothes. Caregivers/teachers can be helpful by having extra clean clothing on hand (5). Children can play in the rain and snow and in low temperatures when wearing clothing that keeps them dry and warm. When it is very warm, children can play outdoors, if they play in shady areas, and wear sunscreen, sun-protective clothing, and insect repellent, if necessary (6). Caregivers/teachers should have water available for children to mist, sprinkle, and drink while in warmer weather.

COMMENTS

For assistance in creating and writing physical activity policies, Nemours provides several resources and best practice advice on program implementation. Information is available at https://www.nemours.org/service/health/growuphealthy/activity/educators.html.

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
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.4.6.1 Strangulation Hazards
5.3.1.1 Indoor and Outdoor Equipment, Materials, and Furnishing
6.1.0.2 Size and Requirements of Indoor Play Area
9.2.6.1 Policy on Use and Maintenance of Play Areas
Appendix S: Physical Activity: How Much Is Needed?
REFERENCES

  1. Weinberger N, Butler, AG, Schumacher P. Looking inside and out: perceptions of physical activity in childcare spaces. Early Child Development and Care. 2014;184(2):194-210

  2. 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

  3. Bento G, Dias G. The importance of outdoor play for young children’s healthy development. Porto Biomed J. 2017;2(5):157–160. http://dx.doi.org/10.1016/j.pbj.2017.03.003. Accessed January 11, 2018

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

  5. 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

  6. American Academy of Pediatrics. Choosing an insect repellent for your child. HealthyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-play/Pages/Insect-Repellents.aspx. Updated March 1, 2017. Accessed January 11, 2018

NOTES

Content in the Standard was modified on 08/25/2016 and 05/30/2018.

9.2.3.2: Policy Development for Care of Children and Staff Who Are Ill

Content in the STANDARD was modified on 02/25/2022.

All early care and education programs should develop written policies for the management and care of children and staff who are ill. It is important to meet the needs of the individual who is ill while also protecting the health and well-being of others in the program. The policy should be developed in consultation with the program’s child care health consultant and should include:

  • Procedures for obtaining urgent and/or emergency healthcare
  • Seasonal and pandemic infectious disease procedures
  • Procedures for obtaining and maintaining updated individual care plans for children with special health care needs
  • Inclusion/exclusion and re-entry policies for children and staff
  • A description of common childhood illnesses, their management, illness-related precautions, and information to protect the health of other children and staff
  • Medication administration procedures
  • Circumstances and procedures for separating ill children while awaiting family/guardian pickup (taking into account the physical facility and availability of staff to monitor ill children)
  • Procedures for reaching the child’s emergency contact(s) when a child becomes ill
  • Procedures for documenting illnesses in the program including name of person(s) affected, date and time of illness, description of symptoms, the response of the staff person to these symptoms, and who was notified (such as a family/guardian, health care professional, or health department) and the response
RATIONALE

Early care and education programs should develop policies and procedures because children and staff can become ill frequently and at unpredictable times. Children and staff come into close and frequent contact with one another in group settings, increasing the risk for spreading infectious diseases.1 Additionally, staff may have known health conditions (e.g., pregnancy, immunocompromised) that may make them more vulnerable to common childhood illnesses. Documenting the occurrence of illness in a program, and the response, can help identify outbreaks of infectious disease in the program and larger community.

COMMENTS

It is important to develop policies and procedures in consultation with a child care health consultant who is knowledgeable in appropriate response and reporting for common childhood illnesses. A model policy can be found in the current edition of Managing Infectious Diseases in Child Care and Schools, a publication of the American Academy of Pediatrics (AAP). This publication includes handouts and resources for families/guardians and staff about managing infectious diseases in early care and education programs. Other model policies can be found in Model Child Care Health Policies.2 For more resources, contact your state or local health department.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.4.3.1 Medical Emergency Procedures
3.4.3.3 Response to Fire and Burns
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
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
3.6.4.4 List of Excludable and Reportable Conditions for Parents/Guardians
5.6.0.1 First Aid and Emergency Supplies
7.2.0.3 Immunization of Staff
9.2.3.9 Written Policy on Use of Medications
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.4.2.1 Contents of Child’s Records
9.4.2.6 Contents of Medication Record
Appendix F: Enrollment/Attendance/Symptom Record
Appendix AA: Medication Administration Packet
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. Pennsylvania chapter of the American Academy of Pediatrics. Model Child Care Health Polices. Aronson SS, ed. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014.

NOTES

Content in the STANDARD was modified on 02/25/2022.

9.2.3.3: Written Policy for Reporting Notifiable Diseases to the Health Department


The facility should have a written policy that complies with the state’s reporting requirements for children who are ill. All notifiable diseases should be reported to the health department. The facility should have the telephone number of the responsible health authority to whom confirmed or suspected cases of these diseases, or outbreaks of other infectious diseases, should be reported, and should designate a staff member as responsible for reporting the disease.
RATIONALE
Reporting to the health department provides the department with knowledge of illnesses within the community and ability to offer preventive measures to children and families exposed to the outbreak of a disease. In some states, caregivers/teachers may not be a mandatory reporter. In those states, caregivers/teachers are encouraged to report any infectious disease to the responsible health authority.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

9.2.3.4: Written Policy for Obtaining Preventive Health Service Information


Each facility should develop and follow a written policy for obtaining necessary medical information including immunizations (see Appendix G: Recommended Childhood Immunization Schedule) and periodic preventive health assessments (see Appendix I: Recommendations for Preventive Pediatric Health Care) as recommended by the American Academy of Pediatrics (AAP) in Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents (1-3). Facility staff should encourage parents/guardians to schedule these preventive health services in a timely fashion.

Documentation of an age-appropriate health assessment that includes current immunizations and health screenings should be filed in the child’s record at the facility. Immunization records should be provided at the time of enrollment. The health assessment should be provided within two weeks of admission or indication that an appointment has been made with the health care provider. Updates of the health record should be maintained according to the American Academy of Pediatrics’ (AAP’s) periodicity schedule, Appendix I: Recommendations for Preventive Pediatric Health Care. Health record information should be reviewed by the staff of the facility and information sharing between the staff, the parents/guardians, and the child’s health care professional should be encouraged and facilitated in order to provide better care for the child in the child care setting.

Centers should have written procedures for the verification of compliance with recommended immunizations and periodic health assessments of children. Centers should maintain confidential records of immunizations, periodic health assessments, including Body Mass Index (BMI) for children age two and older, and any special health considerations.

RATIONALE
Health assessments are important to ensure prevention, early detection of remediable problems, and planning for adaptations needed so that all children can reach their potential. When age-appropriate health assessments and use of health insurance benefits are promoted by caregivers/teachers, children enrolled in child care will have increased access to immunizations and other preventive services (4). With the expansion of eligibility for medical assistance and the federal subsidy of state child health insurance plans (SCHIP), the numbers of children who lack insurance for routine preventive health care should lessen.

Requiring facilities to maintain a current health record encourages and supports discussion of a child’s health needs between parents/guardians, caregivers/teachers, and the child’s primary care provider. It also encourages parents/guardians to seek preventive and primary care services in a timely fashion for their child.

The facility should have accurate, current information regarding the medical status and treatment of each child so it will be able to determine and adjust its capability to provide needed services. This documentation should consist of more than a statement from the child’s primary care provider that the child is up-to-date. Because of the administrative burden posed by requests to fill out forms, unless the specifics of services rendered are requested, the information may not reflect the child’s actual receipt of services according to the nationally recommended schedule. Instead, it may only represent that the child has a current health record in the primary care provider’s office. Until tracking systems become more widespread and effective in health care settings, a joint effort by the education system, family and primary care provider is required to ensure that children receive the preventive health services that ensure they are healthy and ready to learn.

COMMENTS
Assistance for caregivers/teachers and low income parents/guardians can be obtained through the Medicaid Early Periodic Screening and Diagnostic Treatment (EPSDT) program (Title XIX) and the state’s version of the federal Child Health Insurance Program (SCHIP) (5).

Most states require that caregivers/teachers document that the child’s health records are up-to-date to protect the child and other children whom the unimmunized child would expose to increased risk of vaccine-preventable disease. State regulations regarding immunization requirements for children may differ, but the child care facility should strive to comply with the national, annually published, “Recommended Childhood Immunization Schedule,” available at http://www.cispimmunize.org from the AAP, Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians (AAFP).

A child’s entrance into the facility need not be delayed if an appointment for health supervision is scheduled. Often appointments for well-child care must be scheduled several weeks in advance. In such cases, the child care facility should obtain a health history report from the parents/guardians and documentation of an appointment for routine health supervision, as a minimum requirement for the child to attend the facility on a routine basis. The child should receive immunizations on admission or provide evidence of an immunization plan to prevent an increased exposure to vaccine-preventable diseases.

Local public health staff (such as the staff of immunization units, EPSDT programs) should provide assistance to caregivers/teachers in the form of record-keeping materials, educational materials, and on-site visits for education and help with surveillance activities. A copy of a form to use for documentation of routine health supervision services is available from Model Child Care Health Policies at http://www.ecelshealthychildcarepa.org/content/MHP4thEd Total.pdf.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
9.4.1.3 Written Policy on Confidentiality of Records
Appendix I: Recommendations for Preventive Pediatric Health Care
Appendix FF: Child Health Assessment
REFERENCES
  1. American Academy of Pediatrics. 2008. Recommendations for preventive pediatric health care. http://practice.aap.org/content
    .aspx?aid=1599&nodeID=4000.
  2. 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.
  3. Haskins, R., J. Kotch. 1986. Day care and illness: Evidence, costs, and public policy. Pediatrics 77:951-82.
  4. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid. Children’s health insurance program. http://www.cms.hhs.gov/home/chip.asp.
  5. American Academy of Pediatrics. Recomended childhood immunization schedules. http://www2.aap.org/immunization/izschedule.html.
     

9.2.3.5: Documentation of Exemptions and Exclusion of Children Who Lack Immunizations


For children who have been exempted from required, up-to-date immunizations, these exemptions should be documented in the child’s health record as a cross reference, (acceptable documentation includes a statement from the child’s primary provider, a legal exemption with notarization, waiver, or other state-specific required documentation signed by the parent/guardian). See Standard 7.2.0.2 for more information.

Within two weeks of enrollment the parent/guardian should provide documentation to the child care program regarding progress in obtaining immunizations. The parent/guardian should receive written notice of exclusion if noncompliance or lack of progress is evident. If more than one immunization is needed in a series, time should be allowed for the immunizations to be obtained at the appropriate intervals. Exemptions from the requirement related to compliance with the federal McKinney-Vento Homeless Assistance Act for children experiencing homelessness are documented and include a plan for obtaining available documents within a reasonable period of time.

RATIONALE
National surveys document that child care has a positive influence on protection from vaccine-preventable illness (1). Immunizations should be required for all children in child care and early education settings. Facilities must consider the consequences if they accept responsibility for exposing a child who cannot be fully immunized (because of immaturity) to an unimmunized child who may bring disease to the facility. Although up to two weeks after the child starts to participate in child care may be allowed for the acquisition of immunizations for which the child is eligible, parents/guardians should maintain their child’s immunization status according to the nationally recommended schedule to avoid potential exposure of other children in the facility to vaccine-preventable disease.
COMMENTS
An updated immunization schedule is published annually near the beginning of the calendar year in the AAP’s Pediatrics journal and in the CDC’s MMWR and should be consulted for current information. In addition to print versions of the recommended childhood immunization schedule, the “Recommended Immunization Schedules for Persons Aged 0 through 18 Years – United States” is posted on the Websites of the CDC at http://www.cdc.gov/vaccines/schedules/index.html and the AAP at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunization/Pages/Immunization-Schedule.aspx.

When a child who has a medical exemption from immunization is included in child care, reasonable accommodation of that child requires planning to exclude such a child in the event of an outbreak. Caregivers/teachers should check the Website http://www.immunize.org/laws/ for specific state-mandated immunization requirements and exemptions.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
7.2.0.2 Unimmunized/Underimmunized Children
REFERENCES
  1. Aronson, S. S. 1986. Maintaining health in child care settings. In Group care for young children, ed. N. Gunzenhauser, B. M. Caldwell. New Brunswick, NJ: Johnson and Johnson Baby Products Company.

9.2.3.6: Identification of Child’s Medical Home and Parental Consent for Information Exchange


As part of the enrollment of a child, the caregiver/teacher should ask the family to identify the child’s primary care provider, his or her medical home, and other specialty health care professionals. The parent/guardian should provide written consent to enable the caregiver/teacher to establish communication with those providers. The family should always be informed prior to the use of the permission unless it is an emergency. The providers with whom the facility should exchange information (with parental consent) should include:

  1. Sources of regular medical and dental care (such as the child’s primary care provider, dentist, and medical facility);
  2. Special clinics the child may attend, including sessions with medical specialists and registered dietitians;
  3. Special therapists for the child (e.g., occupational, physical, speech, and nutritional), along with written documentation of the services rendered provided by the special therapist;
  4. Counselors, therapists, or mental health service providers for parents/guardians (e.g., social workers, psychologists, or psychiatrists);
  5. Pharmacists for children who take prescription medication on a regular basis or have emergency medications for specific conditions.
RATIONALE
Primary care providers are involved not only in the medical care of the child but also involved in supporting the child’s emotional and developmental needs (1-3). A major barrier to productive working relationships between child care and health care professionals is inadequate communication (1,2).

Knowing who is treating the child and coordinating services with these sources of service is vital to the ability of the caregivers/teachers to offer appropriate care to the child. Every child should have a medical home and those with special health care needs may have additional specialists and therapists (4-7). The primary care provider and needed specialists will create the Care Plan which will be the blueprint for healthy and safe inclusion into child care for the child with special health care needs.

COMMENTS
A source of health care may be a community or specialty clinic, a public health department, specialist, or a private primary care provider. Families should also know the location of the hospital emergency room departments nearest to their home and child care facility.

The California Childcare Health Program has developed a form to help facilitate the exchange of information between the health professionals and the parents/guardians and caregivers/teachers at http://ucsfchildcarehealth.org/pdfs/forms/CForm_ExchangeofInfo.pdf. They also release an information form at http://ucsfchildcarehealth.org/pdfs/forms/CF_ReferralRel.pdf. For more information on the medical home concept, see the American Academy of Pediatrics’ (AAP) Medical Home Website at http://www.medicalhome
info.org.

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior
3.5.0.1 Care Plan for Children with Special Health Care Needs
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians
Appendix AA: Medication Administration Packet
Appendix FF: Child Health Assessment
Appendix O: Care Plan for Children with Special Health Care Needs
REFERENCES
  1. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.
  2. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th 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. Starfield, B., L. Shi. 2004. The medical home, access to care, and insurance: A review of evidence. Pediatrics 113:1493-98.
  5. Homer, C. J., K. Klatka, D. Romm, K. Kuhlthau, S. Bloom, P. Newacheck, J. Van Cleave, J. M. Perrin. 2008. A review of the evidence for the medical home for children with special health care needs. Pediatrics 122:e922–37.
  6. Inkelas, M., M. Regolado, N. Halfon. 2005. Stategies for integrating developmental services and promoting medical homes. Los Angeles: National Center for Infant and Early Childhood Health Policy.
  7. Nowak, A. J., P. S. Casamassimo. 2002. The dental home: A primary care concept. JADA 133:93-98.

9.2.3.7: Information Sharing on Therapies and Treatments Needed


The person at the child care facility who is responsible for planning care for the child with special therapies or treatments should obtain an individualized care plan, developed by the child’s primary care provider or specialist on allergies, medications, therapies, and treatments being provided to the child that are directly relevant to the health and safety of the child in the child care facility. The written consent of the child’s parents/guardians and, where appropriate, the child’s primary care provider should be obtained before this confidential information is sought from outside sources. Therapies and treatments need to meet the criteria for evidenced based practices.
RATIONALE
The facility must have accurate, current information regarding the health status and treatment of the child so it will be able to determine the facility’s capability to provide needed services or to obtain them elsewhere.

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.

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 primary care provider 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
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.6.3.1 Medication Administration
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians
Appendix AA: Medication Administration Packet
Appendix O: Care Plan for Children with Special Health Care Needs

9.2.3.8: Information Sharing on Family Health


Families should be asked to share information about family health (such as chronic diseases) that might affect the child’s health. Families should be guaranteed that all information will be kept confidential.
RATIONALE
A family history of chronic disease helps caregivers/teachers understand family stress and experiences of the child within the family.
COMMENTS
Information on family health can be gathered by asking parents/guardians to tell the caregiver/teacher about any chronic health problems that the child’s parents/guardians, siblings, or household members have that might affect the child’s health. This information could also be obtained from the child’s primary care provider with permission from the parent/guardian.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

9.2.3.9: Written Policy on Use of Medications


The facility should have a written policy for the administration of any prescription or non-prescription (over-the-counter [OTC]) medication. The policy should address at least the following:

  1. The use of written parental/guardian consent forms for each prescription and OTC medication to be administered at the child care facility. The consent form should include:
    1. The child’s name;
    2. The name of the medication;
    3. The date(s) and times the medication is to be given;
    4. The dose or amount of medication to be given;
    5. How the medication is to be administered;
    6. The period of time the consent form is valid, which may not exceed the length of time the medication is prescribed for, the expiration date of the medication or one year, whichever is less.
  2. The use of the prescribing health professional’s authorization forms for each prescription and OTC medication to be administered at the child care facility.
  3. The circumstances under which the facility will agree to administer medication. This may include the administration of:
    1. Topical medications such as non-medicated diaper creams, insect repellants, and sun screens;
    2. OTC medicines for fever including acetaminophen and ibuprofen;
    3. Long-term medications that are administered daily for children with chronic health conditions that are managed with medications;
    4. Controlled substances, such as psychotropic medications;
    5. Emergency medications for children with health conditions that may become life-threatening such as asthma, diabetes, and severe allergies;
    6. One-time medications to prevent conditions such as febrile seizures.
  4. The circumstances under which the facility will not administer medication. This should include:
    1. No authorization from parent/guardian and/or prescribing health professional;
    2. Prohibition of administering OTC cough and cold medication;
    3. Not administering a new medication for the first time to a child while he or she is in child care;
    4. If the instructions are unclear or the supplies needed to measure doses or administer the medication are not available or not in good working condition;
    5. The medication has expired;
    6. If a staff person or his/her backup who has been trained to give that particular medication is not present (in the case of training for medications that require specific skills to administer properly, such as inhalers, injections, or feeding tubes/ports).
  5. The process of accepting medication from parents/guardians. This should include:
    1. Verifying the consent form;
    2. Verifying the medication matches what is on the consent form;
    3. Accepting authorization for prescription medications from the child’s prescribing health professional only if the medications are in their original container and have the child’s name, the name of the medication, the dose and directions for giving the medication, the expiration date of the medication, and a list of warnings and possible side effects;
    4. Accepting authorization for OTC medications from the child’s prescribing health professional only if the authorization indicates the purpose of the medication and time intervals of administration, and if the medications are in their original container and include the child’s name, the name of the medication, dose and directions for use, an expiration date for the medication, and a list of warnings and possible side effects;
    5. Verifying that a valid Care Plan accompanies all long-term medications (i.e., medications that are to be given routinely or available routinely for chronic conditions such as asthma, allergies, and seizures);
    6. Verifying any special storage requirements and any precautions to take while the child is on the prescription or OTC medication.
  6. The proper handling and storage of medications, including:
    1. Emergency medications – totally inaccessible to children but readily available to supervising caregivers/teachers trained to give them;
    2. Medications that require refrigeration;
    3. Controlled substances;
    4. Expired medications;
    5. A policy to insure confidentiality;
    6. Storing and preparing distribution in a quiet area completely out of access to children;
    7. Keeping all medication at all times totally inaccessible to children (e.g., locked storage);
    8. Whether to require even short-term medications be kept at the facility overnight.
  7. The procedures to follow when administering medications. These should include:
    1. Assigning administration only to an adequately trained, designated staff;
    2. Checking the written consent form;
    3. Adhering to the “six rights” of safe medication administration (child, medication, time/date, dose, route, and documentation) (1);
    4. Documenting and reporting any medication errors;
    5. Documenting and reporting and adverse effects of the medication;
    6. Documenting and reporting whether the child vomited or spit up the medication.
  8. The procedures to follow when returning medication to the family, including:
    1. An accurate account of controlled substances being administered and the amount being returned to the family;
    2. When disposing of unused medication, the remainder of a medication, including controlled substances.
  9. The disposal of medications that cannot be returned to the parent/guardian.

A medication administration record should be maintained on an ongoing basis by designated staff and should include the following:

  1. Specific, signed parental/guardian consent for the caregiver/teacher to administer medication including documentation of receiving controlled substances and verification of the amount received;
  2. Specific, signed authorization from the child’s prescribing health professional, prescribing the medication, including medical need, medication, dosage, and length of time to give medication.
  3. Information about the medication including warnings and possible side effects;
  4. Written documentation of administration of medication and any side effects;
  5. Medication errors log.

The facility should consult with the State Board of Nursing, other interested organizations and their child care health consultant about required training and documentation for medication administration. Based on the information, the facility should develop and implement a plan regarding medication administration training (9).

RATIONALE
Administering medication requires skill, knowledge and careful attention to detail. Parents/guardians and prescribing health professionals must give a caregiver/teacher written authorization to administer medication to the child (12). Caregivers/teachers must be diligent in their adherence to the medication administration policy and procedures to prevent any inadvertent medication errors, which may be harmful to the child (11). There is always a risk that a child may have a negative reaction to a medication, and children should be monitored for serious side effects that may require an emergency response. Because children twenty-four months of age and younger are in a period of rapid development and are more vulnerable to the possible side effects of medications, extra care should be given to the circumstances under which medications will be administered to this population. A child may have a negative reaction to a medication that was given at home or to one administered while attending child care. For these reasons caregivers/teachers need to be aware of each of the medications a child received at child care as well as at home. They should know the names of the medication(s), when each was given, who prescribed them, and what the known reactions or side effects may be in the event that a child has a negative reaction to the medicine (2,10).

OTC medicines are often assumed to be safe and not afforded the proper diligence. Even common drugs such as acetaminophen and ibuprofen can result in significant toxicity for infants and small children. Inaccurate dosing from the use of inaccurate measuring tools can result in illness or even death (2,3).

Cough and cold medications (CCM) are readily available OTC in the United States and are widely used to treat upper respiratory infection. These products are not safe for infants and young children and were withdrawn by the Consumer Healthcare Products Association for children less than two years of age in 2007 (4-6,8). The Food and Drug Administration (FDA) issued a public health advisory in 2008 stating these medications should not be used in children less than two years of age. The American Academy of Pediatrics (AAP) states that CCMs are not effective for children less than six years of age and their use can result in serious, adverse effects (7).

The medication record protects the person administering medication by documenting the process. The medication errors log can be reviewed and will point out what kind of intervention, if any, will be helpful in reducing the number of medication errors. Accounting for medications administered and thrown away is important for several reasons. It may assist a health professional in determining whether the child is actually getting the medicine, especially when the child is not getting better from treatment. Some medications are “controlled substances,” meaning that the medication is regulated by the federal government due to potential for abuse. Controlled substances include narcotic pain medicine, some behavior medications for ADHD, and some seizure medications. A prescribing health professional may need proper accounting for these types of medications to assure that requests for refills are because the medication was given to the patient and not used/abused by adults. Some medications, (i.e., antibiotics), can have a harmful affect on the environment if not disposed of properly.

For children with chronic health conditions or special health care needs, administering medications while the child is attending child care may be part of the child’s individualized family service plan (IFSP) or individualized education plan (IEP). Child care facilities must comply with the Americans with Disabilities Act.

COMMENTS
When a child care facility cannot return unused medication to the parent/guardian, the facility needs to dispose of the medication. An example of when medication cannot be returned is when a parent/guardian has removed the child from care and the facility cannot reach the parent/guardian to return the medication. Herbal and folk medicines and home remedies are not regulated and should not be given at child cares without a prescribing health professional’s order and complete pharmaceutical labeling. If they are given at home, the caregiver/teacher should be aware of their use and possible side effects.

A curriculum for child care providers on safe administration of medications in child care is available from the AAP at http://www.healthychildcare.org/HealthyFutures.html. A sample medication administration policy is located in Appendix AA: Medication Administration Packet.

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
3.6.3.3 Training of Caregivers/Teachers to Administer Medication
9.4.2.6 Contents of Medication Record
Appendix AA: Medication Administration Packet
REFERENCES
  1. North Carolina Child Care Health & Safety Resource Center. 2007. Steps to administering medication. http://www.healthychild
    carenc.org/PDFs/steps_admin_medication.pdf.
  2. American Academy of Pediatrics. 2009. Healthy futures: Medication administration in early education and child care settings. http://www.healthychildcare.org/HealthyFutures.html.
  3. American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
  4. American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.
  5. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Sloan Survey. Pediatrics 122:e323-29.
  6. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medicines in children. Pediatrics 121:783-87.
  7. Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.
  8. U.S. Food and Drug Administration. 2007. Nonperscription cough and cold medicine use in children. http://www.fda.gov/Safety/
    MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm152691.htm.
  9. Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/pressroom/10_11_07_OralInfantMedicines.aspx.
  10. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and medication administration in child care setttings: A case study. Policy, Politics, and Nurs Prac 6:86-98.
  11. Friedman, J. F., G. M. Lee, K. P. Kleinman, J. A. Finkelstein. 2004. Child care center policies and practices for management of ill children. Ambulatory Pediatrics 4:455-60.
  12. Sinkovits, H. S., M. W. Kelly, M. E. Ernst. 2003. Medication administration in day care centers for children. J Am Pharm Assoc 43:379-82.

9.2.3.10: Sanitation Policies and Procedures


*STANDARD UNDERGOING FULL REVISION*

The child care facility should have written sanitation policies and procedures for the following items:

  1. Maintaining equipment used for hand hygiene, toilet use, and toilet learning/training in a sanitary condition;
  2. Maintaining diaper changing areas and equipment in a sanitary condition;
  3. Maintaining toys in a sanitary condition;
  4. Managing animals in a safe and sanitary manner;
  5. Practicing proper handwashing and diapering procedures (the facility should display proper handwashing instruction signs conspicuously);
  6. Practicing proper personal hygiene of caregivers/teachers and children;
  7. Practicing environmental sanitation policies and procedures, such as sanitary disposal of soiled diapers;
  8. Maintaining sanitation for food preparation and food service.
RATIONALE
Many infectious diseases can be prevented through appropriate hygiene and sanitation practices. Bacterial cultures of environmental surfaces in facilities, which are used to gauge the adequacy of sanitation and hygiene practices, have demonstrated evidence of fecal contamination. Contamination of hands, toys, and other equipment in the room has appeared to play a role in the transmission of diseases in child care settings (1). Regular and thorough cleaning of toys, equipment, and rooms helps to prevent transmission of illness (1).

Animals can be a source of illness for people, and people may be a source of illness for animals (1).

The steps involved in effective handwashing (to reduce the amount of bacterial contamination) can be easily forgotten. Posted signs provide frequent reminders to staff and orientation for new staff. Education of caregivers/teachers regarding handwashing, cleaning, and other sanitation procedures can reduce the occurrence of illness in the group of children with whom they work (2).

Illnesses may be spread by way of:

  1. Human waste (such as urine and feces);
  2. Body fluids (such as saliva, nasal discharge, eye discharge, open skin sores, and blood);
  3. Direct skin-to-skin contact;
  4. Touching a contaminated object;
  5. The air (by droplets that result from sneezes and coughs).

Since many infected people carry communicable diseases without symptoms, and many are contagious before they experience a symptom, caregivers/teachers need to protect themselves and the children they serve by carrying out, on a routine basis, standard precautions and sanitation procedures that approach every potential illness-spreading condition in the same way.

Handling food in a safe and careful manner prevents the spread of bacteria, viruses, and fungi. Outbreaks of foodborne illness have occurred in many settings, including child care facilities.

COMMENTS
State health department rules and regulations may also guide the child care provider.
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
3.2.1.4 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
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.4.2.1 Animals that Might Have Contact with Children and Adults
3.4.2.2 Prohibited Animals
3.4.2.3 Care for Animals
4.8.0.1 Food Preparation Area
4.8.0.2 Design of Food Service Equipment
4.8.0.3 Maintenance of Food Service Surfaces and Equipment
4.8.0.4 Food Preparation Sinks
4.8.0.5 Handwashing Sinks in Food Preparation Areas
4.8.0.6 Maintaining Safe Food Temperatures
4.8.0.7 Ventilation Over Cooking Surfaces
4.8.0.8 Microwave Ovens
4.9.0.1 Compliance with U.S. Food and Drug Administration Food Sanitation Standards, State and Local Rules
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply
4.9.0.4 Leftovers
4.9.0.5 Preparation for and Storage of Food in the Refrigerator
4.9.0.6 Storage of Foods Not Requiring Refrigeration
4.9.0.7 Storage of Dry Bulk Foods
4.9.0.9 Cleaning Food Areas and Equipment
4.9.0.10 Cutting Boards
4.9.0.11 Dishwashing in Centers
4.9.0.12 Dishwashing in Small and Large Family Child Care Homes
4.9.0.13 Method for Washing Dishes by Hand
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.5 Chemical Toilets
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning and Training Equipment
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)
5.4.1.10 Handwashing Sinks
5.4.1.11 Handwashing Sinks Prohibited Uses
5.4.1.12 Mop Sinks
5.4.2.1 Diaper Changing Tables
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.3 Handwashing Sinks for Diaper Changing Areas in Homes
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.2.5 Changing Table Requirements
5.4.2.6 Maintenance of Changing Tables
5.4.3.1 Ratio and Location of Bathtubs and Showers
5.4.3.2 Safety of Bathtubs and Showers
5.7.0.6 Storage Area Maintenance and Ventilation
5.7.0.7 Structure Maintenance
5.7.0.8 Electrical Fixtures and Outlets Maintenance
5.7.0.9 Plumbing and Gas Maintenance
5.7.0.10 Cleaning of Humidifiers and Related Equipment
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
REFERENCES
  1. Chin, J., ed. 2000. Control of communicable diseases manual. Washington, DC: American Public Health Association.
  2. Kotch, J., 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:e29-36.

9.2.3.11: Food and Nutrition Service Policies and Plans

Content in the STANDARD was modified on 05/21/2019.

Early care and education programs should have food handling, feeding, and written nutrition policies and plans under the direction of the administration that address the following items:

  1. Age-appropriate eating utensils and tableware
  2. Age-appropriate portion sizes to meet nutritional needs
  3. Emergency preparedness for water and nutrition services
  4. Food allergies and special dietary restrictions, including family/cultural food preferences
  5. Food brought from home, including food brought for celebrations
  6. Food budget
  7. Food safety, sanitation, preparation, and service
  8. Food procurement and storage
  9. Kitchen and meal service staffing
  10. Kitchen layout
  11. Menu and meal planning
  12. Nutrition education for children, staff, and parents/guardians
  13. Promotion of breastfeeding and provision of community resources to support mothers

A nutritionist/registered dietitian and a food service expert should provide input for and facilitate the development and implementation of a written nutrition plan for the early care and education program.1

RATIONALE

Children spend a significant amount of time in out-of-home care; this requires 1 or 2 meals to be served during the day.2 Having a plan that clearly assigns responsibility and that encompasses the pertinent nutrition elements will promote the optimal health of all children and staff in early care and education settings. Centers following safe steps in food handling, cooking, and storage safeguard against foodborne illness.3

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
4.2.0.1 Written Nutrition Plan
4.2.0.9 Written Menus and Introduction of New Foods
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.4.0.2 Use of Nutritionist/Registered Dietitian
4.6.0.1 Selection and Preparation of Food Brought From Home
4.6.0.2 Nutritional Quality of Food Brought From Home
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
4.9.0.8 Supply of Food and Water for Disasters
5.2.6.5 Emergency Safe Drinking Water and Bottled Water
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix JJ: Breastfeeding/Chestfeeding Support in Early Care and Education Programs
REFERENCES

  1. School Nutrition Association. School nutrition professionals: roles & responsibilities. https://schoolnutrition.org/AboutSchoolMeals/SNPRolesResponsibilities. Accessed December 20, 2018

  2. Swindle T, Sigman-Grant M, Branen LJ, Fletcher J, Johnson SL. About feeding children: factor structure and internal reliability of a survey to assess mealtime strategies and beliefs of early childhood education teachers. Int J Behav Nutr Phys Act. 2018;15(1):85

  3. US Department of Agriculture, Food Safety and Inspection Service. Basics for handling food safely. https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/basics-for-handling-food-safely/ct_index. Modified March 24, 2015. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 05/21/2019.

9.2.3.12: Infant Feeding Policy


A policy about infant feeding should be developed with the input and approval from the nutritionist/registered dietitian and should include the following:

  1. Storage and handling of expressed human milk;
  2. Determination of the kind and amount of commercially prepared formula to be prepared for infants as appropriate;
  3. Preparation, storage, and handling of infant formula;
  4. Proper handwashing of the caregiver/teacher and the children;
  5. Use and proper sanitizing of feeding chairs and of mechanical food preparation and feeding devices, including blenders, feeding bottles, and food warmers;
  6. Whether expressed human milk, formula, or infant food should be provided from home, and if so, how much food preparation and use of feeding devices, including blenders, feeding bottles, and food warmers, should be the responsibility of the caregiver/teacher;
  7. Holding infants during bottle-feeding or feeding them sitting up;
  8. Prohibiting bottle propping during feeding or prolonging feeding;
  9. Responding to infants’ need for food in a flexible fashion to allow cue feedings in a manner that is consistent with the developmental abilities of the child (policy acknowledges that feeding infants on cue rather than on a schedule may help prevent obesity) (1,2);
  10. Introduction and feeding of age-appropriate solid foods (complementary foods);
  11. Specification of the number of children who can be fed by one adult at one time;
  12. Handling of food intolerance or allergies (e.g., cow’s milk, peanuts, orange juice, eggs, wheat).

Individual written infant feeding plans regarding feeding needs and feeding schedule should be developed for each infant in consultation with the infant’s primary care provider and parents/guardians.

RATIONALE
Growth and development during infancy require that nourishing, wholesome, and developmentally appropriate food be provided, using safe approaches to feeding. Because individual needs must be accommodated and improper practices can have dire consequences for the child’s health and safety, the policy for infant feeding should be developed with professional nutritionists/registered dietitians. The infant feeding plans should be developed with each infant’s parents/guardians and, when appropriate, in collaboration with the child’s primary care provider.
TYPE OF FACILITY
Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.8.0.8 Microwave Ovens
Appendix JJ: Breastfeeding/Chestfeeding Support in Early Care and Education Programs
REFERENCES
  1. Birch, L., W. Dietz. 2008. Eating behaviors of young child: Prenatal and postnatal influences on healthy eating, 59-93. Elk Grove Village, IL: American Academy of Pediatrics.
  2. Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry, M. W. Gillman. 2006. To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction? Pediatrics 118:2341-48.

9.2.3.13: Plans for Evening and Nighttime Child Care


Facilities that provide evening and nighttime care should have plans for such care that include the supervision of sleeping children and the management and maintenance of sleep equipment including their sanitation and disinfection. Evacuation drills should occur during hours children are in care. Centers should have these plans in writing.
RATIONALE
Evening child care routines are similar to those required for daytime child care with the exception of sleep routines. Evening and nighttime child care requires special attention to sleep routines, safe sleep environment, supervision of sleeping children, and personal care routines, including bathing and tooth brushing. Nighttime child care must meet the nutritional needs of the children and address morning personal care routines such as toileting/diapering, hygiene, and dressing for the day. Children and staff must be familiar with evacuation procedures in case a natural or human generated disaster occurs during evening child care and nighttime child care hours.
COMMENTS
Sleeping time is a very sensitive time for infants and young children. Attention should be paid to individual needs, transitional objects, lighting preferences, and bedtime routines.
TYPE OF FACILITY
Center, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
2.2.0.1 Methods of Supervision of Children
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.4 Futons
5.4.5.5 Bunk Beds
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.2.4.5 Emergency and Evacuation Drills Policy

9.2.3.14: Oral Health Policy


The program should have an oral health policy that includes the following:

  1. Information about fluoride content of water at the facility;
  2. Contact information for each child’s dentist;
  3. Resource list for children without a dentist;
  4. Implementation of daily tooth brushing or rinsing the mouth with water after eating;
  5. Use of sippy cups and bottles only at mealtimes during the day, not at naptimes;
  6. Prohibition of serving sweetened food products;
  7. Promotion of healthy foods per the USDA’s Child and Adult Care Food Program (CACFP);
  8. Early identification of tooth decay;
  9. Age-appropriate oral health educational activities;
  10. Plan for handling dental emergencies.
RATIONALE
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 (1). Tooth brushing and activities at home may not suffice to develop the skill of proper tooth brushing or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care.
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
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
5.5.0.1 Storage and Labeling of Personal Articles
REFERENCES
  1. American Academy of Pediatric Dentistry. 2009. Clinical guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. Pediatric Dentistry 30:112-18.

9.2.3.15: Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances

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

 

Facilities should have written policies addressing the use and possession of tobacco and electronic cigarette (e-cigarette) products, alcohol, illegal drugs, legal drugs (e.g. medicinal/recreational marijuana, prescribed narcotics, etc.) that have side effects that diminish the ability to properly supervise and care for children or safely drive program vehicles, and other potentially toxic substances. Policies should include that all of these substances are prohibited inside the facility, on facility grounds, and in any vehicles that transport children at all times. Policies should specify that smoking and vaping is prohibited at all times and in all areas (indoor and outdoor) of the program. This includes any vehicles that are used to transport children.

Policies must also specify that use and possession of all substances referred to above are prohibited during all times when caregivers/teachers are responsible for the supervision of children, including times when children are transported, when playing in outdoor play areas not attached to the facility, and during field trips and staff breaks.

Child care centers and large family child care homes should provide information to employees about available drug, alcohol, and tobacco counseling and rehabilitation, and any available employee assistance programs.

RATIONALE
The age, defenselessness, and lack of discretion of the child under care make this prohibition an absolute requirement. 

The hazards of second-hand and third-hand smoke exposure warrant the prohibition of smoking in proximity of child care areas at any time (1-10). Third-hand smoke refers to gases and particles clinging to smokers’ hair and clothing, cushions, carpeting and outdoor equipment after visible tobacco smoke has dissipated (9). The residue includes heavy metals, carcinogens, and even 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 (10). 

Safe child care necessitates sober caregivers/teachers. Alcohol and drug use, including the misuse of prescription, over-the-counter (OTC), or recreational drugs, prevent caregivers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and response time. Off-site use prior to or during work, of alcohol and illegal drugs is prohibited. OTC medications or prescription medications that have not been prescribed for the user or that could impair motor coordination, judgment, and response time is prohibited.

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

COMMENTS
The policies related to smoking and use of prohibited substances should be discussed with staff and parents/guardians. Educational material such as handouts could include information on the health risks and dangers of these prohibited substances and referrals to services for counseling or rehabilitation programs.

It is strongly recommended that, whenever possible, all caregivers/teachers should be non-tobacco and non-electronic cigarette (e-cigarette) users. Family child care homes should be kept smoke-free at all times to prevent exposure of the children who are cared for in these spaces.

In states that permit recreational and/or medicinal use of marijuana, special care is needed to store edible marijuana products securely and apart from other foods. State regulations typically required that these products be clearly labeled as containing an intoxicating substance and stored in the original packaging that is tamper-proof and child-proof. Any legal edible marijuana products in a family child care home should be helpy in a locked and child-resistant storage device. 

TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
5.2.9.1 Use and Storage of Toxic Substances
6.5.1.2 Qualifications for Drivers
REFERENCES
  1. U.S. Environmental Protection Agency. Secondhand tobacco smoke and smoke-free homes. 2016. https://www.epa.gov/indoor-air-quality-iaq/secondhand-tobacco-smoke-and-smoke-free-homes.
  2. 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. 
  3. 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.
  4. Dreyfuss, J.H. Thirdhand smoke identified as potent, enduring carcinogen. CA Cancer J Clin. 2010;60(4):203-204. https://www.ncbi.nlm.nih.gov/pubmed/20530799.
  5. 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. 
  6. Hang, B., Sarker, A.H., Havel, C., et al. Thirdhand smoke causes DNA damage in human cells. Mutagenesis. 2013;28(4):381-391. https://www.ncbi.nlm.nih.gov/pubmed/23462851. 
  7. 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.
  8. 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.
  9. 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/. 
  10. Campaign for Tobacco-Free Kids. Secondhand smoke, kids and cars. 2016. http://www.tobaccofreekids.org/research/factsheets/pdf/0334.pdf.
  11. ADDITIONAL REFERENCES
     
    U.S. Fire Administration. Electronic cigarette fires and explosions. 2014. https://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf.
     
    Campbell. R. Electronic Cigarette Explosions and Fires: The 2015 Experience. 2016. http://www.nfpa.org/news-and-research/fire-statistics-and-reports/fire-statistics/fire-causes/electrical-and-consumer-electronics/electronic-cigarette-explosions-and-fires-the-2015-experience.
     
    National Institute on Drug Abuse. 2016. What is marijuana? https://www.drugabuse.gov/publications/drugfacts/marijuana.
     
    Rapoport, M.J., Lanctôt, K.L., Streiner, D.L., Bédard, M., Vingilis, E., Murray, B., Schaffer, A., Shulman, K.I., Herrmann, N. Benzodiazepine use and driving: A meta-analysis. J Clin Psychiatry. 2009;70(5):663-73. doi:10.4088/JCP.08m04325.
     
    Sansone, R.A., Sansome, L.A. Driving on Antidepressants: Cruising for a crash?. Psychiatry (Edgmont). 2009:6(9): 13–16. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766284/.
     
    Volkow, N.D., Baler, R.D., Compton, W.M., R.B. Weiss, S.R.B. Adverse health effects of marijuana use. N Engl J Med 2014:370:2219-2227. DOI: 10.1056/NEJMra1402309.
     
    Lenné MG, Dietze PM, Triggs TJ, Walmsley S, Murphy B, Redman JR. The effects of cannabis and alcohol on simulated arterial driving: Influences of driving experience and task demand. Accid Anal Prev. 2010;42(3):859-866. doi:10.1016/j.aap.2009.04.021.
     
    Hartman RL, Huestis MA. Cannabis effects on driving skills.Clin Chem. 2013;59(3):478-492. doi:10.1373/clinchem.2012.194381.
     
    Verster, J. C., D. S. Veldhuijzen, E. R. Volkerts. 2005. Is it safe to drive a car when treated with anxiolytics? Evidence from on the road driving studies during normal traffic. Current Psychiatry Reviews1:215-25.
     
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    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/.
     
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NOTES

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

 

9.2.3.16: Policy Prohibiting Firearms


Centers should have a written policy prohibiting firearms, ammunition, and ammunition supplies.

Large or small family homes should have a written policy that if firearms and other weapons are present, they should:

  1. Have child protective devices;
  2. Be unloaded or disarmed;
  3. Be kept under lock and key;
  4. Be inaccessible to children.

For large and small family homes the policy should include that ammunition and ammunition supplies should be:

  1. Placed in locked storage;
  2. Separate from firearms;
  3. Inaccessible to children.

Parents/guardians should be notified that firearms and other weapons are on the premises.

RATIONALE
The potential for injury to and death of young children due to firearms is apparent (1-3). These items should not be accessible to children in a facility (2,3).
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, Committee on Injury and Poison Prevention. 2004. Policy statement: Firearm-related injuries affecting the pediatric population. Pediatrics 114:1126.
  2. DiScala, C., R. Sege. 2004. Outcomes in children and young adults who are hospitalized for firearms-related injuries. Pediatrics 113:1306-12.
  3. Grossman, D. C., B. A. Mueller, C. Riedy, et al. 2005. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA 296:707-14.

9.2.3.17: Child Care Health Consultant’s Review of Health Policies


At least annually, after an incident or injury has occurred, or when changes are made in the health policies, the facility should obtain input and a review of the policies from a child care health consultant.
RATIONALE
Changes in health information may require changes in the health policies of a child care facility. These changes are best known to health professionals who stay in touch with sources of updated information and can suggest how the new information applies to the operation of the child care program (1,2). For example, when the information on the importance of back-positioning for putting infants down to sleep became available, it needed to be added to child care policies. Frequent changes in recommended immunization schedules offer another example of the need for review and modification of health policies.
TYPE OF FACILITY
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS
1.6.0.1 Child Care Health Consultants
REFERENCES
  1. Alkon, A., J. Farrer, J. Bernzweig. 2004. Child care health consultants’ roles and responsibilities: Focus group findings. Pediatric Nursing 30:315-21.
  2. Dellert, J. C, D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37.