Special Collection

Caring for Infants and Toddlers in Early Care and Education (I/T)

Copyright © 2014
American Academy of Pediatrics
American Public Health Association
National Resource Center for Health and Safety in Child Care and Early Education

Caring for Infants and Toddlers in Child Care and Early Education may be reproduced without permission only for educational purposes and/or personal use. To reproduce any portion of this publication, in any form, for commercial purposes, please contact the Permissions Editor at the American Academy of Pediatrics by fax (847/434-8780), mail (PO Box 927, Elk Grove Village, IL 60007-1019), or email (marketing@aap.org).

This project was supported by Grant Number U46MCO9810 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Suggested Citation:

American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. 2014. Caring for infants and toddlers in child care and early education. Applicable standards from: Caring for our children: National health and safety performance standards; Guidelines for early care and education programs, 3rd Edition. Elk Grove Village, IL: American Academy of Pediatrics; Washington, DC: American Public Health Association.

Available at http://nrckids.org.

The Caring for Our Children, 3rd Edition Standards are for reference purposes only and shall not be used as a substitute for medical or legal consultation, nor be used to authorize actions beyond a person’s licensing, training, or ability.

Document Design & Layout: Betty Geer, Lorina Washington

Caring for Infants and Toddlers in Early Care and Education (I/T) Comparison/Compliance Checklist - PDF (Updated January 2019)

Suggestions for Use of the Compliance/Comparison Checklist:

By licensing staff who want to compare Stepping Stones standards to the subject areas covered in their state regulations and determine where there are gaps and where regulations should be added.
By caregivers/teachers/directors who want to be sure they are complying with those standards that have the most potential to prevent harm to children in their settings.
By families who want to be sure their child’s early care and education program is complying with these important standards.
By child care health consultants and trainers to assess what topics need to be covered when providing training.
Be sure to save the checklist to your device in order to use the interactive checklist feature.

I. Enrollment and Admission

1.1.2.1 Minimum Age to Enter Child Care
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian

Staffing, Consultants, and Supervision

1.6.0.1 Child Care Health Consultants
1.6.0.2 Frequency of Child Care Health Consultation Visits
1.6.0.3 Infant and Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants
1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
2.2.0.1 Methods of Supervision of Children
2.2.0.4 Supervision Near Bodies of Water
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves

Staff Qualifications and Training

1.2.0.2 Background Screening
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age
1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.3.3.1 General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home
1.4.1.1 Pre-service Training
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.5.2 Child Abuse and Neglect Education
1.5.0.2 Orientation of Substitutes
7.4.0.2 Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.7.1.1 Staff Education and Policies on Cytomegalovirus (CMV)

Consultants

Supervision

Environment and Equipment

Building and Environment: Inside and Outside

5.1.1.5 Assessment of the Environment at the Site Location
5.1.1.7 Use of Basements and Below Grade Areas
5.1.1.12 Multiple Use of Rooms
5.1.2.1 Space Required per Child
5.1.3.2 Possibility of Exit from Windows
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.1.2 Indoor Temperature and Humidity
5.2.1.6 Ventilation to Control Odors
5.2.1.11 Portable Electric Space Heaters
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.8.1 Integrated Pest Management
5.2.9.4 Radon Concentrations
5.2.9.10 Prohibition of Poisonous Plants
5.2.9.13 Testing for and Remediating Lead Hazards
5.2.9.14 Shoes in Infant Play Areas
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
6.1.0.1 Size and Location of Outdoor Play Area
6.1.0.2 Size and Requirements of Indoor Play Area
6.1.0.4 Elevated Play Areas
6.3.1.1 Enclosure of Bodies of Water

Equipment, Materials, and Toys

Facility

3.4.6.1 Strangulation Hazards
5.1.5.4 Guards at Stairway Access Openings
5.1.6.6 Guardrails and Protective Barriers
5.2.4.2 Safety Covers and Shock Protection Devices for Electrical Outlets
5.2.5.1 Smoke Detection Systems and Smoke Alarms
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.3.1.1 Indoor and Outdoor Equipment, Materials, and Furnishing
5.3.1.3 Size of Furniture
5.3.1.4 Surfaces of Equipment, Furniture, Toys, and Play Materials
5.3.1.7 Facility Arrangements to Minimize Back Injuries
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning and Training Equipment
5.4.2.1 Diaper Changing Tables
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.2.5 Changing Table Requirements
5.4.1.10 Handwashing Sinks
5.4.1.11 Prohibited Uses of Handwashing Sinks
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.3 Handwashing Sinks for Diaper Changing Areas in Homes
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.4 Futons
5.5.0.7 Storage of Plastic Bags
5.5.0.8 Firearms
6.3.3.4 Pool Water Temperature
6.3.5.1 Hot Tubs, Spas, and Saunas
6.3.5.2 Water in Containers
6.4.1.5 Balloons
6.5.2.2 Child Passenger Safety
6.5.2.4 Interior Temperature of Vehicles

Food Preparation and Feeding Area

4.5.0.2 Tableware and Feeding Utensils
4.8.0.1 Food Preparation Area
4.8.0.8 Microwave Ovens
5.3.1.8 High Chair Requirements

Play Areas

5.2.9.7 Proper Use of Art and Craft Materials
5.3.1.9 Carriage, Stroller, Gate, Enclosure, and Play Yard Requirements
6.2.1.1 Play Equipment Requirements
6.2.1.7 Enclosure of Moving Parts on Play Equipment
6.2.1.9 Entrapment Hazards of Play Equipment
6.2.4.3 Sensory Table Materials
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
6.4.1.3 Crib Toys
6.4.2.1 Riding Toys with Wheels and Wheeled Equipment
6.4.2.2 Helmets

Program Activities for Healthy Development

Developmentally Appropriate Practice

2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.1.1.5 Helping Families Cope with Separation
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.1.1.7 Communication in Native Language Other Than English
2.1.1.9 Verbal Interaction
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.2.2 Interactions with Infants and Toddlers
2.1.2.3 Space and Activity to Support Learning of Infants and Toddlers
2.1.2.4 Separation of Infants and Toddlers from Older Children
2.1.2.5 Toilet Learning/Training
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
2.2.0.3 Screen Time/Digital Media Use
2.2.0.5 Behavior Around a Pool
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
5.3.1.10 Restrictive Infant Equipment Requirements
9.2.1.1 Content of Policies
9.2.2.1 Planning for Child’s Transition to New Services

Positive Behavior Management

2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.2.0.10 Using Physical Restraint
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies

Healthy Weight Promotion

Physical Activity

3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
9.2.3.1 Policies and Practices that Promote Physical Activity

B. Nutrition

4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.1 General Plan for Feeding Infants
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.1 Developmentally Appropriate Seating and Utensils for Meals
4.5.0.4 Socialization During Meals
4.5.0.8 Experience with Familiar and New Foods
4.7.0.1 Nutrition Learning Experiences for Children
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy

Safe and Healthy Practices and Procedures

Safe Food Practices

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
4.3.1.9 Warming Bottles and Infant Foods
4.5.0.3 Activities that Are Incompatible with Eating
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult
4.5.0.9 Hot Liquids and Foods
4.5.0.10 Foods that Are Choking Hazards
4.8.0.4 Food Preparation Sinks
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply
5.2.9.9 Plastic Containers and Toys

Health Promotion and Protection

3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.4.2 Swaddling
3.1.4.3 Pacifier Use
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
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
3.2.2.5 Hand Sanitizers
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.5.0.2 Caring for Children Who Require Medical Procedures
4.2.0.10 Care for Children with Food Allergies
9.4.1.9 Records of Injury

C. Cleaning/Sanitizing/Disinfecting Practices

3.2.3.1 Procedure for Nasal Secretions and Use of Nasal Bulb Syringes
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
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
4.3.1.1 General Plan for Feeding Infants
5.4.2.6 Maintenance of Changing Tables
9.2.3.10 Sanitation Policies and Procedures

Infection Control/Disease Prevention and Management

3.1.1.1 Conduct of Daily Health Check
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.3 Guidelines for Taking Children’s Temperatures
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
5.2.7.4 Containment of Soiled Diapers
5.2.7.5 Labeling, Cleaning, and Disposal of Waste and Diaper Containers
5.5.0.1 Storage and Labeling of Personal Articles
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized/Underimmunized Children
7.2.0.3 Immunization of Staff
7.3.2.1 Immunization for Haemophilus Influenzae Type B (HIB)
7.3.3.1 Influenza Immunizations for Children and Staff
7.3.5.1 Recommended Control Measures for Invasive Meningococcal Infection in Child Care
7.3.7.3 Exclusion for Pertussis (Whooping Cough)
7.3.8.1 Attendance of Children with Respiratory Syncytial Virus Infection (RSV)
7.3.11.1 Attendance of Children with Unspecified Respiratory Tract Infection
7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.5.1.1 Conjunctivitis (Pinkeye)
7.5.10.1 Staphylococcus Aureus Skin Infections Including MRSA
7.5.12.1 Thrush (Candidiasis)
7.7.2.1 Disease Recognition and Control of Herpes Simplex Virus

Medication Administration

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

Abuse/Neglect

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
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
3.6.4.5 Death
5.6.0.1 First Aid and Emergency Supplies
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

Appendices

Appendix A: Signs and Symptoms Chart
Appendix D: Gloving
Appendix E: Child Care Staff Health Assessment
Appendix F: Enrollment/Attendance/Symptom Record
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule
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 M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures
Appendix W: Sample Food Service Cleaning Schedule
Appendix Y: Non-Poisonous and Poisonous Plants
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment
Appendix AA: Medication Administration Packet
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America’s Playgrounds Safety Report Card
Appendix II: Bike and Multi-Sport Helmets: Quick-Fit Check
Appendix JJ: Our Child Care Center Supports Breastfeeding
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix NN: First Aid and Emergency Supply Lists
Appendix P: Situations that Require Medical Attention Right Away
Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule
Appendix Q: MyPlate: Make It Yours
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix R: Choose MyPlate: 10 Tips to a Great Plate
Appendix S: Physical Activity: How Much Is Needed?
Appendix CC: Incident Report Form

I. Enrollment and Admission

Standard 1.1.2.1: Minimum Age to Enter Child Care

Reader’s Note: This standard reflects a desirable goal when sufficient resources are available; it is understood that for some families, waiting until three months of age to enter their infant in child care may not be possible.

Healthy full-term infants can be enrolled in child care settings as early as three months of age. Premature infants or those with chronic health conditions should be evaluated by their primary care providers and developmental specialists to make an individual determination concerning the appropriate age for child care enrollment.

RATIONALE

Brain anatomy, chemistry, and physiology undergo rapid development over the first ten to twelve weeks of life (1-6). Concurrently, and as a direct consequence of these shifts in central nervous system structure and function, infants demonstrate significant growth, irregularity, and eventually, organization of their behavior, physiology, and social responsiveness (1-3,5). Arousal responses to stimulation mature before the ability to self-regulate and control such responses in the first six to eight weeks of life causing infants to demonstrate an expanding range and fluctuation of behavioral state changes from quiet to alert to irritable (1-3,6). Infant behavior is most disorganized, most difficult to read and most frustrating to support at the six to eight week period (2,3). At approximately eight to twelve weeks after birth, full term infants typically undergo changes in brain function and behavior that helps caregivers/teachers understand and respond effectively to infants’ increasingly stable sleep-wake states, attention, self-calming efforts, feeding patterns and patterns of social engagement. Over the course of the third month, infants demonstrate an emerging capacity to sustain states of sleep and alert attention.

Infants, birth to three months of age, can become seriously ill very quickly without obvious signs (7). This increased risk to infants, birth to three months makes it important to minimize their exposure to children and adults outside their family, including exposures in child care (8). In addition, infants of mothers who return to work, particularly full-time, before twelve weeks of age, and are placed in group care may be at even greater risk for developing serious infectious diseases. These infants are less likely to receive recommended well-child care and immunizations and to be breastfed or are likely to have a shorter duration of breastfeeding (16,22).

Researchers report that breastfeeding duration was significantly higher in women with longer maternity leaves as compared to those with less than nine to twelve weeks leave (9,22). A leave of less than six weeks was associated with a much higher likelihood of stopping breastfeeding (10,22). Continuing breastfeeding after returning to work may be particularly difficult for lower income women who may have fewer support systems (11).

It takes women who have given birth about six weeks to return to the physical health they had prior to pregnancy (12). A significant portion of women reported child birth related symptoms five weeks after delivery (17). In contrast, women’s general mental health, vitality, and role function were improved with maternity leaves at twelve weeks or longer (13).

Birth of a child or adoption of a newborn, especially the first, requires significant transition in the family. First time parents/guardians are learning a new role and even with subsequent children, integration of the new family member requires several weeks of adaptation. Families need time to adjust physically and emotionally to the intense needs of a newborn (14,15).

COMMENTS

In an analysis of twenty-one wealthy countries including Australia, New Zealand, Canada, United States, Japan, and several European countries, the U.S. ranked twentieth in terms of unpaid and paid parental leave available to two-parent families with the birth of their child (18,21). Although Switzerland ranked twenty-first with fourteen versus twenty-four weeks as compared to the U.S. for both parents/guardians, eleven weeks of leave are paid in Switzerland. In this study of twenty-one countries, only Australia and the U.S. do not provide for paid leave after the birth of a child (18).

Major social policies in the U.S. were established with the Social Security Act in 1935 at a time when the majority of women were not employed (19,20). The Family and Medical Leave Act (FMLA) of 1993, which allows twelve weeks of leave, established for the first time job protected maternity leave for qualifying employees (16,20). Despite the importance of FMLA, only about 60% of the women in the workforce are eligible for job protected maternity leave. FMLA does not provide paid leave, which may force many women to return to work sooner than preferred (18). FMLA is not transferable between parents/guardians. However, five U.S. states support five to six weeks of paid maternity leave and a few companies allow generous paid leaves for select employees (21).

In a nationally representative sample, 84% of women and 74% of men supported expansion of the FMLA; furthermore, 90% of women and 72% of men reported that employers and government should do more to support families (21).

Substantial evidence exists to strengthen social policies, specifically job protected paid leave for all families, for at least the first twelve weeks of life, in order to promote the health and development of children and families (22). Investing in families during an important life transition, the birth or adoption of a child, reflects a society’s values and may in fact contribute to a healthier and more productive work force.

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.1.5 Helping Families Cope with Separation

REFERENCES

Staehelin, K., P. C. Bertea, E. Z. Stutz. 2007. Length of maternity leave and health of mother and child–a review. Int J Public Health 52:202-9.
Guendelman, S., J. L. Kosc, M. Pearl, S. Graham, J. Goodman, M. Kharrazi. 2009. Juggling work and breastfeeding: Effects of maternity leave and occupational characteristics. Pediatrics 123: e38-e46.
McGovern P., B. Dowd, D. Gjerdingen, I. Moscovice, L. Kochevar, W. Lohman. 1997. Time off work and the postpartum health of employed women. Medical Care 35:507-21.
Cunningham, F. G., F. F. Gont, K. J. Leveno, L. C. Gilstrap, J. C. Hauth, K. D. Wenstrom. 2005. Williams obstretrics. 21st ed. New York: McGraw Hill.
Kimbro, R. T. 2006. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Maternal Child Health J 10:19-26.
Carter, B., M. McGoldrick, eds. 2005. The expanded family life cycle: Individual, family, and social perspectives. 3rd ed. New York: Allyn and Bacon Classics.
Ishimine, P. 2006. Fever without source in children 0-36 months. Pediatric Clinics North Am 53:167.
Harper, M. 2004. Update on the management of the febrile infant. Clin Pediatric Emerg Med 5:5-12.
Carey, W. B., A. C. Crocker, E. R. Elias, H. M. Feldman, W. L. Coleman. 2009. Developmental-behavioral pediatrics. 4th ed. Philadelphia: W. B. Saunders.
Parmelee, A. H. Jr, W. Weiner, H. Schultz. 1964. Infant sleep patterns: From birth to 16 weeks of age. J Pediatrics 65:576-82.
Brazelton, T. B. 1962. Crying in infancy. Pediatrics 29:579-88.
Huttenlocher, P. R., C. de Courten. 1987. The development of synapses in striate cortex of man. Human Neurobiology 6:1-9.
Anders, T. F. 1992. Sleeping through the night: A developmental perspective. Pediatrics 90:554-60.
Edelstein, S., J. Sharlin, S. Edelstein. 2008. Life cycle nutrition: An evidence-based approach. Boston: Jones and Bartlett.
Robertson, S. S. 1987. Human cyclic motility: Fetal-newborn continuities and newborn state differences. Devel Psychobiology 20:425-42.
Berger, L. M., J. Hill, J. Waldfogel. 2005. Maternity leave, early maternal employment and child health and development in the US. Economic J 115: F29-F47.
McGovern, P., B. Dowd, D. Gjerdingen, C. R. Gross, S. Kenney, L. Ukestad, D. McCaffrey, U. Lundberg. 2006. Postpartum health of employed mothers 5 weeks after childbirth. Annals Fam Med 4:159-67.
Ray, R., J. C. Gornick, J. Schmitt. 2009. Parental leave policies in 21 countries: Assessing generosity and gender equality. Rev. ed. Washington, DC: Center for Economic and Policy Research.
Social Security Act. 1935. 42 USC 7.
Family and Medical Leave Act. 1993. 29 USC 2601.
Lovell, V., E. O’Neill, S. Olsen. 2007. Maternity leave in the United States: Paid parental leave is still not standard, even among the best U.S. employers. Washington, DC: Institute for Women’s Policy Research. http://iwpr.org/pdf/parentalleaveA131.pdf.
Human Rights Watch. 2011. Failing its families: Lack of paid leave and work-family supports in the U.S. http://www.hrw.org/en/reports/2011/02/23/failing-its-families-0/.

Standard 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/Teachers

At enrollment, and before assumption of supervision of children by caregivers/teachers at the facility, the facility should provide parents/guardians and caregivers/teachers with a statement of services, policies, and procedures, including, but not limited, to the following:

The licensed capacity, child:staff ratios, ages and number of children in care. If names of children and parents/guardians are made available, parental/guardian permission for any release to others should be obtained;
Services offered to children including a written daily activity plan, sleep positioning policies and arrangements, napping routines, guidance and discipline policies, diaper changing and toilet learning/training methods, child handwashing, medication administration policies, oral health, physical activity, health education, and willingness for special health or therapy services delivered at the program (special requirements for a child should be clearly defined in writing before enrollment);
Hours and days of operation;
Admissions criteria, enrollment procedures, and daily sign-in/sign-out policies, including authorized individuals for pick-up and allowing parent/guardian access whenever their child is in care;
Payment of fees, deposits, and refunds;
Methods and schedules for conferences or other methods of communication between parents/guardians and staff.

Policies on:

Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
Inclusion of children with special health care needs;
Nondiscrimination;
Termination and parent/guardian notification of termination;
Supervision;
Discipline;
Care of children and caregivers/teachers who are ill;
Temporary exclusion and alternative care for children who are ill;
Health assessments and immunizations;
Handling urgent medical care or threatening incidents;
Medication administration;
Use of child care health consultants, education and mental health consultants;
Plan for health promotion and prevention (tracking routine child health care, health consultation, health education for children/staff/families, oral health, sun safety, safety surveillance, etc.);
Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
Security;
Confidentiality of records;
Transportation and field trips;
Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
Sanitation and hygiene;
Presence and care of any animals on the premises;
Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
Evening and night care plan;
Smoking, tobacco use, alcohol, prohibited substances, and firearms;
Preventing and reporting child abuse and neglect;
Use of pesticides and other potentially toxic substances in or around the facility.

Parents/guardians and caregivers/teachers should sign that they have reviewed and accepted this statement of services, policies, and procedures. Policies, plans and procedures should generally be reviewed annually or when any changes are made.

RATIONALE

Model Child Care Health Policies, available at http://www.ecels-healthychildcarepa.org/content/MHP4thEd Total.pdf, has text to comply with many of the topics covered in this standard. Each policy has a place for the facility to fill in blanks to customize the policies for a specific site. The text of the policies can be edited to match individual program operations. Starting with a template such as the one in Model Child Care Health Policies can be helpful.

COMMENTS

For large and small family child care homes, a written statement of services, policies, and procedures is strongly recommended and should be added to the “Parent Handbook.” Conflict over policies can lead to termination of services and inconsistency in the child’s care arrangements. If the statement is provided orally, parents/guardians should sign a statement attesting to their acceptance of the statement of services, policies and procedures presented to them. Model Child Care Health Policies can be adapted to these smaller settings.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
2.1.1.1 Written Daily Activity Program and Statement of Principles
1.6.0.1 Child Care Health Consultants
3.1.1.1 Conduct of Daily Health Check
3.1.1.2 Documentation of the Daily Health Check
3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
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
3.3.0.1 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
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
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
3.4.3.1 Medical Emergency Procedures
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.2.1 Exclusion and Alternative Care for Children Who Are Ill
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
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
4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition
4.2.0.12 Vegetarian/Vegan Diets
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
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.6.0.1 Selection and Preparation of Food Brought From Home
4.6.0.2 Nutritional Quality of Food Brought From Home
9.2.1.1 Content of Policies
9.2.3.2 Policy Development for Care of Children and Staff Who Are Ill
9.2.3.9 Written Policy on Use of Medications
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
9.2.3.13 Plans for Evening and Nighttime Child Care
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
9.2.3.16 Policy Prohibiting Firearms
9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.2.4.2 Review of Written Plan for Urgent Care and Threatening Incidents
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
9.2.4.6 Use of Daily Roster During Evacuation Drills
9.2.4.7 Sign-In/Sign-Out System
9.2.4.8 Authorized Persons to Pick Up Child
9.2.4.9 Policy on Actions to Be Followed When No Authorized Person Arrives to Pick Up a Child
9.2.4.10 Documentation of Drop-Off, Pick-Up, Daily Attendance of Child, and Parent/Provider Communication
9.4.1.3 Written Policy on Confidentiality of Records
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.1.1.5 Helping Families Cope with Separation
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.1.1.7 Communication in Native Language Other Than English
2.1.1.8 Diversity in Enrollment and Curriculum
2.1.1.9 Verbal Interaction
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.1.2.2 Interactions with Infants and Toddlers
2.1.2.3 Space and Activity to Support Learning of Infants and Toddlers
2.1.2.4 Separation of Infants and Toddlers from Older Children
2.1.2.5 Toilet Learning/Training
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.1.3.2 Opportunities for Learning for Three- to Five-Year-Olds
2.1.3.3 Selection of Equipment for Three- to Five-Year-Olds
2.1.3.4 Expressive Activities for Three- to Five-Year-Olds
2.1.3.5 Fostering Cooperation of Three- to Five-Year-Olds
2.1.3.6 Fostering Language Development of Three- to Five-Year-Olds
2.1.3.7 Body Mastery for Three- to Five-Year-Olds
2.1.4.1 Supervised School-Age Activities
2.1.4.2 Space for School-Age Activity
2.1.4.3 Developing Relationships for School-Age Children
2.1.4.4 Planning Activities for School-Age Children
2.1.4.5 Community Outreach for School-Age Children
2.1.4.6 Communication Between Child Care and School
2.2.0.1 Methods of Supervision of Children
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
2.2.0.3 Screen Time/Digital Media Use
2.2.0.4 Supervision Near Bodies of Water
2.2.0.5 Behavior Around a Pool
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.2.0.10 Using Physical Restraint
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
2.4.1.3 Gender and Body Awareness
2.4.2.1 Health and Safety Education Topics for Staff
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians
2.4.3.2 Parent/Guardian Education Plan
6.4.2.2 Helmets
6.4.2.3 Bike Routes
6.5.1.1 Competence and Training of Transportation Staff
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized/Underimmunized Children
7.2.0.3 Immunization of Staff

Standard 9.4.2.3: Contents of Admission Agreement Between Child Care Program and Parent/Guardian

The file for each child should include an admission agreement signed by the parent/guardian at enrollment. The admission agreement should contain the following topics and documentation of consent:

General topics:
1. Operating days and hours;
2. Holiday closure dates;
3. Payment for services;
4. Drop-off and pick-up procedures;
5. Family access (visiting site at any time when their child is there and admitted immediately under normal circumstances) and involvement in child care activities;
6. Name and contact information of any primary staff person designation, especially primary caregivers/teachers designated for infants and toddlers, to make parent/guardian contact of a caregiver/teacher more comfortable.
Health topics:
1. Immunization record;
2. Breast feeding policy;
3. For infants, statement that parent/guardian(s) has received and discussed a copy of the program’s infant safe sleep policy;
4. Documentation of written consent signed and dated by the parent/guardian for:
5. Any health service obtained for the child by the facility on behalf of the parent/guardian. Such consent should be specific for the type of care provided to meet the tests for “informed consent” to cover on-site screenings or other services provided;
6. Administration of medication for prescriptions and non-prescription medications (over-the-counter [OTC]) including records and special care plans (if needed).
Safety topics:
1. Prohibition of corporal punishment in the child care facility;
2. Statement that parent/guardian has received and discussed a copy of the state child abuse and neglect reporting requirements;
3. Documentation of written consent signed and dated by the parent/guardian for:
4. Emergency transportation;
5. All other transportation provided by the facility;
6. Planned or unplanned activities off-premises (such consent should give specific information about where, when, and how such activities should take place, including specific information about walking to and from activities away from the facility);
7. Swimming, if the child will be participating;
8. Release of any information to agencies, schools, or providers of services;
9. Written authorization to release the child to designated individuals other than the parent/guardian.

RATIONALE

These records and reports are necessary to protect the health and safety of children in care.

These consents are needed by the person delivering the medical care. Advance consent for emergency medical or surgical service is not legally valid, since the nature and extent of injury, proposed medical treatment, risks, and benefits cannot be known until after the injury occurs, but it does allow the parent/guardian to guide the caregiver/teacher in emergency situations when the parent/guardian cannot be reached (1). See Appendix KK: Authorization for Emergency Medical/Dental Care for an example.

The parent/guardian/child care partnership is vital.

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
Appendix KK: Authorization for Emergency Medical/Dental Care

REFERENCES

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. 2007. Policy statement: Consent for emergency medical services for children and adolescents. Pediatrics 120:683-84.

Staffing, Consultants, and Supervision

Standard 1.6.0.1: Child Care Health Consultants

COVID-19 modification as of May 21, 2021

*STANDARD UNDERGOING FULL REVISION*

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

A facility should identify and engage/partner with a child care health consultant (CCHC) who is a licensed health professional with education and experience in child and community health and child care and preferably specialized training in child care health consultation.

CCHCs have knowledge of resources and regulations and are comfortable linking health resources with child care facilities.

The child care health consultant should be knowledgeable in the following areas:

Consultation skills both as a child care health consultant as well as a member of an interdisciplinary team of consultants;
National health and safety standards for out-of-home child care;
Indicators of quality early care and education;
Day-to-day operations of child care facilities;
State child care licensing and public health requirements;
State health laws, Federal and State education laws [e.g., Americans with Disabilities Act (ADA), Individuals with Disabilities Education Act (IDEA)], and state professional practice acts for licensed professionals (e.g., State Nurse Practice Acts);
Infancy and early childhood development, social and emotional health, and developmentally appropriate practice;
Recognition and reporting requirements for infectious diseases;
American Academy of Pediatrics (AAP) and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening recommendations and immunizations schedules for children;
Importance of medical home and local and state resources to facilitate access to a medical home as well as child health insurance programs including Medicaid and State Children’s Health Insurance Program (SCHIP);
Injury prevention for children;
Oral health for children;
Nutrition and age-appropriate physical activity recommendations for children including feeding of infants and children, the importance of breastfeeding and the prevention of obesity;
Inclusion of children with special health care needs, and developmental disabilities in child care;
Safe medication administration practices;
Health education of children;
Recognition and reporting requirements for child abuse and neglect/child maltreatment;
Safe sleep practices and policies (including reducing the risk of SIDS);
Development and implementation of health and safety policies and practices including poison awareness and poison prevention;
Staff health, including adult health screening, occupational health risks, and immunizations;
Disaster planning resources and collaborations within child care community;
Community health and mental health resources for child, parent/guardian and staff health;
Importance of serving as a healthy role model for children and staff.

The child care health consultant should be able to perform or arrange for performance of the following activities:

Assessing caregivers’/teachers’ knowledge of health, development, and safety and offering training as indicated;
Assessing parents’/guardians’ health, development, and safety knowledge, and offering training as indicated;
Assessing children’s knowledge about health and safety and offering training as indicated;
Conducting a comprehensive indoor and outdoor health and safety assessment and on-going observations of the child care facility;
Consulting collaboratively on-site and/or by telephone or electronic media;
Providing community resources and referral for health, mental health and social needs, including accessing medical homes, children’s health insurance programs (e.g., CHIP), and services for special health care needs;
Developing or updating policies and procedures for child care facilities (see comment section below);
Reviewing health records of children;
Reviewing health records of caregivers/teachers;
Assisting caregivers/teachers and parents/guardians in the management of children with behavioral, social and emotional problems and those with special health care needs;
Consulting a child’s primary care provider about the child’s individualized health care plan and coordinating services in collaboration with parents/guardians, the primary care provider, and other health care professionals (the CCHC shows commitment to communicating with and helping coordinate the child’s care with the child’s medical home, and may assist with the coordination of skilled nursing care services at the child care facility);
Consulting with a child’s primary care provider about medications as needed, in collaboration with parents/guardians;
Teaching staff safe medication administration practices;
Monitoring safe medication administration practices;
Observing children’s behavior, development and health status and making recommendations if needed to staff and parents/guardians for further assessment by a child’s primary care provider;
Interpreting standards, regulations and accreditation requirements related to health and safety, as well as providing technical advice, separate and apart from an enforcement role of a regulation inspector or determining the status of the facility for recognition;
Understanding and observing confidentiality requirements;
Assisting in the development of disaster/emergency medical plans (especially for those children with special health care needs) in collaboration with community resources;
Developing an obesity prevention program in consultation with a nutritionist/registered dietitian (RD) and physical education specialist;
Working with other consultants such as nutritionists/RDs, kinesiologists (physical activity specialists), oral health consultants, social service workers, infant and early childhood mental health consultants, and education consultants.

The role of the CCHC is to promote the health and development of children, families, and staff and to ensure a healthy and safe child care environment (11).

The CCHC is not acting as a primary care provider at the facility but offers critical services to the program and families by sharing health and developmental expertise, assessments of child, staff, and family health needs and community resources. The CCHC assists families in care coordination with the medical home and other health and developmental specialists. In addition, the CCHC should collaborate with an interdisciplinary team of early childhood consultants, such as, early childhood education, mental health, and nutrition consultants.

In order to provide effective consultation and support to programs, the CCHC should avoid conflict of interest related to other roles such as serving as a caregiver/teacher or regulator or a parent/guardian at the site to which child care health consultation is being provided.

The CCHC should have regular contact with the facility’s administrative authority, the staff, and the parents/guardians in the facility. The administrative authority should review, and collaborate with the CCHC in implementing recommended changes in policies and practices. In the case of consulting about children with special health care needs, the CCHC should have contact with the child’s medical home with permission from the child’s parent/guardian.

Programs with a significant number of non-English-speaking families should seek a CCHC who is culturally sensitive and knowledgeable about community health resources for the parents’/guardians’ native culture and languages.

COVID-19 modification as of May 21, 2021

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 early childhood programs:

Follow guidance from your state and local health department as well as your state child care licensing agency.

Use child care health consultants (CCHCs) during COVID for their knowledge and relationships with local pediatric and public health professionals to:

Share up-to-date information with programs
Support implementation of new guidance for operation during COVID-19
Review and update pertinent health and safety policies
Offer opportunities to deliver timely staff trainings via webinar
Share updates on local COVID-19 vaccination efforts, be open to answer questions and listen to concerns from staff and families

Address the many delays in children’s health care due to missed health and dental appointments during COVID-19 by working with the CCHC to:

Develop a plan to identify and assess overdue childhood immunizations and missed medical, behavioral health and dental appointments
Connect families with health care resources that provide medical homes and support preventative care and developmental screenings
Regularly monitor the overall health status of children and follow up with needed referrals and resources

Consider alternatives to CCHC onsite consultation and schedule other methods for delivering services:

Use virtual video visits or phone conferencing to review health care plans, medications, address health and safety issues and any training needs
Share video of the environment, without children present, for the CCHC to review
Plan outdoor visits, if weather allows, using face mask and physical distancing

Refer to the COVID-19 modifications in CFOC Standard 1.7.0.2: Daily Staff Health Check when on site visits are essential.

Additional Resources:

Centers for Disease Control and Prevention. How Schools and Early Care and Education (ECE) Programs Can Support COVID-19 Vaccination

American Academy of Pediatrics. Guidance Related to Childcare During COVID-19

Center for Health Care Strategies. COVID-19 and the Decline of Well-Child Care: Implications for Children, Families, and States

Child Care Aware of America. Conducting Child Care Program Visits During COVID-19 (childcareaware.org)

RATIONALE

CCHCs provide consultation, training, information and referral, and technical assistance to caregivers/teachers (10). Growing evidence suggests that CCHCs support healthy and safe early care and education settings and protect and promote the healthy growth and development of children and their families (1-10). Setting health and safety policies in cooperation with the staff, parents/guardians, health professionals, and public health authorities will help ensure successful implementation of a quality program (3). The specific health and safety consultation needs for an individual facility depend on the characteristics of that facility (1-2). All facilities should have an overall child care health consultation plan (1,2,10).

The special circumstances of group care may not be part of the health care professional’s usual education. Therefore, caregivers/teachers should seek child care health consultants who have the necessary specialized training or experience (10). Such training is available from instructors who are graduates of the National Training Institute for Child Care Health Consultants (NTI) and in some states from state-level mentoring of seasoned child care health consultants known to chapter child care contacts networked through the Healthy Child Care America (HCCA) initiatives of the AAP.

Some professionals may not have the full range of knowledge and expertise to serve as a child care health consultant but can provide valuable, specialized expertise. For example, a sanitarian may provide consultation on hygiene and infectious disease control and a Certified Playground Safety Inspector would be able to provide consultation about gross motor play hazards.

COMMENTS

The U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) has supported the development of state systems of child care health consultants through HCCA and State Early Childhood Comprehensive Systems grants. Child care health consultants provide services to centers as well as family child care homes through on-site visits as well as phone or email consultation. Approximately twenty states are funding child care health consultant initiatives through a variety of funding sources, including Child Care Development Block Grants, TANF, and Title V. In some states a wide variety of health consultants, e.g., nutrition, kinesiology (physical activity), mental health, oral health, environmental health, may be available to programs and those consultants may operate through a team approach. Connecticut is an example of one state that has developed interdisciplinary training for early care and education consultants (health, education, mental health, social service, nutrition, and special education) in order to develop a multidisciplinary approach to consultation (8).

Some states offer CCHC training with continuing education units, college credit, and/or a certificate of completion. Credentialing is an umbrella term referring to the various means employed to designate that individuals or organizations have met or exceeded established standards. These may include accreditation of programs or organizations and certification, registration, or licensure of individuals. Accreditation refers to a legitimate state or national organization verifying that an educational program or organization meets standards. Certification is the process by which a non-governmental agency or association grants recognition to an individual who has met predetermined qualifications specified by the agency or association. Certification is applied for by individuals on a voluntary basis and represents a professional status when achieved. Typical qualifications include 1) graduation from an accredited or approved program and 2) acceptable performance on a qualifying examination. While there is no national accreditation of CCHC training programs or individual CCHCs at this time, this is a future goal.

CCHC services may be provided through the public health system, resource and referral agency, private source, local community action program, health professional organizations, other non-profit organizations, and/or universities. Some professional organizations include child care health consultants in their special interest groups, such as the AAP’s Section on Early Education and Child Care and the National Association of Pediatric Nurse Practitioners (NAPNAP).

CCHCs who are not employees of health, education, family service or child care agencies may be self-employed. Compensating them for their services via fee-for-service, an hourly rate, or a retainer fosters access and accountability.

Listed below is a sample of the policies and procedures child care health consultants should review and approve:

Admission and readmission after illness, including inclusion/exclusion criteria;
Health evaluation and observation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance;
Plans for care and management of children with communicable diseases;
Plans for prevention, surveillance and management of illnesses, injuries, and behavioral and emotional problems that arise in the care of children;
Plans for caregiver/teacher training and for communication with parents/guardians and primary care providers;
Policies regarding nutrition, nutrition education, age-appropriate infant and child feeding, oral health, and physical activity requirements;
Plans for the inclusion of children with special health or mental health care needs as well as oversight of their care and needs;
Emergency/disaster plans;
Safety assessment of facility playground and indoor play equipment;
Policies regarding staff health and safety;
Policy for safe sleep practices and reducing the risk of SIDS;
Policies for preventing shaken baby syndrome/abusive head trauma;
Policies for administration of medication;
Policies for safely transporting children;
Policies on environmental health – handwashing, sanitizing, pest management, lead, etc.

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.3 Infant and Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants

REFERENCES

Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81.
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.
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 Nurs 32:530-37.
Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health consultation: A conceptual model. J for Specialists in Pediatric Nurs 13:74-88.
Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
Heath, J. M., et al. 2005. Creating a statewide system of multi-disciplinary consultation system for early care and education in Connecticut. Farmington, CT: Child Health and Development Institute of Connecticut. http://nitcci.nccic.acf.hhs.gov/resources/10262005_93815_901828.pdf.
Farrer, J., A. Alkon, K. To. 2007. Child care health consultation programs: Barriers and opportunities. Maternal Child Health J 11:111-18.
Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.
Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21.
Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.

NOTES

COVID-19 modification as of May 21, 2021

Standard 1.6.0.2: Frequency of Child Care Health Consultation Visits

Content in the STANDARD was modified on 8/22/2013.

The child care health consultant (CCHC) should visit each facility as needed to review and give advice on the facility’s health component and review the overall health status of the children and staff (1-4). Early childhood programs that serve any child younger than three years of age should be visited at least once monthly by a health professional with general knowledge and skills in child health and safety and health consultation. Child care programs that serve children three to five years of age should be visited at least quarterly and programs serving school-age children should be visited at least twice annually. In all cases, the frequency of visits should meet the needs of the composite group of children and be based on the needs of the program for training, support, and monitoring of child health and safety needs, including (but not limited to) infectious disease, injury prevention, safe sleep, nutrition, oral health, physical activity and outdoor learning, emergency preparation, medication administration, and the care of children with special health care needs. Written documentation of CCHC visits should be maintained at the facility.

RATIONALE

Almost everything that goes on in a facility and almost everything about the facility itself affects the health of the children, families, and staff. (1-4). Because infants are developing rapidly, environmental situations can quickly create harm. Their rapid changes in behavior make regular and frequent visits by the CCHC extremely important (2-4). More frequent visits should be arranged for those facilities that care for children with special health care needs and those programs that experience health and safety problems and high turnover rate to ensure that staff have adequate training and ongoing support (2). In one study, 84% of child care directors who were required to have weekly health consultation visits considered the visits critical for children’s health and program health and safety (2). Growing evidence suggests that frequent visits by a trained health consultant improves health policies and health and safety practices and improves children’s immunization status, access to a medical home, enrollment in health insurance, timely screenings, and potentially reduces the prevalence of obesity with a targeted intervention (5-11). Furthermore, in one state, child care center medication administration regulatory compliance was associated with weekly visits by a trained nurse child care health consultant who delivered a standardized best practice curriculum (12).

COMMENTS

State child care regulations display a wide range of frequency and recommendations in states that require CCHC visits (5,6,13), from as frequently as once a week for programs serving children under three years of age to twice a year for programs serving children three to five years of age (2,5,6,13).

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
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
10.3.4.3 Support for Consultants to Provide Technical Assistance to Facilities
10.3.4.4 Development of List of Providers of Services to Facilities
3.6.2.7 Child Care Health Consultants for Facilities That Care for Children Who Are Ill
4.4.0.1 Food Service Staff by Type of Facility and Food Service
4.6.0.2 Nutritional Quality of Food Brought From Home
9.4.1.17 Documentation of Child Care Health Consultation/Training Visits

REFERENCES

National Resource Center for Health and Safety in Child Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/default/assets/File/CCHC%20by%20state%20NOV%202012_FINAL.pdf.
Crowley, A. A. & Rosenthal, M. S. IMPACT: Ensuring the health and safety of Connecticut’s early care and education programs. 2009. Farmington, CT: The Child Health and Development Institute of Connecticut.
Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Improvement of child care programs’ policies, practices, and children’s access to health care linked to child care health consultation. NHSA Dialog: A Research to Practice Journal 2013;16 (2):34-52 (ISSN:1930-1395).
Bryant, D. “Quality Interventions for Early Care and Education.” Early Developments, Spring 2013, http://fpg.unc.edu/sites/default/files/resources/early-developments/FPG_EarlyDevelopments_v14n1.pdf.
Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. Nutrition and physical activity self-assessment for child care (NAP SACC): Results from a pilot intervention. Journal of Nutrition Education and Behavior 39(3):142-9.
Nurse Consultant Intervention Improves Nutrition and Physical Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care. A. Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, V. Ngyuen, J. Kotch. Head Start Research Conference, Washington, DC. June 20, 2012.
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.
Crowley, A. A. & Kulikowich, J. Impact of training on child care health consultant knowledge and practice. Pediatric Nursing.,2009, 35 (2): 93-100.
Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.
Healthy Child Care Consultant Network Support Center, CHT Resource Group. 2006. The influence of child care health consultants in promoting children’s health and well-being: A report on selected resources. http://hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf.
Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.
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.
Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.

NOTES

Content in the STANDARD was modified on 8/22/2013.

Standard 1.6.0.3: Infant and Early Childhood Mental Health Consultants

COVID-19 modification as of October 10, 2022.

Standard was last updated on September 13, 2022.

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

Early care and education programs should find and work with qualified infant and early childhood mental health consultants (IECMHCs) to help create environments that promote social-emotional development and health in early childhood, to help with behavioral concerns, and to lower staff stress.

Programs should find and work with IECMHCs who:

Have professional credentials and expertise in early childhood development and child mental health such as psychiatry, psychology, developmental-behavioral pediatrics, clinical social work, or nursing
Work well with children, families, and program staff from different racial, ethnic, and cultural/language backgrounds
Have an understanding of infants and young children who have developmental delays or disabilities
Are experienced in trauma-informed care of young children and families
Are familiar with early care and education policies, practices, and regulations
Can partner with program directors, staff, and families, and work together with professionals of other disciplines

Programs should expect an IECMHC to share or help develop:

An assessment of the program’s needs, strengths, and areas for improvement in mental health
Policies on child, family, and staff mental health
Individual observations of children and staff to assess children’s development, behavior, and related needs
Resources for teaching children about understanding their feelings, emotional regulation (managing or expressing their emotional responses effectively), coping strategies, conflict resolution, empathy, and social skills
Connections and/or referrals to community mental health providers and special education systems or resources
Resources to understand the mental health needs of specific children or families
Collaboration for screening or referral of children to early intervention services and/or local providers
Lists of community resources for families and staff who may need mental health support

Program staff should work with an IECMHC to develop the following skills:

Create and keep up healthy social-emotional environments and relationships in the program and with families

Understand and support staff to manage children’s challenging behaviors (such as aggression and tantrums) as well as internalizing behaviors (such as anxiety and depression), and how to respond appropriately
Recognize and respond to the needs of children who are sad or anxious, avoid others, or harm themselves
Partner with staff to make sure children with developmental delays and disabilities are included safely and meaningfully in all activities and experiences, within the scope of the mental health consultant’s expertise
Approach families about behavioral or mental health concerns for their children
Recognize the daily stressors and mental health needs of families and staff
Respond appropriately to child, family, or community crises (such as serious illness, homelessness, substance abuse, divorce, deaths, or natural events like tornados, floods, wildfires)
Understand staff’s obligations and required actions as mandated reporters
Identify and address staff’s work-related stress, responses to stress, and self-care needs

Early care and education program leadership/staff and IECMHCs should meet regularly to discuss program needs and talk about concerns for children’s development and behavior.

COVID-19 modification as of October 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 early childhood programs:

Follow guidance from your state and local health department as well as your state child care licensing agency.

Infant and early childhood mental health consultants (IECMHCs) can support recovery and reduce harm from the social, emotional, and mental health challenges children and families face during COVID-19, such as:

Disrupted learning environments
Disrupted health care access (e.g., missed well-child and immunization visits, limited access to mental, speech, and occupational health services)
Lost security and safety (e.g., food insecurity and housing, increased exposure to violence and online harms, threat of physical illness and future uncertainty)

Refer to the Centers for Disease Control and Prevention’s COVID-19 Parental Resources Kit to support children and families with these challenges.

Use IECMHCs to deliver:

Individual and group staff consultation to guide their work with children and families
Child and family consultation and connect to resources and services as needed

Consider alternatives to IECMHCs onsite consultation and schedule other methods for delivering services:

Use Virtual video visits or phone to review child social and emotional health needs, address health and safety issues and any training needs
Plan outdoor visits, if weather allows

Additional Resources:

Center of Excellence for Infant and Early Childhood Mental Health Consultation. COVID-19 and Infant and Early Childhood Mental Health Consultation (IECMHC): How to Provide Services When Everything Is Different

Center for Early Childhood Mental Health Consultation. https://www.ecmhc.org/
Early Childhood Learning and Knowledge Center. Head Start Heals Campaign

RATIONALE

Infant and early childhood mental health is essential to develop many life skills. ^1-4Many children learn these skills in early care and education settings.^5–6 For example, children learn to take turns, wait for rewards, and respond to challenges and frustrations. However, many factors can interfere with this learning.

Many children have adverse childhood experiences early in life such as child abuse, domestic violence, homelessness, parental substance abuse, and racism.^7–9 Greater exposure to these experiences often results in behaviors that lead to a child’s suspension or expulsion from early care and education programs.¹⁰ Staff may be aware of adverse experiences or see signs of a child’s distress such as acting out, persistent sadness, anxiety, or withdrawal from others.¹¹With training on trauma-informed practices, teachers can help lower the harmful effects of stress on children; this training creates safe, trusting environments for learning and forming relationships.¹²Staff can help to identify children and families who may need referral for mental health care.

When children’s emotional struggles turn into challenging behaviors, they can disrupt group activities. These events may raise staff stress, sometimes causing harsh responses.^13,14 Unintentional prejudices result in more suspension or expulsion of children with disabilities, children with behavioral challenges, and children of color.^15–19 Program staff need strategies to effectively lower and deal with challenging behaviors. They also need to be more aware of their own experiences and biases, and have ways to recognize and lower their stress levels.

Infant and early childhood mental health consultation is an evidence-based strategy that has helped early educators address complex issues for better outcomes for children, families, and staff.²⁰ Qualified consultants can work with a program, classroom, and individual children and families. Consultants can help form policies for child supervision, discipline, suspension/expulsion, preventing and reporting child abuse and neglect, inclusion of children with disabilities, confidentiality of records, and staff wellness, and help staff follow the policies. They can share lessons and classroom strategies to promote development of essential social-emotional skills, reduce challenging behaviors, and eliminate expulsions. They can also build a program’s capacity to identify and support the mental health needs of individual children, families, and staff. ^{13, 18, 21-23}An ongoing relationship with a consultant is strongly recommended for shared understanding and trust.^24,25

COMMENTS

Programs may find qualified consultants by contacting local mental health and behavioral care providers (e.g., child clinical and school psychologists, licensed clinical social workers, child psychiatrists, developmental pediatricians, qualified health care providers). Some state, local, tribal, or territorial child care licensing, early education, or human service agencies may keep lists of qualified mental health consultants. Local colleges and universities may be able to help find graduate school professionals-in-training (trainees). The cost for trainees may be lower than for community professionals, but turnover is likely to be higher as trainees complete their studies. To make sure someone can provide the services, ask about credentials and experience (or ongoing supervision for consultants-in-training). This includes asking about up-to-date professional licensure and certifications, types of services, frequency of contact, and the cost.

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
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age
1.4.5.2 Child Abuse and Neglect Education
1.6.0.4 Early Childhood Education Consultants
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
1.7.0.5 Stress Management for Staff
10.3.4.3 Support for Consultants to Provide Technical Assistance to Facilities
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.17 Documentation of Child Care Health Consultation/Training Visits
9.4.2.8 Release of Child’s Records
2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.1.1.5 Helping Families Cope with Separation
2.2.0.1 Methods of Supervision of Children
2.2.0.6 Discipline Measures
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.10 Using Physical Restraint

REFERENCES

Cummings KP, Swindell J. Using a trauma-sensitive lens to support children with diverse experiences. Young Except Child. 2019;22(3):139-149. https://doi.org/10.1177/1096250618756898
Miles E, Stoker J, Senehi N, et al. Suspension and expulsion in Colorado early care and education settings: child, program, and community‐level predictors. Infant Ment Health J. 2021;42(6):767-783. https://doi.org/10.1002/imhj.21944
Hooper A, Schweiker C. Prevalence and predictors of expulsion in home‐based child care settings. Infant Ment Health J. 2020;41(3):411-425. https://doi.org/10.1002/imhj.21845
Davis AE, Perry DF, Rabinovitz L. Expulsion prevention: framework for the role of infant and early childhood mental health consultation in addressing implicit biases. Infant Ment Health J. 2020;41(3):327-339. doi:10.1002/imhj.21847
Zeng S, Pereira B, Larson A, Corr CP, O’Grady C, Stone-MacDonald A. Preschool suspension and expulsion for young children with disabilities. Except Child. 2021;87(2):199-216. doi:10.1177/0014402920949832
Zinsser KM, Zulauf CA, Das VN, Silver HC. Utilizing social-emotional learning supports to address teacher stress and preschool expulsion. J Appl Dev Psychol. 2019;61:33-42. https://doi.org/10.1016/j.appdev.2017.11.006
Davis AE, Barrueco S, Perry DF. The role of consultative alliance in infant and early childhood mental health consultation: child, teacher, and classroom outcomes. Infant Ment Health J. 2021;42(2):246-262. doi:10.1002/imhj.21889
Gilliam WS, Maupin AN, Reyes CR. Early childhood mental health consultation: results of a statewide random-controlled evaluation. J Am Acad Child Adolesc Psychiatry. 2016;55(9):754-761. doi:10.1016/j.jaac.2016.06.006
Centers for Disease Control and Prevention. Coughing and sneezing. CDC.gov Web site. Last reviewed April 22, 2020. Accessed November 3, 2021. https://www.cdc.gov/healthywater/hygiene/etiquette/coughing_sneezing.html
Silver HC, Zinsser KM. The interplay among early childhood teachers’ social and emotional well-being, mental health consultation, and preschool expulsion. Early Educ Dev. 2020;31(7):1133-1150. https://doi.org/10.1080/10409289.2020.1785267
Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 states. JAMA Pediatr. 2018;172(11):1038-1044. doi:10.1001/jamapediatrics.2018.2537
Stegelin D, Leggett C, Ricketts D, Bryant M, Peterson C, Holzner A. Trauma-informed preschool education in public school classrooms: responding to suspension, expulsion, and mental health issues of young children. J Risk Issues. 2020;23(2):9-24. https://files.eric.ed.gov/fulltext/EJ1286553.pdf
Giano Z, Wheeler DL, Hubach RD. The frequencies and disparities of adverse childhood experiences in the U.S. BMC Public Health. 2020;20(1):1327. doi:10.1186/s12889-020-09411-z
Berry D, Blair C, Willoughby M, Garrett-Peters P, Vernon-Feagans L, Mills-Koonce WR, Family Life Project Key Investigators. Household chaos and children’s cognitive and socio-emotional development in early childhood: does childcare play a buffering role?. Early Child Res Q. 2016;34:115-127. https://doi.org/10.1016/j.ecresq.2015.09.003
Qi CH, Zieher A, Lee Van Horn M, Bulotsky-Shearer R, Carta J. Language skills, behaviour problems, and classroom emotional support among preschool children from low-income families. Early Child Dev Care. 2020;190(14):2278-2290. https://doi.org/10.1080/03004430.2019.1570504
Robson DA, Allen MS, Howard SJ. Self-regulation in childhood as a predictor of future outcomes: a meta-analytic review. Psychol Bull. 2020;146(4):324-354. doi:10.1037/bul0000227
HammerD, Melhuish E, Howard SJ. Antecedents and consequences of social–emotional development: a longitudinal study of academic achievement. Arch Sci Psychol. 2018;6(1):105. http://dx.doi.org/10.1037/arc0000034
Hammer D, Melhuish E, Howard SJ. Do aspects of social, emotional and behavioural development in the pre-school period predict later cognitive and academic attainment?. Aust J Educ. 2017 Nov;61(3):270-287. https://doi.org/10.1177/0004944117729514
Bartlett JD, Smith S. The role of early care and education in addressing early childhood trauma. Am J Community Psychol. 2019;64(3-4):359-372. https://doi.org/10.1002/ajcp.12380
Whitebrook M, McLean C, August LJE, Edwards B. Early childhood workforce index 2018. Berkeley, CA: Center for the Study of Child Care Employment, University of California, Berkeley; 2018. Accessed August 26, 2021. https://cscce.berkeley.edu/wp-content/uploads/2018/06/Early-Childhood-Workforce-Index-2018.pdf
Zeng S, Corr CP, O’Grady C, Guan Y. Adverse childhood experiences and preschool suspension expulsion: a population study. Child Abuse Negl. 2019;97:104149. https://doi.org/10.1016/j.chiabu.2019.104149
Vuyk MA, Sprague‐Jones J, Reed C. Early childhood mental health consultation: an evaluation of effectiveness in a rural community. Infant Ment Health J. 2016;37(1):66-79. https://doi.org/10.1002/imhj.21545
Conners Edge NA, Kyzer A, Abney A, Freshwater A, Sutton M, Whitman K. Evaluation of a statewide initiative to reduce expulsion of young children. Infant Ment Health J. 2021;42(1):124-139. https://doi.org/10.1002/imhj.21894
National Scientific Council on the Developing Child. Establishing a level foundation for life: mental health begins in early childhood: Working Paper 6. Updated Edition. Published December 2012. Accessed February 21, 2022. https://developingchild.harvard.edu/resources/establishing-a-level-foundation-for-life-mental-health-begins-in-early-childhood/
Trivedi P, deMonsabert J, Horen N. Infant and early childhood mental health consultation: overview of research, best practices, and examples. Published 2021. Accessed February 22, 2022. https://childcareta.acf.hhs.gov/sites/default/files/public/pdgb5_iecmhc_rtpbrief_acc.pdf

NOTES

COVID-19 modification as of October 10, 2022.

Standard was last updated on September 13, 2022.

Standard 1.6.0.4: Early Childhood Education Consultants

A facility should engage an early childhood education consultant who will visit the program at minimum semi-annually and more often as needed. The consultant must have a minimum of a Baccalaureate degree and preferably a Master’s degree from an accredited institution in early childhood education, administration and supervision, and a minimum of three years in teaching and administration of an early care/education program. The facility should develop a written plan for this consultation which must be signed annually by the consultant. This plan should outline the responsibilities of the consultant and the services the consultant will provide to the program.

The knowledge base of an early childhood education consultant should include:

Working knowledge of theories of child development and learning for children from birth through eight years across domains, including socio-emotional development and family development;
Principles of health and wellness across the domains, including social and emotional wellness and approaches in the promotion of healthy development and resilience;
Current practices and materials available related to screening, assessment, curriculum, and measurement of child outcomes across the domains, including practices that aid in early identification and individualizing for a wide range of needs;
Resources that aid programs to support inclusion of children with diverse health and learning needs and families representing linguistic, cultural, and economic diversity of communities;
Methods of coaching, mentoring, and consulting that meet the unique learning styles of adults;
Familiarity with local, state, and national regulations, standards, and best practices related to early education and care;
Community resources and services to identify and serve families and children at risk, including those related to child abuse and neglect and parent education;
Consultation skills as well as approaches to working as a team with early childhood consultants from other disciplines, especially child care health consultants, to effectively support program directors and their staff.

The role of the early childhood education consultant should include:

Review of the curriculum and written policies, plans and procedures of the program;
Observations of the program and meetings with the director, caregivers/teachers, and parents/guardians;
Review of the professional needs of staff and program and provision of recommendations of current resources;
Reviewing and assisting directors in implementing and monitoring evidence based approaches to classroom management;
Maintaining confidences and following all Family Educational Rights and Privacy Act (FERPA) regulations regarding disclosures;
Keeping records of all meetings, consultations, recommendations and action plans and offering/providing summary reports to all parties involved;
Seeking and supporting a multidisciplinary approach to services for the program, children and families;
Following the National Association for the Education of Young Children (NAEYC) Code of Ethics;
Availability by telecommunication to advise regarding practices and problems;
Availability for on-site visit to consult to the program;
Familiarity with tools to evaluate program quality, such as the Early Childhood Environment Rating Scale–Revised (ECERS–R), Infant/Toddler Environment Rating Scale–Revised (ITERS–R), Family Child Care Environment Rating Scale–Revised (FCCERS–R), School-Age Care Environment Rating Scale (SACERS), Classroom Assessment Scoring System (CLASS), as well as tools used to support various curricular approaches.

RATIONALE

The early childhood education consultant provides an objective assessment of a program and essential knowledge about implementation of child development principles through curriculum which supports the social and emotional health and learning of infants, toddlers and preschool age children (1-5). Furthermore, utilization of an early childhood education consultant can reduce the need for mental health consultation when challenging behaviors are the result of developmentally inappropriate curriculum (6,7). Together with the child care health consultant, the early childhood education consultant offers core knowledge for addressing children’s healthy development.

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
1.6.0.3 Infant and Early Childhood Mental Health Consultants

REFERENCES

Connecticut Department of Public Health. Child day care licensing program. http://www.ct.gov/dph/cwp/view
.asp?a=3141&Q=387158&dphNav_GID=1823/.
The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org.
Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Rev ed. National Association for the Education of Young Children (NAEYC). Publication no. 234. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. Baltimore, MD: Brookes Publishing.
Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53.
Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics Early Childhood Special Ed 26:131-41.
Dunn, L., K. Susan. 1997. What have we learned about developmentally appropriate practice? Young Children 52:4-13.

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

The small family child care home caregiver/teacher child:staff ratios should conform to the following table:

If the small family child care home caregiver/teacher has no children under two years of age in care,	then the small family child care home caregiver/teacher may have one to six children over two years of age in care
If the small family child care home caregiver/teacher has one child under two years of age in care,	then the small family child care home caregiver/teacher may have one to three children over two years of age in care
If the small family child care home caregiver/teacher has two children under two years of age in care,	then the small family child care home caregiver/teacher may have no children over two years of age in care

The small family child care home caregiver’s/teacher’s own children as well as any other children in the home temporarily requiring supervision should be included in the child:staff ratio. During nap time, at least one adult should be physically present in the same room as the children.

RATIONALE

Low child:staff ratios are most critical for infants and toddlers (birth to thirty-six months) (1). Infant and child development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower child:staff ratios (3). Small ratios are very important for young children’s development (7). The recommended group size and child:staff ratio allow three- to five-year-old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4).

The National Fire Protection Association (NFPA) requires in the NFPA 101: Life Safety Code that small family child care homes serve no more than two clients incapable of self-preservation (5).

Direct, warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers/teachers must be recognized as performing a job for groups of children that parents/guardians of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes (6,8).

COMMENTS

It is best practice for the caregiver/teacher to remain in the same room as the infants when they are sleeping to provide constant supervision. However in small family child care programs, this may be difficult in practice because the caregiver/teacher is typically alone, and all of the children most likely will not sleep at the same time. In order to provide constant supervision during sleep, caregivers/teachers could consider discontinuing the practice of placing infant(s) in a separate room for sleep, but instead placing the infant’s crib in the area used by the other children so the caregiver/teacher is able to supervise the sleeping infant(s) while caring for the other children. Care must be taken so that placement of cribs in an area used by other children does not encroach upon the minimum usable floor space requirements. Infants do not require a dark and quiet place for sleep. Once they become accustomed, infants are able to sleep without problems in environments with light and noise. By placing infants (as well as all children in care) on the main (ground) level of the home for sleep and remaining on the same level as the children, the caregiver/teacher is more likely able to evacuate the children in less time; thus, increasing the odds of a successful evacuation in the event of a fire or another emergency. Caregivers/teachers must also continually monitor other children in this area so they are not climbing on or into the cribs. If the caregiver/teacher cannot remain in the same room as the infant(s) when the infant is sleeping, it is recommended that the caregiver/teacher should do visual checks every ten to fifteen minutes to make sure the infant’s head is uncovered, and assess the infant’s breathing, color, etc. Supervision is recommended for toddlers and preschoolers to ensure safety and prevent behaviors such as inappropriate touching or hurting other sleeping children from taking place. These behaviors may go undetected if a caregiver/teacher is not present. If caregiver/teacher is not able to remain in the same room as the children, frequent visual checks are also recommended for toddlers and preschoolers when they are sleeping.

Each state has its own set of regulations that specify child:staff ratios. To view a particular state’s regulations, go to the National Resource Center for Health and Safety in Child Care and Early Education’s (NRC) Website: http://nrckids.org. Some states are setting limits on the number of school-age children that are allowed to be cared for in small family child care homes, e.g., two school-age children in addition to the maximum number allowed for infants/preschool children. No data are available to support using a different ratio where school-age children are in family child care homes. Since school-age children require focused caregiver/teacher time and attention for supervision and adult-child interaction, this standard applies the same ratio to all children three-years-old and over. The family child care caregiver/teacher must be able to have a positive relationship and provide guidance for each child in care. This standard is consistent with ratio requirements for toddlers in centers as described in Standard 1.1.1.2.

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.2.1 Minimum Age to Enter Child Care
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities

REFERENCES

Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main .zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact _Sheet.pdf.
National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
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.
Zigler, E., W. S. Gilliam, S. M. Jones. 2006. A vision for universal preschool education, 107-29. New York: Cambridge University Press.
Stebbins, H. 2007. State policies to improve the odds for the healthy development and school readiness of infants and toddlers. Washington, DC: Zero to Three. http://main.zerotothree.org/site/DocServer/NCCP_article_for_BM_final.pdf.

Standard 1.1.1.2: Ratios for Large Family Child Care Homes and Centers

Child:staff ratios in large family child care homes and centers should be maintained as follows during all hours of operation, including in vehicles during transport.

Large Family Child Care Homes

Age	Maximum Child:Staff Ratio	Maximum Group Size

≤ 12 months	2:1	6
13-23 months	2:1	8
24-35 months	3:1	12
3-year-olds	7:1	12
4- to 5-year-olds	8:1	12
6- to 8-year-olds	10:1	12
9- to 12-year-olds	12:1	12

During nap time for children birth through thirty months of age, the child:staff ratio must be maintained at all times regardless of how many infants are sleeping. They must also be maintained even during the adult’s break time so that ratios are not relaxed.

Child Care Centers

Age	Maximum Child:Staff Ratio	Maximum Group Size

≤ 12 months	3:1	6
13-35 months	4:1	8
3-year-olds	7:1	14
4-year-olds	8:1	16
5-year-olds	8:1	16
6- to 8-year-olds	10:1	20
9- to 12-year-olds	12:1	24

During nap time for children ages thirty-one months and older, at least one adult should be physically present in the same room as the children and maximum group size must be maintained. Children over thirty-one months of age can usually be organized to nap on a schedule, but infants and toddlers as individuals are more likely to nap on different schedules. In the event even one child is not sleeping the child should be moved to another activity where appropriate supervision is provided.

If there is an emergency during nap time other adults should be on the same floor and should immediately assist the staff supervising sleeping children. The caregiver/teacher who is in the same room with the children should be able to summon these adults without leaving the children.

When there are mixed age groups in the same room, the child:staff ratio and group size should be consistent with the age of most of the children. When infants or toddlers are in the mixed age group, the child:staff ratio and group size for infants and toddlers should be maintained. In large family child care homes with two or more caregivers/teachers caring for no more than twelve children, no more than three children younger than two years of age should be in care.

Children with special health care needs or who require more attention due to certain disabilities may require additional staff on-site, depending on their special needs and the extent of their disabilities (1). See Standard 1.1.1.3.

At least one adult who has satisfactorily completed a course in pediatric first aid, including CPR skills within the past three years, should be part of the ratio at all times.

RATIONALE

These child:staff ratios are within the range of recommendations for each age group that the National Association for the Education of Young Children (NAEYC) uses in its accreditation program (5). The NAEYC recommends a range that assumes the director and staff members are highly trained and, by virtue of the accreditation process, have formed a staffing pattern that enables effective staff functioning. The standard for child:staff ratios in this document uses a single desired ratio, rather than a range, for each age group. These ratios are more likely than less stringent ratios to support quality experiences for young children.

Low child:staff ratios for non-ambulatory children are essential for fire safety. The National Fire Protection Association (NFPA), in its NFPA 101: Life Safety Code, recommends that no more than three children younger than two years of age be cared for in large family child care homes where two staff members are caring for up to twelve children (6).

Children benefit from social interactions with peers. However, larger groups are generally associated with less positive interactions and developmental outcomes. Group size and ratio of children to adults are limited to allow for one to one interaction, intimate knowledge of individual children, and consistent caregiving (7).

Studies have found that children (particularly infants and toddlers) in groups that comply with the recommended ratio receive more sensitive and appropriate caregiving and score higher on developmental assessments, particularly vocabulary (1,9).

As is true in small family child care homes, Standard 1.1.1.1, child:staff ratios alone do not predict the quality of care. Direct, warm social interaction between adults and children is more common and more likely with lower child:staff ratios. Caregivers/teachers must be recognized as performing a job for groups of children that parents/guardians of twins, triplets, or quadruplets would rarely be left to handle alone. In child care, these children do not come from the same family and must learn a set of common rules that may differ from expectations in their own homes (10).

Similarly, low child:staff ratios are most critical for infants and young toddlers (birth to twenty-four months) (1). Infant development and caregiving quality improves when group size and child:staff ratios are smaller (2). Improved verbal interactions are correlated with lower ratios (3). For three- and four-year-old children, the size of the group is even more important than ratios. The recommended group size and child:staff ratio allow three- to five-year-old children to have continuing adult support and guidance while encouraging independent, self-initiated play and other activities (4).

In addition, the children’s physical safety and sanitation routines require a staff that is not fragmented by excessive demands. Child:staff ratios in child care settings should be sufficiently low to keep staff stress below levels that might result in anger with children. Caring for too many young children, in particular, increases the possibility of stress to the caregiver/teacher, and may result in loss of the caregiver’s/teacher’s self-control (11).

Although observation of sleeping children does not require the physical presence of more than one caregiver/teacher for sleeping children thirty-one months and older, the staff needed for an emergency response or evacuation of the children must remain available on site for this purpose. Ratios are required to be maintained for children thirty months and younger during nap time due to the need for closer observation and the frequent need to interact with younger children during periods while they are resting. Close proximity of staff to these younger groups enables more rapid response to situations where young children require more assistance than older children, e.g., for evacuation. The requirement that a caregiver/teacher should remain in the sleeping area of children thirty-one months and older is not only to ensure safety, but also to prevent inappropriate behavior from taking place that may go undetected if a caregiver/teacher is not present. While nap time may be the best option for regular staff conferences, staff lunch breaks, and staff training, one staff person should stay in the nap room, and the above staff activities should take place in an area next to the nap room so other staff can assist if emergency evacuation becomes necessary. If a child with a potentially life-threatening special health care need is present, a staff member trained in CPR and pediatric first aid and one trained in administration of any potentially required medication should be available at all times.

COMMENTS

The child:staff ratio indicates the maximum number of children permitted per caregiver/teacher (8). These ratios assume that caregivers/teachers do not have time-consuming bookkeeping and housekeeping duties, so they are free to provide direct care for children. The ratios do not include other personnel (such as bus drivers) necessary for specialized functions (such as driving a vehicle).

Group size is the number of children assigned to a caregiver/teacher or team of caregivers/teachers occupying an individual classroom or well-defined space within a larger room (8). The “group” in child care represents the “home room” for school-age children. It is the psychological base with which the school-aged child identifies and from which the child gains continual guidance and support in various activities. This standard does not prohibit larger numbers of school-aged children from joining in occasional collective activities as long as child:staff ratios and the concept of “home room” are maintained.

Unscheduled inspections encourage compliance with this standard.

These standards are based on what children need for quality nurturing care. Those who question whether these ratios are affordable must consider that efforts to limit costs can result in overlooking the basic needs of children and creating a highly stressful work environment for caregivers/teachers. Community resources, in addition to parent/guardian fees and a greater public investment in child care, can make critical contributions to the achievement of the child:staff ratios and group sizes specified in this standard. Each state has its own set of regulations that specify child:staff ratios. To view a particular state’s regulations, go to the National Resource Center for Health and Safety in Child Care and Early Education’s (NRC) Website: http://nrckids.org.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play

REFERENCES

Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main
.zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact
_Sheet.pdf.
National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being of children. Arch Ped Adolescent Med 161:669-76.
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.
Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it matter and does it need to be improved? Washington, DC: U.S. Department of Health and Human Services. http://aspe.hhs.gov/hsp/ccquality00/.
De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.
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.
Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in the United States. Am Socio Rev 70:729-57.

Standard 1.1.1.3: Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities

Facilities enrolling children with special health care needs and disabilities should determine, by an individual assessment of each child’s needs, whether the facility requires a lower child:staff ratio.

RATIONALE

The child:staff ratio must allow the needs of the children enrolled to be met. The facility should have sufficient direct care professional staff to provide the required programs and services. Integrated facilities with fewer resources may be able to serve children who need fewer services, and the staffing levels may vary accordingly. Adjustment of the ratio allows for the flexibility needed to meet each child’s type and degree of special need and encourage each child to participate comfortably in program activities. Adjustment of the ratio produces flexibility without resulting in a need for care that is greater than the staff can provide without compromising the health and safety of other children. The facility should seek consultation with parents/guardians, a child care health consultant (CCHC), and other professionals, regarding the appropriate child:staff ratio. The facility may wish to increase the number of staff members if the child requires significant special assistance (1).

COMMENTS

These ratios do not include personnel who have other duties that might preclude their involvement in needed supervision while they are performing those duties, such as therapists, cooks, maintenance workers, or bus drivers.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers

REFERENCES

University of North Carolina at Chapel Hill, FPG Child Development Institute. The national early childhood technical assistance center. https://ectacenter.org/

Standard 1.1.1.4: Ratios and Supervision During Transportation

Child:staff ratios established for out-of-home child care should be maintained on all transportation the facility provides or arranges. Drivers should not be included in the ratio. No child of any age should be left unattended in or around a vehicle, when children are in a car, or when they are in a car seat. A face-to-name count of children should be conducted prior to leaving for a destination, when the destination is reached, before departing for return to the facility and upon return. Caregivers/teachers should also remember to take into account in this head count if any children were picked up or dropped off while being transported away from the facility.

RATIONALE

Children must receive direct supervision when they are being transported, in loading zones, and when they get in and out of vehicles. Drivers must be able to focus entirely on driving tasks, leaving the supervision of children to other adults. This is especially important with young children who will be sitting in close proximity to one another in the vehicle and may need care during the trip. In any vehicle making multiple stops to pick up or drop off children, this also permits one adult to get one child out and take that child to a home, while the other adult supervises the children remaining in the vehicle, who would otherwise be unattended for that time (1). Children require supervision at all times, even when buckled in seat restraints. A head count is essential to ensure that no child is inadvertently left behind in or out of the vehicle. Child deaths in child care have occurred when children were mistakenly left in vehicles, thinking the vehicle was empty.

TYPE OF FACILITY

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

RELATED STANDARDS

5.6.0.1 First Aid and Emergency Supplies

REFERENCES

Aird, L. D. 2007. Moving kids safely in child care: A refresher course. Child Care Exchange (January/February): 25-28. http://www.childcareexchange.com/library/5017325.pdf.

Standard 1.1.1.5: Ratios and Supervision for Swimming, Wading, and Water Play

The following child:staff ratios should apply while children are swimming, wading, or engaged in water play:

Developmental Levels	Child:Staff Ratio
Infants	1:1
Toddlers	1:1
Preschoolers	4:1
School-age Children	6:1

Constant and active supervision should be maintained when any child is in or around water (4). During any swimming/wading/water play activities where either an infant or a toddler is present, the ratio should always be one adult to one infant/toddler. The required ratio of adults to older children should be met without including the adults who are required for supervision of infants and/or toddlers. An adult should remain in direct physical contact with an infant at all times during swimming or water play (4). Whenever children thirteen months and up to five years of age are in or around water, the supervising adult should be within an arm’s length providing “touch supervision” (6). The attention of an adult who is supervising children of any age should be focused on the child, and the adult should never be engaged in other distracting activities (4), such as talking on the telephone, socializing, or tending to chores.

A lifeguard should not be counted in the child:staff ratio.

RATIONALE

The circumstances surrounding drownings and water-related injuries of young children suggest that staffing requirements and environmental modifications may reduce the risk of this type of injury. Essential elements are close continuous supervision (1,4), four-sided fencing and self-locking gates around all swimming pools, hot tubs, and spas, and special safety covers on pools when they are not in use (2,7). Five-gallon buckets should not be used for water play (4). Water play using small (one quart) plastic pitchers and plastic containers for pouring water and plastic dish pans or bowls allow children to practice pouring skills. Between 2003 and 2005, a study of drowning deaths of children younger than five years of age attributed the highest percentage of drowning reports to an adult losing contact or knowledge of the whereabouts of the child (5). During the time of lost contact, the child managed to gain access to the pool (3).

COMMENTS

Water play includes wading. Touch supervision means keeping swimming children within arm’s reach and in sight at all times. Drowning is a “silent killer” and children may slip into the water silently without any splashing or screaming.

Ratios for supervision of swimming, wading and water play do not include personnel who have other duties that might preclude their involvement in supervision during swimming/wading/water play activities while they are performing those duties. This ratio excludes cooks, maintenance workers, or lifeguards from being counted in the child:staff ratio if they are involved in specialized duties at the same time. Proper ratios during swimming activities with infants are important. Infant swimming programs have led to water intoxication and seizures because infants may swallow excessive water when they are engaged in any submersion activities (1).

TYPE OF FACILITY

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

RELATED STANDARDS

6.3.1.3 Sensors or Remote Monitors
6.3.1.4 Safety Covers for Swimming Pools
2.2.0.4 Supervision Near Bodies of Water
6.3.1.7 Pool Safety Rules
6.3.2.1 Lifesaving Equipment
6.3.2.2 Lifeline in Pool
6.3.5.2 Water in Containers
6.3.5.3 Portable Wading Pools

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). Pool and spa safety: The Virginia Graeme Baker pool and spa safety act. http://www.poolsafely.gov/wp-content/uploads/VGBA.pdf.
U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
Gipson, K. 2009. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: CPSC. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.
American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.
Consumer Product Safety Commission. Steps for safety around the pool: The pool and spa safety act. Pool Safely. http://www.poolsafely.gov/wp-content/uploads/360.pdf.
Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.
American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.

Standard 2.2.0.1: Methods of Supervision of Children

Content in the STANDARD was modified on 10/09/2018.

Caregivers/teachers should provide active and positive supervision of infants, toddlers, preschoolers, and school-aged children by sight and hearing at all times, including when children are resting or sleeping, eating, being diapered, or using the bathroom (as age appropriate) and when children are outdoors.

Active supervision requires focused attention and intentional observation of children at all times. Caregivers/teachers position themselves so that they can observe all of the children: watching, counting, and listening at all times. During transitions, caregivers/teachers account for all children with name-to-face recognition by visually identifying each child. They also use their knowledge of each child’s development and abilities to anticipate what they will do, then get involved and redirect them when necessary. This constant vigilance helps children learn safely.

All children in out-of-home care must be directly supervised at all times. The following strategies allow children to explore their environments safely. (1,2)

Set Up the Environment
Caregivers/teachers set up the environment so that they can supervise children and be accessible at all times. When activities are grouped together and furniture is at waist height or shorter, adults are always able to see and hear children. Small spaces are kept clutter-free and big spaces are set up so that children have clear play spaces that caregivers/teachers can observe.
Position Staff
Caregivers/teachers carefully plan where they will position themselves in the environment to prevent children from harm. They place themselves so that they can see and hear all of the children in their care. They make sure there are always clear paths to where children are playing, sleeping, and eating so they can react quickly when necessary. Caregivers/teachers stay close to children who may need additional support. Their location helps them provide support, if necessary.
Scan and Count
Caregivers/teachers are always able to account for the children in their care. They continuously scan the entire environment to know where everyone is and what they are doing. They count the children frequently. This is especially important during transitions when children are moving from one location to another.
Listen
Specific sounds or the absence of them may signify reason for concern. Caregivers/teachers who are listening closely to children immediately identify signs of potential danger. Programs that think systemically implement additional strategies to safeguard children. For example, bells added to doors help alert adults when a child leaves or enters the room.
Anticipate Children's Behavior
Caregivers/teachers use what they know about each child’s individual interests and skills to predict what he/she will do. They create challenges that children are ready for and support them in succeeding. But, they also recognize when children might wander, get upset, or take a dangerous risk. Information from the daily health check (e.g., illness, allergies, lack of sleep or food, etc.) informs adults’ observations and helps them anticipate children’s behavior. Caregivers/teachers who know what to expect are better able to protect children from harm.

6. Engage and Redirect

Caregivers/teachers use what they know about each child’s individual needs and development to offer support. They wait until children are unable to problem-solve on their own to get involved. They may offer different levels of assistance or redirection depending on each individual child’s needs.

Caregivers/teachers should always be on the same floor and in the same room as the children. If toilets are not on the same floor as the child care area or within sight or hearing of a caregiver/teacher, an adult should accompany children younger than 5 years to and from the toilet area. Younger children who request privacy and have shown the capability to use toilet facilities properly should be given permission to use separate and private toilet facilities. School-aged children may use toilet facilities without direct visual observation but must remain within hearing range in case children need assistance and/or to prevent unsafe behavior.

Program spaces should be designed with visibility that allows constant, unobtrusive adult supervision and allow for children to have alone time or quiet play in small groups. To protect children from maltreatment, including sexual abuse, the environment layout should limit situations in which an adult or older child can be alone with a child without another adult present (1,2).

Children are going to be more active in the outdoor learning/play environment and need more supervision rather than less time outside. Playground supervisors need to be designated and trained to supervise children in all outdoor play areas. Staff supervision of the playground should incorporate strategic watching all the children within a specific territory and not engaging in prolonged dialog with any one child or group of children (or other staff). Other adults not designated to supervise may facilitate outdoor learning/play activities and engage in conversations with children about their exploration and discoveries. Caregivers/teachers should make an effort to maintain close proximity to children who are developing new motor skills and may need additional support to ensure the safety of the children.

Caregivers/teachers should repeatedly count children, record the count, ensure accuracy, and be able to verbally state how many children are in care at all times. Caregivers/teachers should record the count on an attendance sheet or on a pocket card, along with notations of any children joining or leaving the group. An accurate count is required at all times. Caregivers/teachers should participate in a counting routine that encourages duplicate counts to verify the attendance record to ensure constant supervision and safety of all children in care.

School-aged children should be permitted to participate in activities off the premises with appropriate adult supervision and with written approval by a parent/guardian. If parents/guardians give written permission for the school-aged child to participate in off-premises activities, the facility would no longer be responsible for the child during the off-premises activity. The facility would not need to provide staff for the off-premises activity.

Developmentally appropriate child to staff ratios should be met during all hours of operation, including indoor and outdoor play and field trips. Additionally, all safety precautions for specific areas and equipment should be followed. No center-based facility or large family child care home should operate with fewer than 2 staff members if more than 6 children are in care, even if the group otherwise meets the child to staff ratio. Although centers often downsize the number of staff for early arrival and late departure times, another adult should be present to help in the event of an emergency. See Related Standards below for further information regarding ratios.

Planning must include advance assignments, monitoring, and contingency plans to maintain appropriate staffing. During times when children are typically being dropped off and picked up, the number of children present can vary. There should be a plan in place to monitor and address unanticipated changes, allowing for caregivers/teachers to receive additional help without leaving the area. Sufficient staff must be maintained to evacuate children safely in case of emergency. Compliance with proper child to staff ratios should be measured by structured observation, counting caregivers/teachers and children in each group at varied times of the day, and reviewing written policies.

RATIONALE

Supervision is directly tied to safety and the prevention of injury and maintaining quality child care for infants, toddlers, preschoolers, and school-aged children. Parents/guardians depend on caregivers/teachers to supervise their children. To be available for supervision or rescue in an emergency, an adult must be able to hear and see the children. With proper supervision and in the event of an emergency, supervising adults can quickly and efficiently remove children from any potential harm.

The importance of supervision is to protect children not only from physical injury (3) but also from harm that can occur from topics discussed by children or by teasing/bullying/inappropriate behavior. It is the responsibility of caregivers/teachers to monitor what children are talking about and intervene when necessary.

Children like to test their skills and abilities, which is encouraged, as it is developmentally appropriate behavior. This is particularly noticeable around playground equipment. Playgrounds, when compared with indoor play areas, pose a higher risk when it comes to injuries in children (4). Even if the highest safety standards for playground layout, design, and surfacing are met, serious injuries can happen if children are left unsupervised. Adults who are involved and aware of children’s behavior are in the best position to safeguard their well-being.

Regular counting (or use of active supervision) will reduce opportunities for a child to become separated from the group, especially during transitions between locations.

These practices encourage responsive interactions and understanding each child’s strengths and challenges while providing active supervision in infant, toddler, preschool, and school-age environments.

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

National Center on Early Childhood Health and Wellness. Active Supervision. https://eclkc.ohs.acf.hhs.gov/safety-practices/article/active-supervision. Published February 5th 2018. Accessed August 28, 2018.
National Association for the Education of Young Children: Program Administrator Guide to Evaluating Child Supervision Practices. http://www.naeyc.org/academy/files/
academy/Supervision%20Resource_0.pdf. 2016. Accessed August 28, 2018.
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 25, 2018
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 25, 2018
Schwebel, D. Internet-based training to improve preschool playground safety: Evaluation of the Stamp-in-Safety Programme. The Health Education Journal. 74(1), 37. Published January 20, 2015. Accessed August 28, 2018.
National Safety Council. Landing lightly: playgrounds don’t have to hurt. http://www.nsc.org/learn/safety-knowledge/Pages/news-and-resources-playground-safety.aspx. Accessed June 25, 2018

NOTES

Content in the STANDARD was modified on 10/09/2018.

Standard 2.2.0.4: Supervision Near Bodies of Water

Constant and active supervision should be maintained when any child is in or around water (1). During any swimming/wading/water play activities where either an infant or a toddler is present, the ratio should always be one adult to one infant/toddler. Children ages thirteen months to five years of age should not be permitted to play in areas where there is any body of water, including swimming pools, ponds and irrigation ditches, built-in wading pools, tubs, pails, sinks, or toilets unless the supervising adult is within an arm’s length providing “touch supervision”.

Caregivers/teachers should ensure that all pools meet the Virginia Graeme Baker Pool and Spa Safety Act, requiring the retrofitting of safe suction-type devices for pools and spas to prevent underwater entrapment of children in such locations with strong suction devices that have led to deaths of children of varying ages (2).

RATIONALE

Small children can drown within thirty seconds, in as little as two inches of liquid (3).

In a comprehensive study of drowning and submersion incidents involving children under five years of age in Arizona, California, and Florida, the U.S. Consumer Product Safety Commission (CPSC) found that:

Submersion incidents involving children usually happen in familiar surroundings;
Pool submersions involving children happen quickly, 77% of the victims had been missing from sight for five minutes or less;
Child drowning is a silent death, and splashing may not occur to alert someone that the child is in trouble (4).

Drowning is the second leading cause of unintentional injury-related death for children ages one to fourteen (5).

In 2006, approximately 1,100 children under the age of twenty in the U.S died from drowning (11). A national study that examined where drowning most commonly takes place concluded that infants are most likely to drown in bathtubs, toddlers are most likely to drown in swimming pools and older children and adolescents are most likely to drown in freshwater (rivers, lakes, ponds) (11).

While swimming pools pose the greatest risk for toddlers, about one-quarter of drowning among toddlers are in freshwater sites, such as ponds or lakes.

The American Academy of Pediatrics (AAP) recommends:

Swimming lessons for children based on the child’s frequency of exposure to water, emotional maturity, physical limitations, and health concerns related to swimming pools;
“Touch supervision” of infants and young children through age four when they are in the bathtub or around other bodies of water;
Installation of four-sided fencing that completely separates homes from residential pools;
Use of approved personal flotation devices (PFDs) when riding on a boat or playing near a river, lake, pond, or ocean;
Teaching children never to swim alone or without adult supervision;
Stressing the need for parents/guardians and teens to learn first aid and cardiopulmonary resuscitation (CPR) (3).

Deaths and nonfatal injuries have been associated with infant bathtub “supporting ring” devices that are supposed to keep an infant safe in the tub. These rings usually contain three or four legs with suction cups that attach to the bottom of the tub. The suction cups, however, may release suddenly, allowing the bath ring and infant to tip over. An infant also may slip between the legs of the bath ring and become trapped under it. Caregivers/teachers must not rely on these devices to keep an infant safe in the bath and must never leave an infant alone in these bath support rings (1,6,7).

Thirty children under five years of age died from drowning in buckets, pails, and containers from 2003-2005 (10). Of all buckets, the five-gallon size presents the greatest hazard to young children because of its tall straight sides and its weight with even just a small amount of liquid. It is nearly impossible for top-heavy (their heads) infants and toddlers to free themselves when they fall into a five-gallon bucket head first (8).

The Centers for Disease Control (CDC) National Center for Injury Prevention and Control recommends that whenever young children are swimming, playing, or bathing in water, an adult should be watching them constantly. The supervising adult should not read, play cards, talk on the telephone, mow the lawn, or do any other distracting activity while watching children (1,9).

COMMENTS

“Touch supervision” means keeping swimming children within arm’s reach and in sight at all times. Flotation devices should never be used as a substitute for supervision. Knowing how to swim does not make a child drown-proof.

The need for constant supervision is of particular concern in dealing with very young children and children with significant motor dysfunction or developmental delays. Supervising adults should be CPR-trained and should have a telephone accessible to the pool and water area at all times should emergency services be required.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
6.3.1.1 Enclosure of Bodies of Water
6.3.1.7 Pool Safety Rules

REFERENCES

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.
Gipson, K. 2008. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.
U.S. Consumer Product Safety Commission. 1997. CPSC reminds pool owners that barriers, supervision prevent drowning. Release #97-152. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/PREREL/PRHTML97/97152.html.
U.S. Consumer Product Safety Commission. 1994. Infants and toddlers can drown in 5-gallon buckets: A hidden hazard in the home. Document #5006. Washington, DC: CPSC. http://www.cpsc
.gov/cpscpub/pubs/5006.html.
Rauchschwalbe, R., R. A. Brenner, S. Gordon. 1997. The role of bathtub seats and rings in infant drowning deaths. Pediatrics 100:e1.
U.S. Consumer Product Safety Commission. 1994. Drowning hazard with baby “supporting ring” devices. Document #5084. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/
5084.html.
Centers for Disease Control and Prevention (CDC). 2010. Unintentional drowning: Fact sheet. http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries
-factsheet.html.
U.S. Consumer Product Safety Commission. 2002. How to plan for the unexpected: Preventing child drownings. Publication #359. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/PUBS/359.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement-prevention of drowning. Pediatrics 126: 178-85.
U.S. Congress. 2007. Virginia Graeme Baker Pool and Spa Safety Act. 15 USC 8001. http://www.cpsc.gov/businfo/vgb/pssa.pdf.
U.S. Consumer Product Safety Commission. 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.

Standard 4.5.0.6: Adult Supervision of Children Who Are Learning to Feed Themselves

Children in mid-infancy who are learning to feed themselves should be supervised by an adult seated within arm’s reach of them at all times while they are being fed. Children over twelve months of age who can feed themselves should be supervised by an adult who is seated at the same table or within arm’s reach of the child’s highchair or feeding table. When eating, children should be within sight of an adult at all times.

RATIONALE

A supervising adult should watch for several common problems that typically occur when children in mid-infancy begin to feed themselves. “Squirreling” of several pieces of food in the mouth increases the likelihood of choking. A choking child may not make any noise, so adults must keep their eyes on children who are eating. Active supervision is imperative. Supervised eating also promotes the child’s safety by discouraging activities that can lead to choking (1). For best practice, children of all ages should be supervised when eating. Adults can monitor age-appropriate portion size consumption.

COMMENTS

Adults can help children while they are learning, by modeling active chewing (i.e., eating a small piece of food, showing how to use their teeth to bite it) and making positive comments to encourage children while they are eating. Adults can demonstrate how to eat foods on the menu, how to serve food, and how to ask for more food as a way of helping children learn the names of foods (e.g., “please pass the bowl of noodles”).

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Staff Qualifications and Training

Standard 1.2.0.2: Background Screening

Content in the STANDARD was modified on 5/22/2018.

To ensure their safety and physical and mental health, children should be protected from any risk of abuse or neglect. Directors of centers and large family child care homes and caregivers/teachers in small family child care homes should conduct a complete background screening before employing any staff member, including substitutes, cooks, clerical staff, transportation staff, bus drivers, or custodians who will be on the premises or in vehicles when children are present.

The background screening should include (1-4).

Name and address verification
Social Security number verification
Education verification
Employment history
Alias search
Driving history through state Department of Motor Vehicles records
Background screening of
1. State, tribal, and federal criminal history records, including fingerprint checks
2. Child abuse and neglect registries
3. Licensing history with any other state agencies (eg, foster care, mental health, nursing homes)
4. Sex offender registries
Court records (misdemeanors and felonies)
Reference checks; These should come from a variety of employment or volunteer sources and should not be limited to an applicant’s family and/or friends (5).
In-person interview; Open-ended questions about establishing appropriate and inappropriate boundaries with young children should be asked to all job applicants during the in-person interview; for example, “How would you handle a situation in which a child asked you to keep a secret?” (6).

Directors should contact their state child care licensing agency for the appropriate background screening documentation required by their state’s licensing regulations. All family members older than 10 years living in large and small family child care homes should also have background screenings. Drug tests/screens may be incorporated into the background screening. Written permission to obtain the background screening (with or without a drug screen) should be obtained from the prospective employee. Consent to the background investigation should be required for employment consideration. Prospective employers should verbally ask applicants about previous convictions and arrests, investigation findings, or court cases with child abuse/neglect or child sexual abuse. Failure of the prospective employee to disclose previous history of child abuse/neglect or child sexual abuse is grounds for immediate dismissal. Persons should not be hired or allowed to work or volunteer in the child care facility if they acknowledge being sexually attracted to children or having physically or sexually abused children, or if they are known to have committed such acts.

Background screenings should be repeated periodically, mirroring state laws and/or requirements. If there are concerns about an employee’s performance or behavior, background screenings should be conducted as needed.

RATIONALE

Properly executed reference checks, as well as in-person interviews, help seek out and prevent possible child abuse from occurring in child care centers. The use of open-ended questions and request for verbal references require personal conversations and, in turn, can uncover a lot of warranted information about the applicant.

Performing diligent background screenings also protects the child care facility against future legal challenges (2,3).

COMMENTS

The following resources can help the director screen individual applicants:

If fingerprinting is required, it can be secured at local law enforcement offices or the State Bureau of Investigation.
Court records are public information and can be obtained from county court offices; some states have statewide online court records.
Driving records are available from the state Department of Motor Vehicles.
A Social Security number trace is a report, derived from credit bureau records, that will return all current and reported addresses for the last 7 to 10 years on a specific individual based on his or her Social Security number. If there are alternate names (aliases), these are also reported on the Social Security record.
State child abuse registries can be accessed at https://www.adoptuskids.org/for-professionals/interstate-adoptions/state-child-abuse-registries. Sex offender registries can be accessed at https://www.nsopw.gov.
Companies also offer background check services. The National Association of Professional Background Screeners (https://www.napbs.com) provides a directory of its membership.

For more information on state licensing requirements regarding criminal background screenings, see the current National Association for Regulatory Administration Licensing Study at www.naralicensing.org/resources.

TYPE OF FACILITY

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

REFERENCES

Child Care and Development Block Grant Act, 42 USC §9857
Social Security Act, 42 USC §618
Child Care and Development Fund, 42 USC §9858f(c)(1)(D), 42 USC §9858f(h)(1)
Head Start Early Childhood Learning & Knowledge Center. 1302.90 personnel policies. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii/1302-90-personnel-policies. Accessed January 11, 2018
Alliance of Schools for Cooperative Insurance Programs. Best Practices for Child Abuse Prevention. Cerritos, CA: Alliance of Schools for Cooperative Insurance Programs; 2015. http://ascip.org/wp-content/uploads/2014/05/Child-Abuse-Best-Practices.pdf. Published April 15, 2015. Accessed January 11, 2018
Berkower F. Preventing child sexual abuse in your organization. Denver’s Early Childhood Council Web site. https://denverearlychildhood.org/preventing-child-sexual-abuse-organization. Published April 23, 2016. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 5/22/2018.

Standard 1.3.1.1: General Qualifications of Directors

The director of a center enrolling fewer than sixty children should be at least twenty-one-years-old and should have all the following qualifications:

Have a minimum of a Baccalaureate degree with at least nine credit-bearing hours of specialized college-level course work in administration, leadership, or management, and at least twenty-four credit-bearing hours of specialized college-level course work in early childhood education, child development, elementary education, or early childhood special education that addresses child development, learning from birth through kindergarten, health and safety, and collaboration with consultants OR documents meeting an appropriate combination of relevant education and work experiences (6);
A valid certificate of successful completion of pediatric first aid that includes CPR;
Knowledge of health and safety resources and access to education, health, and mental health consultants;
Knowledge of community resources available to children with special health care needs and the ability to use these resources to make referrals or achieve interagency coordination;
Administrative and management skills in facility operations;
Capability in curriculum design and implementation, ensuring that an effective curriculum is in place;
Oral and written communication skills;
Certificate of satisfactory completion of instruction in medication administration;
Demonstrated life experience skills in working with children in more than one setting;
Interpersonal skills;
Clean background screening.

Knowledge about parenting training/counseling and ability to communicate effectively with parents/guardians about developmental-behavioral issues, child progress, and in creating an intervention plan beginning with how the center will address challenges and how it will help if those efforts are not effective.

The director of a center enrolling more than sixty children should have the above and at least three years experience as a teacher of children in the age group(s) enrolled in the center where the individual will act as the director, plus at least six months experience in administration.

RATIONALE

The director of the facility is the team leader of a small business. Both administrative and child development skills are essential for this individual to manage the facility and set appropriate expectations. College-level coursework has been shown to have a measurable, positive effect on quality child care, whereas experience per se has not (1-3,5).

The director of a center plays a pivotal role in ensuring the day-to-day smooth functioning of the facility within the framework of appropriate child development principles and knowledge of family relationships (6).

The well-being of the children, the confidence of the parents/guardians of children in the facility’s care, and the high morale and consistent professional growth of the staff depend largely upon the knowledge, skills, and dependable presence of a director who is able to respond to long-range and immediate needs and able to engage staff in decision-making that affects their day-to-day practice (5,6). Management skills are important and should be viewed primarily as a means of support for the key role of educational leadership that a director provides (6). A skilled director should know how to use early care and education consultants, such as health, education, mental health, and community resources and to identify specialized personnel to enrich the staff’s understanding of health, development, behavior, and curriculum content. Past experience working in an early childhood setting is essential to running a facility.

Life experience may include experience rearing one’s own children or previous personal experience acquired in any child care setting. Work as a hospital aide or at a camp for children with special health care needs would qualify, as would experience in school settings. This experience, however, must be supplemented by competency-based training to determine and provide whatever new skills are needed to care for children in child care settings.

COMMENTS

The profession of early childhood education is being informed by research on the association of developmental outcomes with specific practices. The exact combination of college coursework and supervised experience is still being developed. For example, the National Association for the Education of Young Children (NAEYC) has published the Standards for Early Childhood Professional Preparation Programs (4). The National Child Care Association (NCCA) has developed a curriculum based on administrator competencies; more information on the NCCA is available at http://www.nccanet.org.

TYPE OF FACILITY

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

RELATED STANDARDS

1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education

REFERENCES

National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.
National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
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.
Helburn, S., ed. 1995. Cost, quality and child outcomes in child care centers. Denver, CO: University of Colorado at Denver.
Howes, C. 1997. Children’s experiences in center-based child care as a function of teacher background and adult:child ratio. Merrill-Palmer Q 43:404-24.
Roupp, R., J. Travers, F. M., Glantz, C. Coelen. 1979. Children at the center: Summary findings and their implications. Vol. 1 of Final report of the National day care study. Cambridge, MA: Abt Associates.

Standard 1.3.2.2: Qualifications of Lead Teachers and Teachers

Lead teachers and teachers should be at least twenty-one years of age and should have at least the following education, experience, and skills:

A Bachelor’s degree in early childhood education, school-age care, child development, social work, nursing, or other child-related field, or an associate’s degree in early childhood education and currently working towards a bachelor’s degree;
A minimum of one year on-the-job training in providing a nurturing indoor and outdoor environment and meeting the child’s out-of-home needs;
One or more years of experience, under qualified supervision, working as a teacher serving the ages and developmental abilities of the children in care;
A valid certificate in pediatric first aid, including CPR;
Thorough knowledge of normal child development and early childhood education, as well as knowledge of indicators that a child is not developing typically;
The ability to respond appropriately to children’s needs;
The ability to recognize signs of illness and safety/injury hazards and respond with prevention interventions;
Oral and written communication skills;
Medication administration training (8).

Every center, regardless of setting, should have at least one licensed/certified lead teacher (or mentor teacher) who meets the above requirements working in the child care facility at all times when children are in care.

Additionally, facilities serving children with special health care needs associated with developmental delay should employ an individual who has had a minimum of eight hours of training in inclusion of children with special health care needs.

RATIONALE

Child care that promotes healthy development is based on the developmental needs of infants, toddlers, and preschool children. Caregivers/teachers are chosen for their knowledge of, and ability to respond appropriately to, the needs of children of this age generally, and the unique characteristics of individual children (1-4). Both early childhood and special educational experience are useful in a center. Caregivers/teachers that have received formal education from an accredited college or university have shown to have better quality of care and outcomes of programs. Those teachers with a four-year college degree exhibit optimal teacher behavior and positive effects on children (6).

Caregivers/teachers are more likely to administer medications than to perform CPR. Seven thousand children per year require emergency department visits for problems related to cough and cold medication (7).

COMMENTS

The profession of early childhood education is being informed by the research on early childhood brain development, child development practices related to child outcomes (5). For additional information on qualifications for child care staff, refer to the Standards for Early Childhood Professional Preparation Programs from the National Association for the Education of Young Children (NAEYC) (4). Additional information on the early childhood education profession is available from the Center for the Child Care Workforce (CCW).

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play

REFERENCES

American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough and cold medication: Unsupervised ingestion accounts for 66 percent of incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/r080128.htm.
Kagan, S. L., K. Tarrent, K. Kauerz. 2008. The early care and education teaching workforce at the fulcrum, 44-47, 90-91. New York: Teachers College Press.
Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: National Academy Press.
U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.
Bredekamp, S., C. Copple, eds. 1997. Developmentally appropriate practice in early childhood programs. Rev ed. Washington, DC: National Association for the Education of Young Children.
National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1996. Characteristics of infant child care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306.
National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.

Standard 1.3.2.3: Qualifications for Assistant Teachers, Teacher Aides, and Volunteers

Assistant teachers and teacher aides should be at least eighteen years of age, have a high school diploma or GED, and participate in on-the-job training, including a structured orientation to the developmental needs of young children and access to consultation, with periodic review, by a supervisory staff member. At least 50% of all assistant teachers and teacher aides must have or be working on either a Child Development Associate (CDA) credential or equivalent, or an associate’s or higher degree in early childhood education/child development or equivalent (9).

Volunteers should be at least sixteen years of age and should participate in on-the-job training, including a structured orientation to the developmental needs of young children. Assistant teachers, teacher aides, and volunteers should work only under the continual supervision of lead teacher or teacher. Assistant teachers, teacher aides, and volunteers should never be left alone with children. Volunteers should not be counted in the child:staff ratio.

All assistant teachers, teacher aides, and volunteers should possess:

The ability to carry out assigned tasks competently under the supervision of another staff member;
An understanding of and the ability to respond appropriately to children’s needs;
Sound judgment;
Emotional maturity; and
Clearly discernible affection for and commitment to the well-being of children.

RATIONALE

While volunteers and students can be as young as sixteen, age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one allows for the maturity necessary to meet the responsibilities of managing a center or independently caring for a group of children who are not one’s own.

Child care that promotes healthy development is based on the developmental needs of infants, toddlers, preschool, and school-age children. Caregivers/teachers should be chosen for their knowledge of, and ability to respond appropriately to, the general needs of children of this age and the unique characteristics of individual children (1,3-5).

Staff training in child development and/or early childhood education is related to positive outcomes for children. This training enables the staff to provide children with a variety of learning and social experiences appropriate to the age of the child. Everyone providing service to, or interacting with, children in a center contributes to the child’s total experience (8).

Adequate compensation for skilled workers will not be given priority until the skills required are recognized and valued. Teaching and caregiving requires skills to promote development and learning by children whose needs and abilities change at a rapid rate.

COMMENTS

Experience and qualifications used by the Child Development Associate (CDA) program and the National Child Care Association (NCCA) credentialing program, and included in degree programs with field placement are valued (10). Early childhood professional knowledge must be required whether programs are in private homes, centers, public schools, or other settings. Go to http://www
.cdacouncil.org/the-cda-credential/how-to-earn-a-cda/ to view appropriate training and qualification information on the CDA Credential.

The National Association for the Education of Young Children’s (NAEYC) National Academy for Early Childhood Program Accreditation, the National Early Childhood Program Accreditation (NECPA) and the National Association of Family Child Care (NAFCC) have established criteria for staff qualifications (2,6,7).

Caregivers/teachers who lack educational qualifications may be employed as continuously supervised personnel while they acquire the necessary educational qualifications if they have personal characteristics, experience, and skills in working with parents, guardians and children, and the potential for development on the job or in a training program.

States may have different age requirements for volunteers.

TYPE OF FACILITY

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

RELATED STANDARDS

6.5.1.2 Qualifications for Drivers

REFERENCES

U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.
National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net.
National Child Care Association (NCCA). NCCA official Website. http://www.nccanet.org.
Council for Professional Recognition. 2011. How to obtain a CDA. http://www.cdacouncil.org/the-cda-credential/
how-to-earn-a-cda/.
National Association for the Education of Young Children (NAEYC). Candidacy requirements. http://www.naeyc.org/academy/pursuing/candreq/.
Da Ros-Voseles, D., S. Fowler-Haughey. 2007. Why children’s dispositions should matter to all teachers. Young Children (September): 1-7. http://www.naeyc.org/files/yc/file/200709/
DaRos-Voseles.pdf.
National Association for the Education of Young Children (NAEYC). 2009. Standards for Early Childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
National Association for the Education of Young Children (NAEYC). 2009. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
National Association for the Education of Young Children (NAEYC). 2005. Accreditation and criteria procedures of the National Academy of Early Childhood Programs. Washington, DC: NAEYC.
National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network. 1996. Characteristics of infant child care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306.

Standard 1.3.2.4: Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age

Caregivers/teachers should be prepared to work with infants and toddlers and, when asked, should be knowledgeable and demonstrate competency in tasks associated with caring for infants and toddlers:

Diapering and toileting;
Bathing;
Feeding, including support for continuation of breastfeeding;
Holding;
Comforting;
Practicing safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) (3);
Providing warm, consistent, responsive caregiving and opportunities for child-initiated activities;
Stimulating communication and language development and pre-literacy skills through play, shared reading, song, rhyme, and lots of talking;
Promoting cognitive, physical, and social emotional development;
Preventing shaken baby syndrome/abusive head trauma;
Promoting infant mental health;
Promoting positive behaviors;
Setting age-appropriate limits with respect to safety, health, and mutual respect;
Using routines to teach children what to expect from caregivers/teachers and what caregivers/teachers expect from them.

Caregivers/teachers should demonstrate knowledge of development of infants and toddlers as well as knowledge of indicators that a child is not developing typically; knowledge of the importance of attachment for infants and toddlers, the importance of communication and language development, and the importance of nurturing consistent relationships on fostering positive self-efficacy development.

To help manage atypical or undesirable behaviors of children, caregivers/teachers, in collaboration with parents/guardians, should seek professional consultation from the child’s primary care provider, an early childhood mental health professional, or an early childhood mental health consultant.

RATIONALE

The brain development of infants is particularly sensitive to the quality and consistency of interpersonal relationships. Much of the stimulation for brain development comes from the responsive interactions of caregivers/teachers and children during daily routines. Children need to be allowed to pursue their interests within safe limits and to be encouraged to reach for new skills (1-7).

COMMENTS

Since early childhood mental health professionals are not always available to help with the management of challenging behaviors in the early care and education setting early childhood mental health consultants may be able to help. The consultant should be viewed as an important part of the program’s support staff and should collaborate with all regular classroom staff, consultants, and other staff. Qualified potential consultants may be identified by contacting mental health and behavioral providers in the local area, as well as accessing the National Mental Health Information Center (NMHIC) at http://store.samhsa.gov/
mhlocator/ and Healthy Child Care America (HCCA) at http://www.healthychildcare.org/Contacts.html.

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.3 Infant and Early Childhood Mental Health Consultants
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.1.2 Mixed Director/Teacher Role
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
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
4.3.1.6 Use of Soy-Based Formula and Soy Milk
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants

REFERENCES

Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.
Cohen, J., N. Onunaku, S. Clothier, J. Poppe. 2005. Helping young children succeed: Strategies to promote early childhood social and emotional development. Washington, DC: National Conference of State Legislatures; Zero to Three. http://main.zerotothree.org/site/DocServer/help_yng_child_succeed.pdf.
Shonkoff, J. P., D. A. Phillips, eds. 2000. From neurons to neighborhoods: The science of early childhood development. Washington, DC: National Academy Press.
Shore, R. 1997. Rethinking the brain: New insights into early development. New York: Families and Work Inst.
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.
Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.
National Forum on Early Childhood Policy and Programs, National Scientific Council on the Developing Child. 2007. A science-based framework for early childhood policy: Using evidence to improve outcomes in learning, behavior, and health for vulnerable children. http://developingchild.harvard.edu/index.php/library/reports_and_working_papers/policy_framework/.

Standard 1.3.2.7: Qualifications and Responsibilities for Health Advocates

Each facility should designate at least one administrator or staff person as the health advocate to be responsible for policies and day-to-day issues related to health, development, and safety of individual children, children as a group, staff, and parents/guardians. In large centers it may be important to designate health advocates at both the center and classroom level. The health advocate should be the primary contact for parents/guardians when they have health concerns, including health-related parent/guardian/staff observations, health-related information, and the provision of resources. The health advocate ensures that health and safety is addressed, even when this person does not directly perform all necessary health and safety tasks.

The health advocate should also identify children who have no regular source of health care, health insurance, or positive screening tests with no referral documented in the child’s health record. The health advocate should assist the child’s parent/guardian in locating a Medical Home by referring them to a primary care provider who offers routine child health services.

For centers, the health advocate should be licensed/certified/credentialed as a director or lead teacher or should be a health professional, health educator, or social worker who works at the facility on a regular basis (at least weekly).

The health advocate should have documented training in the following:

Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, and reporting requirements;
Childhood immunization requirements, record-keeping, and at least quarterly review and follow-up for children who need to have updated immunizations;
Child health assessment form review and follow-up of children who need further medical assessment or updating of their information;
How to plan for, recognize, and handle an emergency;
Poison awareness and poison safety;
Recognition of safety, hazards, and injury prevention interventions;
Safe sleep practices and the reduction of the risk of Sudden Infant Death Syndrome (SIDS);
How to help parents/guardians, caregivers/teachers, and children cope with death, severe injury, and natural or man-made catastrophes;
Recognition of child abuse, neglect/child maltreatment, shaken baby syndrome/abusive head trauma (for facilities caring for infants), and knowledge of when to report and to whom suspected abuse/neglect;
Facilitate collaboration with families, primary care providers, and other health service providers to create a health, developmental, or behavioral care plan;
Implementing care plans;
Recognition and handling of acute health related situations such as seizures, respiratory distress, allergic reactions, as well as other conditions as dictated by the special health care needs of children;
Medication administration;
Recognizing and understanding the needs of children with serious behavior and mental health problems;
Maintaining confidentiality;
Healthy nutritional choices;
The promotion of developmentally appropriate types and amounts of physical activity;
How to work collaboratively with parents/guardians and family members;
How to effectively seek, consult, utilize, and collaborate with child care health consultants, and in partnership with a child care health consultant, how to obtain information and support from other education, mental health, nutrition, physical activity, oral health, and social service consultants and resources;
Knowledge of community resources to refer children and families who need health services including access to State Children’s Health Insurance (SCHIP), importance of a primary care provider and medical home, and provision of immunizations and Early Periodic Screening, Diagnosis, and Treatment (EPSDT).

RATIONALE

The effectiveness of an intentionally designated health advocate in improving the quality of performance in a facility has been demonstrated in all types of early childhood settings (1). A designated caregiver/teacher with health training is effective in developing an ongoing relationship with the parents/guardians and a personal interest in the child (2,3). Caregivers/teachers who are better trained are more able to prevent, recognize, and correct health and safety problems. An internal advocate for issues related to health and safety can help integrate these concerns with other factors involved in formulating facility plans.

Children may be current with required immunizations when they enroll, but they sometimes miss scheduled immunizations thereafter. Because the risk of vaccine-preventable disease increases in group settings, assuring appropriate immunizations is an essential responsibility in child care. Caregivers/teachers should contact their child care health consultant or the health department if they have a question regarding immunization updates/schedules. They can also provide information to share with parents/guardians about the importance of vaccines.

Child health records are intended to provide information that indicates that the child has received preventive health services to stay well, and to identify conditions that might interfere with learning or require special care. Review of the information on these records should be performed by someone who can use the information to plan for the care of the child, and recognize when updating of the information by the child’s primary care provider is needed. Children must be healthy to be ready to learn. Those who need accommodation for health problems or are susceptible to vaccine-preventable diseases will suffer if the staff of the child care program is unable to use information provided in child health records to ensure that the child’s needs are met (5,6).

COMMENTS

The director should assign the health advocate role to a staff member who seems to have an interest, aptitude, and training in this area. This person need not perform all the health and safety tasks in the facility but should serve as the person who raises health and safety concerns. This staff person has designated responsibility for seeing that plans are implemented to ensure a safe and healthful facility (1).

A health advocate is a regular member of the staff of a center or large or small family child care home, and is not the same as the child care health consultant recommended in Child Care Health Consultants, Standard 1.6.0.1. The health advocate works with a child care health consultant on health and safety issues that arise in daily interactions (4). For small family child care homes, the health advocate will usually be the caregiver/teacher. If the health advocate is not the child’s caregiver/teacher, the health advocate should work with the child’s caregiver/teacher. The person who is most familiar with the child and the child’s family will recognize atypical behavior in the child and support effective communication with parents/guardians.

A plan for personal contact with parents/guardians should be developed, even though this contact will not be possible daily. A plan for personal contact and documentation of a designated caregiver/teacher as health advocate will ensure specific attempts to have the health advocate communicate directly with caregivers/teachers and families on health-related matters.

The immunization record/compliance review may be accomplished by manual review of child health records or by use of software programs that use algorithms with the currently recommended vaccine schedules and service intervals to test the dates when a child received recommended services and the child’s date of birth to identify any gaps for which referrals should be made. On the Website of the Centers for Disease Control and Prevention (CDC), individual vaccine recommendations for children six years of age and younger can be checked at http://www.cdc.gov/vaccines/recs/scheduler/catchup.htm.

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
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.4.2.1 Initial Orientation of All Staff
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.4.4.2 Continuing Education for Small Family Child Care Home Caregivers/Teachers
1.4.5.1 Training of Staff Who Handle Food
1.4.5.2 Child Abuse and Neglect Education
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.4.5.4 Education of Center Staff
1.4.6.1 Training Time and Professional Development Leave
1.4.6.2 Payment for Continuing Education
3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.3 Protection from Air Pollution While Children Are Outside
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
8.7.0.3 Review of Plan for Serving Children with Disabilities or Children with Special Health Care Needs
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized/Underimmunized Children

REFERENCES

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.
Centers for Disease Control and Prevention (CDC). 2011. Immunization schedules. http://www.cdc.gov/vaccines/recs/schedules/.
Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.
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.
Kendrick, A. S., R. Kaufmann, K. P. Messenger, eds. 1991. Healthy young children: A manual for programs. Washington, DC: National Association for the Education of Young Children.
Ulione, M. S. 1997. Health promotion and injury prevention in a child development center. J Pediatr Nurs 12:148-54.

Standard 1.3.3.1: General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home

All caregivers/teachers in large and small family child care homes should be at least twenty-one years of age, hold an official credential as granted by the authorized state agency, meet the general requirements specified in Standard 1.3.2.4 through Standard 1.3.2.6, based on ages of the children served, and those in Section 1.3.3, and should have the following education, experience, and skills:

Current accreditation by the National Association for Family Child Care (NAFCC) (including entry-level qualifications and participation in required training) and a college certificate representing a minimum of three credit hours of early childhood education leadership or master caregiver/teacher training or hold an Associate’s degree in early childhood education or child development;
A provider who has been in the field less than twelve months should be in the self-study phase of NAFCC accreditation;
A valid certificate in pediatric first aid, including CPR;
Pre-service training in health management in child care, including the ability to recognize signs of illness, knowledge of infectious disease prevention and safety injury hazards;
If caring for infants, knowledge on safe sleep practices including reducing the risk of sudden infant death syndrome (SIDS) and prevention of shaken baby syndrome/abusive head trauma (including how to cope with a crying infant);
Knowledge of normal child development, as well as knowledge of indicators that a child is not developing typically;
The ability to respond appropriately to children’s needs;
Good oral and written communication skills;
Willingness to receive ongoing mentoring from other teachers;
Pre-service training in business practices;
Knowledge of the importance of nurturing adult-child relationships on self-efficacy development;
Medication administration training (6).

Additionally, large family child care home caregivers/teachers should have at least one year of experience serving the ages and developmental abilities of the children in their large family child care home.

Assistants, aides, and volunteers employed by a large family child care home should meet the qualifications specified in Standard 1.3.2.3.

RATIONALE

In both large and small family child care homes, staff members must have the education and experience to meet the needs of the children in care (7). Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of small numbers of children in their care.

Most SIDS deaths in child care occur on the first day of care or within the first week; unaccustomed prone (tummy) sleeping increases the risk of SIDS eighteen times (3). Shaken baby syndrome/abusive head trauma is completely preventable. Pre-service training and frequent refresher training can prevent deaths (4).

Age eighteen is the earliest age of legal consent. Mature leadership is clearly preferable. Age twenty-one is more likely to be associated with the level of maturity necessary to independently care for a group of children who are not one’s own.

The NAFCC has established an accreditation process to enhance the level of quality and professionalism in small and large family child care (2).

COMMENTS

A large family child care home caregiver/teacher, caring for more than six children and employing one or more assistants, functions as the primary caregiver as well as the facility director. An operator of a large family-child-care home should be offered training relevant to the management of a small child care center, including training on providing a quality work environment for employees.

For more information on assessing the work environment of family child care employees, see Creating Better Family Child Care Jobs: Model Work Standards, a publication by the Center for the Child Care Workforce (CCW) (1).

TYPE OF FACILITY

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

RELATED STANDARDS

1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age
1.3.1.2 Mixed Director/Teacher Role
1.3.2.1 Differentiated Roles
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.6 Additional Qualifications for Caregivers/Teachers Serving School-Age Children
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction

REFERENCES

U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough and cold medication: Unsupervised ingestion accounts for 66 percent of incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/r080128.htm.
Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98.
Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.
National Association for Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC.
American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
National Association for Family Child Care. NAFCC official Website. http://nafcc.net.
Center for Child Care Workforce. 1999. Creating better family child care jobs: Model work standards. Washington, DC: Center for Child Care Workforce.

Standard 1.4.1.1: Pre-service Training

In addition to the credentials listed in Standard 1.3.1.1, upon employment, a director or administrator of a center or the lead caregiver/teacher in a family child care home should provide documentation of at least thirty clock-hours of pre-service training. This training should cover health, psychosocial, and safety issues for out-of-home child care facilities. Small family child care home caregivers/teachers may have up to ninety days to secure training after opening except for training on basic health and safety procedures and regulatory requirements.

All directors or program administrators and caregivers/teachers should document receipt of pre-service training prior to working with children that includes the following content on basic program operations:

Typical and atypical child development and appropriate best practice for a range of developmental and mental health needs including knowledge about the developmental stages for the ages of children enrolled in the facility;
Positive ways to support language, cognitive, social, and emotional development including appropriate guidance and discipline;
Developing and maintaining relationships with families of children enrolled, including the resources to obtain supportive services for children’s unique developmental needs;
Procedures for preventing the spread of infectious disease, including hand hygiene, cough and sneeze etiquette, cleaning and disinfection of toys and equipment, diaper changing, food handling, health department notification of reportable diseases, and health issues related to having animals in the facility;
Teaching child care staff and children about infection control and injury prevention through role modeling;
Safe sleep practices including reducing the risk of Sudden Infant Death Syndrome (SIDS) (infant sleep position and crib safety);
Shaken baby syndrome/abusive head trauma prevention and identification, including how to cope with a crying/fussy infant;
Poison prevention and poison safety;
Immunization requirements for children and staff;
Common childhood illnesses and their management, including child care exclusion policies and recognizing signs and symptoms of serious illness;
Reduction of injury and illness through environmental design and maintenance;
Knowledge of U.S. Consumer Product Safety Commission (CPSC) product recall reports;
Staff occupational health and safety practices, such as proper procedures, in accordance with Occupational Safety and Health Administration (OSHA) bloodborne pathogens regulations;
Emergency procedures and preparedness for disasters, emergencies, other threatening situations (including weather-related, natural disasters), and injury to infants and children in care;
Promotion of health and safety in the child care setting, including staff health and pregnant workers;
First aid including CPR for infants and children;
Recognition and reporting of child abuse and neglect in compliance with state laws and knowledge of protective factors to prevent child maltreatment;
Nutrition and age-appropriate child-feeding including food preparation, choking prevention, menu planning, and breastfeeding supportive practices;
Physical activity, including age-appropriate activities and limiting sedentary behaviors;
Prevention of childhood obesity and related chronic diseases;
Knowledge of environmental health issues for both children and staff;
Knowledge of medication administration policies and practices;
Caring for children with special health care needs, mental health needs, and developmental disabilities in compliance with the Americans with Disabilities Act (ADA);
Strategies for implementing care plans for children with special health care needs and inclusion of all children in activities;
Positive approaches to support diversity;
Positive ways to promote physical and intellectual development.

RATIONALE

The director or program administrator of a center or large family child care home or the small family child care home caregiver/teacher is the person accountable for all policies. Basic entry-level knowledge of health and safety and social and emotional needs is essential to administer the facility. Caregivers/teachers should be knowledgeable about infectious disease and immunizations because properly implemented health policies can reduce the spread of disease, not only among the children but also among staff members, family members, and in the greater community (1). Knowledge of injury prevention measures in child care is essential to control known risks. Pediatric first aid training that includes CPR is important because the director or small family child care home caregiver/teacher is fully responsible for all aspects of the health of the children in care. Medication administration and knowledge about caring for children with special health care needs is essential to maintaining the health and safety of children with special health care needs. Most SIDS deaths in child care occur on the first day of child care or within the first week due to unaccustomed prone (on the stomach) sleeping; the risk of SIDS increases eighteen times when an infant who sleeps supine (on the back) at home is placed in the prone position in child care (2). Shaken baby syndrome/abusive head trauma is completely preventable. It is crucial for caregivers/teachers to be knowledgeable of both syndromes and how to prevent them before they care for infants. Early childhood expertise is necessary to guide the curriculum and opportunities for children in programs (3). The minimum of a Child Development Associate credential with a system of required contact hours, specific content areas, and a set renewal cycle in addition to an assessment requirement would add significantly to the level of care and education for children.

The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training based on the needs of the program and the pre-service qualifications of staff (4). Training should address the following areas:

Health and safety (specifically reducing the risk of SIDS, infant safe sleep practices, shaken baby syndrome/abusive head trauma), and poison prevention and poison safety;
Child growth and development, including motor development and appropriate physical activity;
Nutrition and feeding of children;
Planning learning activities for all children;
Guidance and discipline techniques;
Linkages with community services;
Communication and relations with families;
Detection and reporting of child abuse and neglect;
Advocacy for early childhood programs;
Professional issues (5).

In the early childhood field there is often “crossover” regarding professional preparation (pre-service programs) and ongoing professional development (in-service programs). This field is one in which entry-level requirements differ across various sectors within the field (e.g., nursing, family support, and bookkeeping are also fields with varying entry-level requirements). In early childhood, the requirements differ across center, home, and school based settings. An individual could receive professional preparation (pre-service) to be a teaching staff member in a community-based organization and receive subsequent education and training as part of an ongoing professional development system (in-service). The same individual could also be pursuing a degree for a role as a teacher in a program for which licensure is required—this in-service program would be considered pre-service education for the certified teaching position. Therefore, the labels pre-service and in-service must be seen as related to a position in the field, and not based on the individual’s professional development program (5).

COMMENTS

Training in infectious disease control and injury prevention may be obtained from a child care health consultant, pediatricians, or other qualified personnel of children’s and community hospitals, managed care companies, health agencies, public health departments, EMS and fire professionals, pediatric emergency room physicians, or other health and safety professionals in the community.

For more information about training opportunities, contact the local Child Care Resource and Referral Agency (CCRRA), the local chapter of the American Academy of Pediatrics (AAP) (AAP provides online SIDS and medication administration training), the Healthy Child Care America Project, or the National Resource Center for Health and Safety in Child Care and Early Education (NRC). California Childcare Health Program (CCHP) has free curricula for health and safety for caregivers/teachers to become child care health advocates. The curriculum (English and Spanish) is free to download on the Web at http://www.ucsfchildcare
health.org/html/pandr/trainingcurrmain.htm, and is based on the National Training Institute for Child Care Health Consultants (NTI) curriculum for child care health consultants. Online training for caregivers/teachers is also available through some state agencies.

For more information on social-emotional training, contact the Center on the Social and Emotional Foundations for Early Learning (CSEFEL) at http://csefel.vanderbilt.edu.

TYPE OF FACILITY

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

RELATED STANDARDS

1.3.1.1 General Qualifications of Directors
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
10.6.1.1 Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services
10.6.1.2 Provision of Training to Facilities by Health Agencies
9.2.4.5 Emergency and Evacuation Drills Policy
9.4.3.3 Training Record

REFERENCES

National Association for the Education of Young Children. 2010. Definition of early childhood professional development, 12. Eds. M. S. Donovan, J. D. Bransford, J. W. Pellegrino. Washington, DC: National Academy Press.
Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC early childhood program standard and related accreditation criteria. Washington, DC: National Association for the Education of Young Children (NAEYC).
Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
Hayney M. S., J. C. Bartell. 2005. An immunization education program for childcare providers. J of School Health 75:147-49.
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.

Standard 1.4.2.2: Orientation for Care of Children with Special Health Care Needs

When a child care facility enrolls a child with special health care needs, the facility should ensure that all staff members have been oriented in understanding that child’s special health care needs and have the skills to work with that child in a group setting.

Caregivers/teachers in small family child care homes, who care for a child with special health care needs, should meet with the parents/guardians and meet or speak with the child’s primary care provider (if the parent/guardian has provided prior, informed, written consent) or a child care health consultant to ensure that the child’s special health care needs will be met in child care and to learn how these needs may affect his/her developmental progression or play with other children.

In addition to Orientation Training, Standard 1.4.2.1, the orientation provided to staff in child care facilities should be based on the special health care needs of children who will be assigned to their care. All staff oriented for care of children with special health needs should be knowledgeable about the care plans created by the child’s primary care provider in their medical home as well as any care plans created by other health professionals and therapists involved in the child’s care. A template for a care plan for children with special health care needs can be found in Appendix O. Child care health consultants can be an excellent resource for providing health and safety orientation or referrals to resources for such training. This training may include, but is not limited to, the following topics:

Positioning for feeding and handling, and risks for injury for children with physical/mental disabilities;
Toileting techniques;
Knowledge of special treatments or therapies (e.g., PT, OT, speech, nutrition/diet therapies, emotional support and behavioral therapies, medication administration, etc.) the child may need/receive in the child care setting;
Proper use and care of the individual child’s adaptive equipment, including how to recognize defective equipment and to notify parents/guardians that repairs are needed;
How different disabilities affect the child’s ability to participate in group activities;
Methods of helping the child with special health care needs or behavior problems to participate in the facility’s programs, including physical activity programs;
Role modeling, peer socialization, and interaction;
Behavior modification techniques, positive behavioral supports for children, promotion of self-esteem, and other techniques for managing behavior;
Grouping of children by skill levels, taking into account the child’s age and developmental level;
Health services or medical intervention for children with special health care problems;
Communication methods and needs of the child;
Dietary specifications for children who need to avoid specific foods or for children who have their diet modified to maintain their health, including support for continuation of breastfeeding;
Medication administration (for emergencies or on an ongoing basis);
Recognizing signs and symptoms of impending illness or change in health status;
Recognizing signs and symptoms of injury;
Understanding temperament and how individual behavioral differences affect a child’s adaptive skills, motivation, and energy;
Potential hazards of which staff should be aware;
Collaborating with families and outside service providers to create a health, developmental, and behavioral care plan for children with special needs;
Awareness of when to ask for medical advice and recommendations for non-emergent issues that arise in school (e.g., head lice, worms, diarrhea);
Knowledge of professionals with skills in various conditions, e.g., total communication for children with deafness, beginning orientation and mobility training for children with blindness (including arranging the physical environment effectively for such children), language promotion for children with hearing-impairment and language delay/disorder, etc.;
How to work with parents/guardians and other professionals when assistive devices or medications are not consistently brought to the child care program or school;
How to safely transport a child with special health care needs.

RATIONALE

A basic understanding of developmental disabilities and special care requirements of any child in care is a fundamental part of any orientation for new employees. Training is an essential component to ensure that staff members develop and maintain the needed skills. A comprehensive curriculum is required to ensure quality services. However, lack of specialized training for staff does not constitute grounds for exclusion of children with disabilities (1).

Staff members need information about how to help children use and maintain adaptive equipment properly. Staff members need to understand how and why various items are used and how to check for malfunctions. If a problem occurs with adaptive equipment, the staff must recognize the problem and inform the parent/guardian so that the parent/guardian can notify the health care or equipment provider of the problem and request that it be remedied. While the parent/guardian is responsible for arranging for correction of equipment problems, child care staff must be able to observe and report the problem to the parent/guardian. Routine care of adaptive and treatment equipment, such as nebulizers, should be taught.

COMMENTS

These training topics are generally applicable to all personnel serving children with special health care needs and apply to child care facilities. The curriculum may vary depending on the type of facility, classifications of disabilities of the children in the facility, and ages of the children. The staff is assumed to have the training described in Orientation Training, Standard 1.4.2.1, including child growth and development. These additional topics will extend their basic knowledge and skills to help them work more effectively with children who have special health care needs and their families. The number of hours offered in any in-service training program should be determined by the staff’s experience and professional background. Service plans in small family child care homes may require a modified implementation plan.

The parent/guardian is responsible for solving equipment problems. The parent/guardian can request that the child care facility remedy the problem directly if the caregiver/teacher has been trained on the maintenance and repair of the equipment and if the staff agrees to do it.

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.2.1 Initial Orientation of All Staff
3.5.0.1 Care Plan for Children with Special Health Care Needs
9.4.3.3 Training Record
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov.

Standard 1.4.2.3: Orientation Topics

During the first three months of employment, the director of a center or the caregiver/teacher in a large family home should document, for all full-time and part-time staff members, additional orientation in, and the employees’ satisfactory knowledge of, the following topics:

Recognition of symptoms of illness and correct documentation procedures for recording symptoms of illness. This should include the ability to perform a daily health check of children to determine whether any children are ill or injured and, if so, whether a child who is ill should be excluded from the facility;
Exclusion and readmission procedures and policies;
Cleaning, sanitation, and disinfection procedures and policies;
Procedures for administering medication to children and for documenting medication administered to children;
Procedures for notifying parents/guardians of an infectious disease occurring in children or staff within the facility;
Procedures and policies for notifying public health officials about an outbreak of disease or the occurrence of a reportable disease;
Emergency procedures and policies related to unintentional injury, medical emergency, and natural disasters;
Procedure for accessing the child care health consultant for assistance;
Injury prevention strategies and hazard identification procedures specific to the facility, equipment, etc.; and
Proper hand hygiene.

Before being assigned to tasks that involve identifying and responding to illness, staff members should receive orientation training on these topics. Small family child care home caregivers/teachers should not commence operation before receiving orientation on these topics in pre-service training.

RATIONALE

Children in child care are frequently ill (1). Staff members responsible for child care must be able to recognize illness and injury, carry out the measures required to prevent the spread of communicable diseases, handle ill and injured children appropriately, and appropriately administer required medications (2). Hand hygiene is one of the most important means of preventing spread of infectious disease (3).

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.1.1 Pre-service Training
3.1.1.1 Conduct of Daily Health Check
3.1.1.2 Documentation of the Daily Health Check
9.4.3.3 Training Record

REFERENCES

American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
Centers for Disease Control and Prevention (CDC). 2016. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
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; 2020:3.

Standard 1.4.3.1: First Aid and Cardiopulmonary Resuscitation Training for Staff

Content in the STANDARD was modified on 05/17/2019.

All staff members involved in providing direct care to children should complete and document training in pediatric first aid and cardiopulmonary resuscitation (CPR). Courses in pediatric first aid and CPR should be taught in person by instructor-led demonstrations and practiced to ensure the technique could be performed in an emergency. Early care and education programs should follow training renewal cycles recommended by the providing organization (eg, American Heart Association [AHA]).

At least one staff member trained in pediatric first aid and CPR should be in attendance at all times when a child whose special care plan indicates an increased risk of cardiac arrest or complications due to cardiac disease is in attendance.¹ Children with special health care needs who have compromised airways may need to be accompanied to child care by nurses who are able to respond to airway problems (eg, the child who has a tracheostomy and needs suctioning).

While the use of automated external defibrillators (AEDs) on children is rare, early care and education programs should consider having an AED on the premises for potential use on both adults and children. Pediatric pads should be used for children younger than 8 years old.²Trainings should be inclusive to children in care, staff and other adults present in early care and education programs.

Records of successful completion of training and renewal cycles in pediatric first aid and pediatric CPR should be maintained in the employee personnel files on site.

RATIONALE

The 2018 update to the AHA “Guidelines for CPR and Emergency Cardiovascular Care” section on pediatric basic life support includes recommendations for hands-only CPR chest compressions. These recommendations include chest compression rates of 100 to 120 compressions/min for infants and children.³

Early care and education programs with staff trained in pediatric first aid and CPR can mitigate the consequences of injury and reduce the potential for death from life-threatening conditions and emergencies. Furthermore, knowledge of pediatric first aid and CPR includes addressing a blocked airway (choking) as well as rescue breathing. Repetitive training, coupled with the confidence to use these skills, are critically important to the outcome of an emergency.

Documentation of current certification of satisfactory completion of pediatric first aid and demonstration of pediatric CPR skills in the facility assists in implementing and monitoring for proof of compliance.

COMMENTS

Additional Resources:

First aid and CPR courses from the American Red Cross can be found here: https://www.redcross.org/take-a-class/babysitting/babysitting-child-care-preparation/child-care-licensing.

First aid and CPR courses from the AHA can be found here: https://cpr.heart.org/AHAECC/CPRAndECC/FindACourse/UCM_473162_CPR-First-Aid-Training-Classes-American-Heart-Association.jsp.

The American Academy of Pediatrics pediatric course in first aid can be found here: https://www.pedfactsonline.com.

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.3.2 Topics Covered in Pediatric First Aid Training
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
10.6.1.1 Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services
10.6.1.2 Provision of Training to Facilities by Health Agencies
9.4.1.2 Maintenance of Records
9.4.3.3 Training Record

REFERENCES

American Academy of Pediatrics. Using an AED. Healthy Children. https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Using-an-AED.aspx Updated May 09, 2018. Accessed April 25, 2019.
Marino BS, Tabbutt S, MacLaren G, et al; American Heart Association Congenital Cardiac Defects Committee of the Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Emergency Cardiovascular Care Committee. Cardiopulmonary resuscitation in infants and children with cardiac disease: a scientific statement from the American Heart Association. Circulation. 2018;137(22):e691–e782
American Heart Association. Part 11: pediatric basic life support and cardiopulmonary resuscitation quality. https://eccguidelines.heart.org/
index.php/circulation/cpr-ecc-guidelines-2/part-11-pediatric-basic-life-support-and-cardiopulmonary-resuscitation-quality. Updated 2017. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 05/17/2019.

Standard 1.4.5.2: Child Abuse and Neglect Education

Content in the STANDARD was modified on 5/22/2018

Caregivers/teachers are mandatory reporters of child abuse and neglect. Caregivers/teachers should attend child abuse and neglect prevention education programs to educate themselves and establish child abuse and neglect prevention and recognition guidelines for the children, caregivers/teachers, and parents/guardians. The prevention education program should address physical, sexual, and psychological or emotional abuse and neglect. The dangers of shaking infants and toddlers and repeated exposure to domestic violence should be included in the education and prevention materials. Caregivers/teachers should also receive education on promoting protective factors to prevent child maltreatment. (Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (e.g., clergy, coach, teacher, etc.) (1). Caregivers/teachers should be able to identify signs of stress in families and assist families by providing support and access/referral to resources when needed. Children with disabilities are at a higher risk of being abused than healthy children. Special training in child abuse and neglect of children with disabilities should be provided (2).

Risk factors for victimization include a child’s age and special needs that may require increased attention from the caregiver. Risk factors for perpetration include young parental age, single parenthood, many dependent children, low parental income or parental unemployment, substance abuse, and family history of child abuse/neglect, violence, and/or mental illness (2,3). Caregivers/teachers should be aware of these factors so they can support parenting practices when appropriate. Caregivers/teachers should be trained in compliance with their state’s child abuse and neglect reporting laws. Child abuse reporting requirements are available from the child care regulation department in each state (4).

Child abuse and neglect materials should be designed for nonmedical audiences.

RATIONALE

Education is important in identifying manifestations of child maltreatment that can increase the likelihood of appropriate reports to child protection and law enforcement agencies (5).

COMMENTS

Child abuse and neglect resources are available from the American Academy of Pediatrics at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/resilience/Pages/Child-Abuse-and-Neglect.aspx, the Child Welfare Information Gateway at www.childwelfare.gov, Prevent Child Abuse America at www.preventchildabuse.org, and The Early Childhood Learning & Knowledge Center at https://eclkc.ohs.acf.hhs.gov/browse/keyword/child-abuse.

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
3.4.4.2 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
9.2.1.1 Content of Policies
9.4.3.3 Training Record
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.4.2.1 Health and Safety Education Topics for Staff

REFERENCES

Admon Livny K, Katz C. Schools, families, and the prevention of child maltreatment: lessons that can be learned from a literature review. Trauma Violence Abuse. 2016;pii:1524838016650186
US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2014. http://www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf. Published 2016. Accessed January 11, 2018
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
Centers for Disease Control and Prevention. Violence prevention. Child abuse and neglect: risk and protective factors. https://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html. Updated April 18, 2017. Accessed January 11, 2018
Centers for Disease Control and Prevention. Child abuse and neglect prevention. https://www.cdc.gov/violenceprevention/childmaltreatment/index.html. Updated April 17, 2017. Accessed March 8, 2018

NOTES

Content in the STANDARD was modified on 5/22/2018

Standard 1.5.0.2: Orientation of Substitutes

Content in the STANDARD was modified on 5/22/2018

The director of any center or large family child care home and the small family child care home caregiver/teacher should provide orientation training to newly hired substitutes, including a review of all the program’s policies and procedures (see sample that follows). This training should include the opportunity for an evaluation and a repeat demonstration of the training lesson. Orientation should be documented in all child care settings. Substitutes should have background screenings.

All substitutes should be oriented to, and demonstrate competence in, the tasks for which they will be responsible.

On the first day a substitute caregiver/teacher should be oriented on the following topics:

Safe infant sleep practices
1. The practice of putting infants down to sleep positioned on their backs and on a firm surface, along with all safe infant sleep practices, to reduce the risk of sudden infant death syndrome (SIDS), as well as general nap time routines and healthy sleep hygiene for all ages.
Any emergency medical procedure or medication needs of the children
Access to the list of authorized individuals for releasing children
Any special dietary needs of the children

During the first week of employment, all substitute caregivers/teachers should be oriented to, and should demonstrate competence in, at least the following items:

The names of the children for whom the caregiver/teacher will be responsible and their specific developmental and special health care needs
The planned program of activities at the facility
Routines and transitions
Acceptable methods of discipline
Meal patterns and safe food-handling policies of the facility (Special attention should be given to life-threatening food allergies.)
Emergency health and safety procedures
General health policies and procedures as appropriate for the ages of the children cared for, including, but not limited to

1. Hand hygiene techniques, including indications for hand hygiene

2. Diapering technique, if care is provided to children in diapers, including appropriate diaper disposal and diaper changing techniques and use and wearing of gloves

3. Preventing shaken baby syndrome/abusive head trauma

4. Strategies for coping with crying, fussing, or distraught infants and children

5. Early brain development and its vulnerabilities

6. Other injury prevention and safety, including the role of a mandatory child abuse reporter to report any suspected abuse/neglect

7. Correct food preparation and storage techniques, if employee prepares food

8. Proper handling and storage of human (breast) milk, when applicable, and formula preparation, if formula is handled

9. Bottle preparation, including guidelines for human milk and formula, if care is provided to infants or children with bottles

10. Proper use of gloves in compliance with Occupational Safety and Health Administration blood-borne pathogen regulations

_h. Emergency plans and practices

On employment, substitutes should be able to carry out the duties assigned to them.

RATIONALE

Because facilities and the children enrolled in them vary, orientation programs for new substitutes can be most productive. Because of frequent staff turnover, comprehensive orientation programs are critical to protecting the health and safety of children and new staff (1,2). Most SIDS deaths in child care occur on the first day of care or within the first week due to unaccustomed prone (on stomach) sleeping. Unaccustomed prone sleeping increases the risk of SIDS 18 times (3).

TYPE OF FACILITY

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

RELATED STANDARDS

1.2.0.2 Background Screening
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.2.1.1 Type of Diapers Worn
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
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.4.3.1 Medical Emergency Procedures
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
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)
5.4.5.1 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
9.2.2.3 Exchange of Information at Transitions
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.2.4.2 Review of Written Plan for Urgent Care and Threatening Incidents
9.4.1.18 Records of Nutrition Service
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
Appendix D: Gloving

REFERENCES

Landry SH, Zucker TA, Taylor HB, et al. Enhancing early child care quality and learning for toddlers at risk: the responsive early childhood program. Dev Psychol. 2014;50(2):526–541
Ellenbogen S, Klein B, Wekerle C. Early childhood education as a resilience intervention for maltreated children. Early Child Dev Care. 2014;184:1364–1377
Ball HL, Volpe LE. Sudden infant death syndrome (SIDS) risk reduction and infant sleep location—moving the discussion forward. Soc Sci Med. 2013;79:84–91

NOTES

Content in the STANDARD was modified on 5/22/2018

Standard 7.4.0.2: Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections

Content in the STANDARD was modified on 4/5/2017 and 09/13/2022.

Diarrheal (enteric) infections are illnesses where someone develops more watery or more frequent stools than what is normal for them. Diarrhea is caused by intestinal infections and is more common in early care and education programs because these infections spread easily through diapering, poor hand hygiene, and toileting.¹ These infections can cause outbreaks in early care and education programs. To prevent and control the spread of diarrheal infections and hepatitis A, programs should follow procedures and have staff education that includes

Routine education for staff, food handlers, and maintenance workers on proper hand hygiene, proper food preparation and storage, proper diapering, and cleaning, sanitizing, and/or disinfecting surfaces and materials.^2–3
Regular staff education on how to decrease spread of diarrheal illness through information on
- How germs that cause diarrheal illnesses and hepatitis A are spread
- Symptoms of diarrheal illness and hepatitis A
- How to prevent spread of diarrheal illness and hepatitis A
Proper use and cleaning of water play materials³
Information on appropriate choice of and handling of animals in programs⁴
Guidelines for routine administration of hepatitis A and rotavirus vaccines should be enforced to prevent infection and spread in programs.³

At least annually, early care and education programs should review all procedures for preventing diarrheal infections. All staff, food handlers, and maintenance workers should review procedures on preventing diarrheal infections. Staff should review age-specific criteria for inclusion and exclusion of children who have a diarrheal illness or hepatitis A, and infection control procedures.

RATIONALE

Viruses, bacteria, and parasites in stool can cause disease in children and staff in early care and education programs. Infections are spread in these settings from contact with stool during diapering and toileting. Although many intestinal infections can cause diarrhea, rotavirus, other intestinal viruses, Giardia intestinalis, Cryptosporidium, shigella, and E. coli are the most common causes of outbreaks in children in early care and education programs.³ Proper diapering and toileting, and infection control measures can reduce infections.⁴ Following program procedures and regular staff education can reduce spread of diarrheal illnesses.

Routine childhood vaccination for rotavirus and hepatitis A have decreased outbreaks from these viruses.¹ Children and staff in early care and education programs should receive all recommended age-appropriate vaccines. Staff should watch children for signs of disease to detect it early and to carry out steps to control it. Programs should consult the local health department to find out if the increased frequency of diarrheal illness needs public health intervention.

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
3.3.0.2 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
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
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
7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
Appendix G: Recommended Childhood Immunization Schedule
Appendix H: Recommended Adult Immunization Schedule
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

Shane AL, Mody RK, Crump JA, et al. Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clinical Infectious Diseases. 2017;65(12):e45-e80. doi.org/10.1093/cid/cix669
Collins JP, Shane AL. Infections associated with group childcare. Principles and Practice of Pediatric Infectious Diseases. 5^th ed. 2018;25–32.e3. doi.org/10.1016/B978-0-323-40181-4.00003-7
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. 2022.
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; 2021:117-118.

NOTES

Content in the STANDARD was modified on 4/5/2017 and 09/13/2022.

Standard 7.7.1.1: Staff Education and Policies on Cytomegalovirus (CMV)

Content in the STANDARD was modified on 3/31/17.

Cytomegalovirus (CMV) is a viral infection that is common in children. Up to 70% of children ages 1 to 3 years in group care settings excrete the virus (1).
Staff of childbearing age who care for infants and children should be provided the following information:

The increased probability of exposure to cytomegalovirus (CMV) in the child care setting;
The potential for fetal damage when CMV is acquired during pregnancy;
The importance of hand hygiene measures (especially handwashing and avoiding contact with urine, saliva, and nasal secretions) to lower the risk of CMV;
The availability of counseling and testing for serum antibody to CMV to determine the caregiver/teacher’s immune status.

Female employees of childbearing age should be referred to their primary health care provider or to the health department authority for counseling about their risk of CMV infection. This counseling may include testing for serum antibodies to CMV to determine the employee’s immunity against CMV infection.
Since saliva can transmit CMV, staff should be advised not to share cups or eating utensils, kiss children on the lips, or allow children to put their fingers or hands in another person’s mouth.

RATIONALE

CMV is the leading cause of congenital infection in the United State and approximately 1% of live born infants are infected prenatally (1). While most infected fetuses likely escape resulting illness or disability, 10% to 20% may have hearing loss, developmental delay, cerebral palsy, or vision disturbances (1). Although maternal immunity does not entirely prevent congenital CMV infection, evidence indicates that acquisition of CMV during pregnancy (primary maternal infection) carries the greatest risk for resulting illness or disability of the fetus (2).

Children enrolled in child care facilities are more likely to acquire CMV than are children cared for at home (2). Epidemiologic data, as well as laboratory testing of viral strains, has provided evidence for child-to-child transmission of CMV in the child care setting (1). Rates of CMV excretion vary among facilities and between class groups within a facility. Children between one and three years of age have the highest rates of excretion; published studies report excretion rates between 30% and 40% (2). Many children excrete CMV asymptomatically and intermittently for years.

With regard to child-to-staff transmission, studies have shown increased rates of infection with CMV in caregivers/teachers ranging from 8% to 20% (2). The increased risk for exposure to CMV and high rates of acquisition of CMV in caregivers/teachers could lead to increased rates of congenital CMV infection. Meticulous hand hygiene can reduce the rates of infection by preventing CMV transmission. With current knowledge on the risk of CMV infection in child care staff members and the potential consequences of gestational CMV infection, child care staff members should receive counseling in regard to the risks of acquiring CMV from their primary health care provider. However, it is also important for the child care center director to inform infant caregivers/teachers of the increased risk of exposure to CMV during pregnancy (1).

COMMENTS

For additional information regarding CMV, consult the CMV chapter in the current edition of the Red Book from the American Academy of Pediatrics (AAP).

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

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.
American Academy of Pediatrics. Cytomegalovirus (CMV) Infection 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: 310-317

NOTES

Content in the STANDARD was modified on 3/31/17.

Consultants

Standard 1.6.0.1: Child Care Health Consultants

COVID-19 modification as of May 21, 2021

*STANDARD UNDERGOING FULL REVISION*

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

CCHCs have knowledge of resources and regulations and are comfortable linking health resources with child care facilities.

The child care health consultant should be knowledgeable in the following areas:

Consultation skills both as a child care health consultant as well as a member of an interdisciplinary team of consultants;
National health and safety standards for out-of-home child care;
Indicators of quality early care and education;
Day-to-day operations of child care facilities;
State child care licensing and public health requirements;
State health laws, Federal and State education laws [e.g., Americans with Disabilities Act (ADA), Individuals with Disabilities Education Act (IDEA)], and state professional practice acts for licensed professionals (e.g., State Nurse Practice Acts);
Infancy and early childhood development, social and emotional health, and developmentally appropriate practice;
Recognition and reporting requirements for infectious diseases;
American Academy of Pediatrics (AAP) and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening recommendations and immunizations schedules for children;
Importance of medical home and local and state resources to facilitate access to a medical home as well as child health insurance programs including Medicaid and State Children’s Health Insurance Program (SCHIP);
Injury prevention for children;
Oral health for children;
Nutrition and age-appropriate physical activity recommendations for children including feeding of infants and children, the importance of breastfeeding and the prevention of obesity;
Inclusion of children with special health care needs, and developmental disabilities in child care;
Safe medication administration practices;
Health education of children;
Recognition and reporting requirements for child abuse and neglect/child maltreatment;
Safe sleep practices and policies (including reducing the risk of SIDS);
Development and implementation of health and safety policies and practices including poison awareness and poison prevention;
Staff health, including adult health screening, occupational health risks, and immunizations;
Disaster planning resources and collaborations within child care community;
Community health and mental health resources for child, parent/guardian and staff health;
Importance of serving as a healthy role model for children and staff.

The child care health consultant should be able to perform or arrange for performance of the following activities:

Assessing caregivers’/teachers’ knowledge of health, development, and safety and offering training as indicated;
Assessing parents’/guardians’ health, development, and safety knowledge, and offering training as indicated;
Assessing children’s knowledge about health and safety and offering training as indicated;
Conducting a comprehensive indoor and outdoor health and safety assessment and on-going observations of the child care facility;
Consulting collaboratively on-site and/or by telephone or electronic media;
Providing community resources and referral for health, mental health and social needs, including accessing medical homes, children’s health insurance programs (e.g., CHIP), and services for special health care needs;
Developing or updating policies and procedures for child care facilities (see comment section below);
Reviewing health records of children;
Reviewing health records of caregivers/teachers;
Assisting caregivers/teachers and parents/guardians in the management of children with behavioral, social and emotional problems and those with special health care needs;
Consulting a child’s primary care provider about the child’s individualized health care plan and coordinating services in collaboration with parents/guardians, the primary care provider, and other health care professionals (the CCHC shows commitment to communicating with and helping coordinate the child’s care with the child’s medical home, and may assist with the coordination of skilled nursing care services at the child care facility);
Consulting with a child’s primary care provider about medications as needed, in collaboration with parents/guardians;
Teaching staff safe medication administration practices;
Monitoring safe medication administration practices;
Observing children’s behavior, development and health status and making recommendations if needed to staff and parents/guardians for further assessment by a child’s primary care provider;
Interpreting standards, regulations and accreditation requirements related to health and safety, as well as providing technical advice, separate and apart from an enforcement role of a regulation inspector or determining the status of the facility for recognition;
Understanding and observing confidentiality requirements;
Assisting in the development of disaster/emergency medical plans (especially for those children with special health care needs) in collaboration with community resources;
Developing an obesity prevention program in consultation with a nutritionist/registered dietitian (RD) and physical education specialist;
Working with other consultants such as nutritionists/RDs, kinesiologists (physical activity specialists), oral health consultants, social service workers, infant and early childhood mental health consultants, and education consultants.

The role of the CCHC is to promote the health and development of children, families, and staff and to ensure a healthy and safe child care environment (11).

COVID-19 modification as of May 21, 2021

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 early childhood programs:

Follow guidance from your state and local health department as well as your state child care licensing agency.

Use child care health consultants (CCHCs) during COVID for their knowledge and relationships with local pediatric and public health professionals to:

Share up-to-date information with programs
Support implementation of new guidance for operation during COVID-19
Review and update pertinent health and safety policies
Offer opportunities to deliver timely staff trainings via webinar
Share updates on local COVID-19 vaccination efforts, be open to answer questions and listen to concerns from staff and families

Address the many delays in children’s health care due to missed health and dental appointments during COVID-19 by working with the CCHC to:

Develop a plan to identify and assess overdue childhood immunizations and missed medical, behavioral health and dental appointments
Connect families with health care resources that provide medical homes and support preventative care and developmental screenings
Regularly monitor the overall health status of children and follow up with needed referrals and resources

Consider alternatives to CCHC onsite consultation and schedule other methods for delivering services:

Use virtual video visits or phone conferencing to review health care plans, medications, address health and safety issues and any training needs
Share video of the environment, without children present, for the CCHC to review
Plan outdoor visits, if weather allows, using face mask and physical distancing

Refer to the COVID-19 modifications in CFOC Standard 1.7.0.2: Daily Staff Health Check when on site visits are essential.

Additional Resources:

RATIONALE

COMMENTS

Listed below is a sample of the policies and procedures child care health consultants should review and approve:

Admission and readmission after illness, including inclusion/exclusion criteria;
Health evaluation and observation procedures on intake, including physical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance;
Plans for care and management of children with communicable diseases;
Plans for prevention, surveillance and management of illnesses, injuries, and behavioral and emotional problems that arise in the care of children;
Plans for caregiver/teacher training and for communication with parents/guardians and primary care providers;
Policies regarding nutrition, nutrition education, age-appropriate infant and child feeding, oral health, and physical activity requirements;
Plans for the inclusion of children with special health or mental health care needs as well as oversight of their care and needs;
Emergency/disaster plans;
Safety assessment of facility playground and indoor play equipment;
Policies regarding staff health and safety;
Policy for safe sleep practices and reducing the risk of SIDS;
Policies for preventing shaken baby syndrome/abusive head trauma;
Policies for administration of medication;
Policies for safely transporting children;
Policies on environmental health – handwashing, sanitizing, pest management, lead, etc.

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.3 Infant and Early Childhood Mental Health Consultants
1.6.0.4 Early Childhood Education Consultants

REFERENCES

Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81.
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.
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 Nurs 32:530-37.
Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health consultation: A conceptual model. J for Specialists in Pediatric Nurs 13:74-88.
Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
Heath, J. M., et al. 2005. Creating a statewide system of multi-disciplinary consultation system for early care and education in Connecticut. Farmington, CT: Child Health and Development Institute of Connecticut. http://nitcci.nccic.acf.hhs.gov/resources/10262005_93815_901828.pdf.
Farrer, J., A. Alkon, K. To. 2007. Child care health consultation programs: Barriers and opportunities. Maternal Child Health J 11:111-18.
Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.
Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21.
Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.

NOTES

COVID-19 modification as of May 21, 2021

Standard 1.6.0.2: Frequency of Child Care Health Consultation Visits

Content in the STANDARD was modified on 8/22/2013.

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

National Resource Center for Health and Safety in Child Care and Early Education. 2010. Child care health consultant requirements and profiles by state. http://nrckids.org/default/assets/File/CCHC%20by%20state%20NOV%202012_FINAL.pdf.
Crowley, A. A. & Rosenthal, M. S. IMPACT: Ensuring the health and safety of Connecticut’s early care and education programs. 2009. Farmington, CT: The Child Health and Development Institute of Connecticut.
Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Improvement of child care programs’ policies, practices, and children’s access to health care linked to child care health consultation. NHSA Dialog: A Research to Practice Journal 2013;16 (2):34-52 (ISSN:1930-1395).
Bryant, D. “Quality Interventions for Early Care and Education.” Early Developments, Spring 2013, http://fpg.unc.edu/sites/default/files/resources/early-developments/FPG_EarlyDevelopments_v14n1.pdf.
Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. Ward. 2007. Nutrition and physical activity self-assessment for child care (NAP SACC): Results from a pilot intervention. Journal of Nutrition Education and Behavior 39(3):142-9.
Nurse Consultant Intervention Improves Nutrition and Physical Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care. A. Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, V. Ngyuen, J. Kotch. Head Start Research Conference, Washington, DC. June 20, 2012.
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.
Crowley, A. A. & Kulikowich, J. Impact of training on child care health consultant knowledge and practice. Pediatric Nursing.,2009, 35 (2): 93-100.
Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.
Healthy Child Care Consultant Network Support Center, CHT Resource Group. 2006. The influence of child care health consultants in promoting children’s health and well-being: A report on selected resources. http://hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf.
Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.
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.
Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.

NOTES

Content in the STANDARD was modified on 8/22/2013.

Standard 1.6.0.3: Infant and Early Childhood Mental Health Consultants

COVID-19 modification as of October 10, 2022.

Standard was last updated on September 13, 2022.

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

Programs should find and work with IECMHCs who:

Have professional credentials and expertise in early childhood development and child mental health such as psychiatry, psychology, developmental-behavioral pediatrics, clinical social work, or nursing
Work well with children, families, and program staff from different racial, ethnic, and cultural/language backgrounds
Have an understanding of infants and young children who have developmental delays or disabilities
Are experienced in trauma-informed care of young children and families
Are familiar with early care and education policies, practices, and regulations
Can partner with program directors, staff, and families, and work together with professionals of other disciplines

Programs should expect an IECMHC to share or help develop:

An assessment of the program’s needs, strengths, and areas for improvement in mental health
Policies on child, family, and staff mental health
Individual observations of children and staff to assess children’s development, behavior, and related needs
Resources for teaching children about understanding their feelings, emotional regulation (managing or expressing their emotional responses effectively), coping strategies, conflict resolution, empathy, and social skills
Connections and/or referrals to community mental health providers and special education systems or resources
Resources to understand the mental health needs of specific children or families
Collaboration for screening or referral of children to early intervention services and/or local providers
Lists of community resources for families and staff who may need mental health support

Program staff should work with an IECMHC to develop the following skills:

Create and keep up healthy social-emotional environments and relationships in the program and with families

Understand and support staff to manage children’s challenging behaviors (such as aggression and tantrums) as well as internalizing behaviors (such as anxiety and depression), and how to respond appropriately
Recognize and respond to the needs of children who are sad or anxious, avoid others, or harm themselves
Partner with staff to make sure children with developmental delays and disabilities are included safely and meaningfully in all activities and experiences, within the scope of the mental health consultant’s expertise
Approach families about behavioral or mental health concerns for their children
Recognize the daily stressors and mental health needs of families and staff
Respond appropriately to child, family, or community crises (such as serious illness, homelessness, substance abuse, divorce, deaths, or natural events like tornados, floods, wildfires)
Understand staff’s obligations and required actions as mandated reporters
Identify and address staff’s work-related stress, responses to stress, and self-care needs

Early care and education program leadership/staff and IECMHCs should meet regularly to discuss program needs and talk about concerns for children’s development and behavior.

COVID-19 modification as of October 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 early childhood programs:

Follow guidance from your state and local health department as well as your state child care licensing agency.

Disrupted learning environments
Disrupted health care access (e.g., missed well-child and immunization visits, limited access to mental, speech, and occupational health services)
Lost security and safety (e.g., food insecurity and housing, increased exposure to violence and online harms, threat of physical illness and future uncertainty)

Refer to the Centers for Disease Control and Prevention’s COVID-19 Parental Resources Kit to support children and families with these challenges.

Use IECMHCs to deliver:

Individual and group staff consultation to guide their work with children and families
Child and family consultation and connect to resources and services as needed

Consider alternatives to IECMHCs onsite consultation and schedule other methods for delivering services:

Use Virtual video visits or phone to review child social and emotional health needs, address health and safety issues and any training needs
Plan outdoor visits, if weather allows

Additional Resources:

Center for Early Childhood Mental Health Consultation. https://www.ecmhc.org/
Early Childhood Learning and Knowledge Center. Head Start Heals Campaign

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

Cummings KP, Swindell J. Using a trauma-sensitive lens to support children with diverse experiences. Young Except Child. 2019;22(3):139-149. https://doi.org/10.1177/1096250618756898
Miles E, Stoker J, Senehi N, et al. Suspension and expulsion in Colorado early care and education settings: child, program, and community‐level predictors. Infant Ment Health J. 2021;42(6):767-783. https://doi.org/10.1002/imhj.21944
Hooper A, Schweiker C. Prevalence and predictors of expulsion in home‐based child care settings. Infant Ment Health J. 2020;41(3):411-425. https://doi.org/10.1002/imhj.21845
Davis AE, Perry DF, Rabinovitz L. Expulsion prevention: framework for the role of infant and early childhood mental health consultation in addressing implicit biases. Infant Ment Health J. 2020;41(3):327-339. doi:10.1002/imhj.21847
Zeng S, Pereira B, Larson A, Corr CP, O’Grady C, Stone-MacDonald A. Preschool suspension and expulsion for young children with disabilities. Except Child. 2021;87(2):199-216. doi:10.1177/0014402920949832
Zinsser KM, Zulauf CA, Das VN, Silver HC. Utilizing social-emotional learning supports to address teacher stress and preschool expulsion. J Appl Dev Psychol. 2019;61:33-42. https://doi.org/10.1016/j.appdev.2017.11.006
Davis AE, Barrueco S, Perry DF. The role of consultative alliance in infant and early childhood mental health consultation: child, teacher, and classroom outcomes. Infant Ment Health J. 2021;42(2):246-262. doi:10.1002/imhj.21889
Gilliam WS, Maupin AN, Reyes CR. Early childhood mental health consultation: results of a statewide random-controlled evaluation. J Am Acad Child Adolesc Psychiatry. 2016;55(9):754-761. doi:10.1016/j.jaac.2016.06.006
Centers for Disease Control and Prevention. Coughing and sneezing. CDC.gov Web site. Last reviewed April 22, 2020. Accessed November 3, 2021. https://www.cdc.gov/healthywater/hygiene/etiquette/coughing_sneezing.html
Silver HC, Zinsser KM. The interplay among early childhood teachers’ social and emotional well-being, mental health consultation, and preschool expulsion. Early Educ Dev. 2020;31(7):1133-1150. https://doi.org/10.1080/10409289.2020.1785267
Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011-2014 Behavioral Risk Factor Surveillance System in 23 states. JAMA Pediatr. 2018;172(11):1038-1044. doi:10.1001/jamapediatrics.2018.2537
Stegelin D, Leggett C, Ricketts D, Bryant M, Peterson C, Holzner A. Trauma-informed preschool education in public school classrooms: responding to suspension, expulsion, and mental health issues of young children. J Risk Issues. 2020;23(2):9-24. https://files.eric.ed.gov/fulltext/EJ1286553.pdf
Giano Z, Wheeler DL, Hubach RD. The frequencies and disparities of adverse childhood experiences in the U.S. BMC Public Health. 2020;20(1):1327. doi:10.1186/s12889-020-09411-z
Berry D, Blair C, Willoughby M, Garrett-Peters P, Vernon-Feagans L, Mills-Koonce WR, Family Life Project Key Investigators. Household chaos and children’s cognitive and socio-emotional development in early childhood: does childcare play a buffering role?. Early Child Res Q. 2016;34:115-127. https://doi.org/10.1016/j.ecresq.2015.09.003
Qi CH, Zieher A, Lee Van Horn M, Bulotsky-Shearer R, Carta J. Language skills, behaviour problems, and classroom emotional support among preschool children from low-income families. Early Child Dev Care. 2020;190(14):2278-2290. https://doi.org/10.1080/03004430.2019.1570504
Robson DA, Allen MS, Howard SJ. Self-regulation in childhood as a predictor of future outcomes: a meta-analytic review. Psychol Bull. 2020;146(4):324-354. doi:10.1037/bul0000227
HammerD, Melhuish E, Howard SJ. Antecedents and consequences of social–emotional development: a longitudinal study of academic achievement. Arch Sci Psychol. 2018;6(1):105. http://dx.doi.org/10.1037/arc0000034
Hammer D, Melhuish E, Howard SJ. Do aspects of social, emotional and behavioural development in the pre-school period predict later cognitive and academic attainment?. Aust J Educ. 2017 Nov;61(3):270-287. https://doi.org/10.1177/0004944117729514
Bartlett JD, Smith S. The role of early care and education in addressing early childhood trauma. Am J Community Psychol. 2019;64(3-4):359-372. https://doi.org/10.1002/ajcp.12380
Whitebrook M, McLean C, August LJE, Edwards B. Early childhood workforce index 2018. Berkeley, CA: Center for the Study of Child Care Employment, University of California, Berkeley; 2018. Accessed August 26, 2021. https://cscce.berkeley.edu/wp-content/uploads/2018/06/Early-Childhood-Workforce-Index-2018.pdf
Zeng S, Corr CP, O’Grady C, Guan Y. Adverse childhood experiences and preschool suspension expulsion: a population study. Child Abuse Negl. 2019;97:104149. https://doi.org/10.1016/j.chiabu.2019.104149
Vuyk MA, Sprague‐Jones J, Reed C. Early childhood mental health consultation: an evaluation of effectiveness in a rural community. Infant Ment Health J. 2016;37(1):66-79. https://doi.org/10.1002/imhj.21545
Conners Edge NA, Kyzer A, Abney A, Freshwater A, Sutton M, Whitman K. Evaluation of a statewide initiative to reduce expulsion of young children. Infant Ment Health J. 2021;42(1):124-139. https://doi.org/10.1002/imhj.21894
National Scientific Council on the Developing Child. Establishing a level foundation for life: mental health begins in early childhood: Working Paper 6. Updated Edition. Published December 2012. Accessed February 21, 2022. https://developingchild.harvard.edu/resources/establishing-a-level-foundation-for-life-mental-health-begins-in-early-childhood/
Trivedi P, deMonsabert J, Horen N. Infant and early childhood mental health consultation: overview of research, best practices, and examples. Published 2021. Accessed February 22, 2022. https://childcareta.acf.hhs.gov/sites/default/files/public/pdgb5_iecmhc_rtpbrief_acc.pdf

NOTES

COVID-19 modification as of October 10, 2022.

Standard was last updated on September 13, 2022.

Standard 1.6.0.4: Early Childhood Education Consultants

The knowledge base of an early childhood education consultant should include:

Working knowledge of theories of child development and learning for children from birth through eight years across domains, including socio-emotional development and family development;
Principles of health and wellness across the domains, including social and emotional wellness and approaches in the promotion of healthy development and resilience;
Current practices and materials available related to screening, assessment, curriculum, and measurement of child outcomes across the domains, including practices that aid in early identification and individualizing for a wide range of needs;
Resources that aid programs to support inclusion of children with diverse health and learning needs and families representing linguistic, cultural, and economic diversity of communities;
Methods of coaching, mentoring, and consulting that meet the unique learning styles of adults;
Familiarity with local, state, and national regulations, standards, and best practices related to early education and care;
Community resources and services to identify and serve families and children at risk, including those related to child abuse and neglect and parent education;
Consultation skills as well as approaches to working as a team with early childhood consultants from other disciplines, especially child care health consultants, to effectively support program directors and their staff.

The role of the early childhood education consultant should include:

Review of the curriculum and written policies, plans and procedures of the program;
Observations of the program and meetings with the director, caregivers/teachers, and parents/guardians;
Review of the professional needs of staff and program and provision of recommendations of current resources;
Reviewing and assisting directors in implementing and monitoring evidence based approaches to classroom management;
Maintaining confidences and following all Family Educational Rights and Privacy Act (FERPA) regulations regarding disclosures;
Keeping records of all meetings, consultations, recommendations and action plans and offering/providing summary reports to all parties involved;
Seeking and supporting a multidisciplinary approach to services for the program, children and families;
Following the National Association for the Education of Young Children (NAEYC) Code of Ethics;
Availability by telecommunication to advise regarding practices and problems;
Availability for on-site visit to consult to the program;
Familiarity with tools to evaluate program quality, such as the Early Childhood Environment Rating Scale–Revised (ECERS–R), Infant/Toddler Environment Rating Scale–Revised (ITERS–R), Family Child Care Environment Rating Scale–Revised (FCCERS–R), School-Age Care Environment Rating Scale (SACERS), Classroom Assessment Scoring System (CLASS), as well as tools used to support various curricular approaches.

RATIONALE

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
1.6.0.3 Infant and Early Childhood Mental Health Consultants

REFERENCES

Connecticut Department of Public Health. Child day care licensing program. http://www.ct.gov/dph/cwp/view
.asp?a=3141&Q=387158&dphNav_GID=1823/.
The Connecticut Early Education Consultation Network. CEECN: Guidance, leadership, support. http://ctconsultationnetwork.org.
Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Rev ed. National Association for the Education of Young Children (NAEYC). Publication no. 234. Washington, DC: NAEYC. http://www.naeyc.org/files/naeyc/file/positions/position statement Web.pdf.
Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. Baltimore, MD: Brookes Publishing.
Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53.
Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics Early Childhood Special Ed 26:131-41.
Dunn, L., K. Susan. 1997. What have we learned about developmentally appropriate practice? Young Children 52:4-13.

Supervision

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

The small family child care home caregiver/teacher child:staff ratios should conform to the following table:

If the small family child care home caregiver/teacher has no children under two years of age in care,	then the small family child care home caregiver/teacher may have one to six children over two years of age in care
If the small family child care home caregiver/teacher has one child under two years of age in care,	then the small family child care home caregiver/teacher may have one to three children over two years of age in care
If the small family child care home caregiver/teacher has two children under two years of age in care,	then the small family child care home caregiver/teacher may have no children over two years of age in care

RATIONALE

The National Fire Protection Association (NFPA) requires in the NFPA 101: Life Safety Code that small family child care homes serve no more than two clients incapable of self-preservation (5).

COMMENTS

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.2.1 Minimum Age to Enter Child Care
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities

REFERENCES

Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main .zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact _Sheet.pdf.
National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
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.
Zigler, E., W. S. Gilliam, S. M. Jones. 2006. A vision for universal preschool education, 107-29. New York: Cambridge University Press.
Stebbins, H. 2007. State policies to improve the odds for the healthy development and school readiness of infants and toddlers. Washington, DC: Zero to Three. http://main.zerotothree.org/site/DocServer/NCCP_article_for_BM_final.pdf.

Standard 1.1.1.2: Ratios for Large Family Child Care Homes and Centers

Child:staff ratios in large family child care homes and centers should be maintained as follows during all hours of operation, including in vehicles during transport.

Large Family Child Care Homes

Age	Maximum Child:Staff Ratio	Maximum Group Size

≤ 12 months	2:1	6
13-23 months	2:1	8
24-35 months	3:1	12
3-year-olds	7:1	12
4- to 5-year-olds	8:1	12
6- to 8-year-olds	10:1	12
9- to 12-year-olds	12:1	12

Child Care Centers

Age	Maximum Child:Staff Ratio	Maximum Group Size

≤ 12 months	3:1	6
13-35 months	4:1	8
3-year-olds	7:1	14
4-year-olds	8:1	16
5-year-olds	8:1	16
6- to 8-year-olds	10:1	20
9- to 12-year-olds	12:1	24

At least one adult who has satisfactorily completed a course in pediatric first aid, including CPR skills within the past three years, should be part of the ratio at all times.

RATIONALE

COMMENTS

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main
.zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact
_Sheet.pdf.
National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being of children. Arch Ped Adolescent Med 161:669-76.
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.
Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it matter and does it need to be improved? Washington, DC: U.S. Department of Health and Human Services. http://aspe.hhs.gov/hsp/ccquality00/.
De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.
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.
Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in the United States. Am Socio Rev 70:729-57.

Standard 1.1.1.3: Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers

REFERENCES

University of North Carolina at Chapel Hill, FPG Child Development Institute. The national early childhood technical assistance center. https://ectacenter.org/

Standard 1.1.1.4: Ratios and Supervision During Transportation

RATIONALE

TYPE OF FACILITY

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

RELATED STANDARDS

5.6.0.1 First Aid and Emergency Supplies

REFERENCES

Aird, L. D. 2007. Moving kids safely in child care: A refresher course. Child Care Exchange (January/February): 25-28. http://www.childcareexchange.com/library/5017325.pdf.

Standard 1.1.1.5: Ratios and Supervision for Swimming, Wading, and Water Play

The following child:staff ratios should apply while children are swimming, wading, or engaged in water play:

Developmental Levels	Child:Staff Ratio
Infants	1:1
Toddlers	1:1
Preschoolers	4:1
School-age Children	6:1

A lifeguard should not be counted in the child:staff ratio.

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). Pool and spa safety: The Virginia Graeme Baker pool and spa safety act. http://www.poolsafely.gov/wp-content/uploads/VGBA.pdf.
U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
Gipson, K. 2009. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: CPSC. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.
American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.
Consumer Product Safety Commission. Steps for safety around the pool: The pool and spa safety act. Pool Safely. http://www.poolsafely.gov/wp-content/uploads/360.pdf.
Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.
American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.

Standard 2.2.0.1: Methods of Supervision of Children

Content in the STANDARD was modified on 10/09/2018.

All children in out-of-home care must be directly supervised at all times. The following strategies allow children to explore their environments safely. (1,2)

Set Up the Environment
Caregivers/teachers set up the environment so that they can supervise children and be accessible at all times. When activities are grouped together and furniture is at waist height or shorter, adults are always able to see and hear children. Small spaces are kept clutter-free and big spaces are set up so that children have clear play spaces that caregivers/teachers can observe.
Position Staff
Caregivers/teachers carefully plan where they will position themselves in the environment to prevent children from harm. They place themselves so that they can see and hear all of the children in their care. They make sure there are always clear paths to where children are playing, sleeping, and eating so they can react quickly when necessary. Caregivers/teachers stay close to children who may need additional support. Their location helps them provide support, if necessary.
Scan and Count
Caregivers/teachers are always able to account for the children in their care. They continuously scan the entire environment to know where everyone is and what they are doing. They count the children frequently. This is especially important during transitions when children are moving from one location to another.
Listen
Specific sounds or the absence of them may signify reason for concern. Caregivers/teachers who are listening closely to children immediately identify signs of potential danger. Programs that think systemically implement additional strategies to safeguard children. For example, bells added to doors help alert adults when a child leaves or enters the room.
Anticipate Children's Behavior
Caregivers/teachers use what they know about each child’s individual interests and skills to predict what he/she will do. They create challenges that children are ready for and support them in succeeding. But, they also recognize when children might wander, get upset, or take a dangerous risk. Information from the daily health check (e.g., illness, allergies, lack of sleep or food, etc.) informs adults’ observations and helps them anticipate children’s behavior. Caregivers/teachers who know what to expect are better able to protect children from harm.

6. Engage and Redirect

RATIONALE

Regular counting (or use of active supervision) will reduce opportunities for a child to become separated from the group, especially during transitions between locations.

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

National Center on Early Childhood Health and Wellness. Active Supervision. https://eclkc.ohs.acf.hhs.gov/safety-practices/article/active-supervision. Published February 5th 2018. Accessed August 28, 2018.
National Association for the Education of Young Children: Program Administrator Guide to Evaluating Child Supervision Practices. http://www.naeyc.org/academy/files/
academy/Supervision%20Resource_0.pdf. 2016. Accessed August 28, 2018.
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 25, 2018
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 25, 2018
Schwebel, D. Internet-based training to improve preschool playground safety: Evaluation of the Stamp-in-Safety Programme. The Health Education Journal. 74(1), 37. Published January 20, 2015. Accessed August 28, 2018.
National Safety Council. Landing lightly: playgrounds don’t have to hurt. http://www.nsc.org/learn/safety-knowledge/Pages/news-and-resources-playground-safety.aspx. Accessed June 25, 2018

NOTES

Content in the STANDARD was modified on 10/09/2018.

Standard 2.2.0.4: Supervision Near Bodies of Water

RATIONALE

Small children can drown within thirty seconds, in as little as two inches of liquid (3).

Submersion incidents involving children usually happen in familiar surroundings;
Pool submersions involving children happen quickly, 77% of the victims had been missing from sight for five minutes or less;
Child drowning is a silent death, and splashing may not occur to alert someone that the child is in trouble (4).

Drowning is the second leading cause of unintentional injury-related death for children ages one to fourteen (5).

While swimming pools pose the greatest risk for toddlers, about one-quarter of drowning among toddlers are in freshwater sites, such as ponds or lakes.

The American Academy of Pediatrics (AAP) recommends:

Swimming lessons for children based on the child’s frequency of exposure to water, emotional maturity, physical limitations, and health concerns related to swimming pools;
“Touch supervision” of infants and young children through age four when they are in the bathtub or around other bodies of water;
Installation of four-sided fencing that completely separates homes from residential pools;
Use of approved personal flotation devices (PFDs) when riding on a boat or playing near a river, lake, pond, or ocean;
Teaching children never to swim alone or without adult supervision;
Stressing the need for parents/guardians and teens to learn first aid and cardiopulmonary resuscitation (CPR) (3).

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62.
Gipson, K. 2008. Submersions related to non-pool and non-spa products, 2008 report. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf.
U.S. Consumer Product Safety Commission. 1997. CPSC reminds pool owners that barriers, supervision prevent drowning. Release #97-152. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/PREREL/PRHTML97/97152.html.
U.S. Consumer Product Safety Commission. 1994. Infants and toddlers can drown in 5-gallon buckets: A hidden hazard in the home. Document #5006. Washington, DC: CPSC. http://www.cpsc
.gov/cpscpub/pubs/5006.html.
Rauchschwalbe, R., R. A. Brenner, S. Gordon. 1997. The role of bathtub seats and rings in infant drowning deaths. Pediatrics 100:e1.
U.S. Consumer Product Safety Commission. 1994. Drowning hazard with baby “supporting ring” devices. Document #5084. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/
5084.html.
Centers for Disease Control and Prevention (CDC). 2010. Unintentional drowning: Fact sheet. http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries
-factsheet.html.
U.S. Consumer Product Safety Commission. 2002. How to plan for the unexpected: Preventing child drownings. Publication #359. Washington, DC: CPSC. http://www.cpsc.gov/CPSCPUB/PUBS/359.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement-prevention of drowning. Pediatrics 126: 178-85.
U.S. Congress. 2007. Virginia Graeme Baker Pool and Spa Safety Act. 15 USC 8001. http://www.cpsc.gov/businfo/vgb/pssa.pdf.
U.S. Consumer Product Safety Commission. 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.

Standard 4.5.0.6: Adult Supervision of Children Who Are Learning to Feed Themselves

RATIONALE

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.2.3 Encouraging Self-Feeding by Older Infants and Toddlers
4.5.0.4 Socialization During Meals
4.5.0.5 Numbers of Children Fed Simultaneously by One Adult

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Environment and Equipment

Building and Environment: Inside and Outside

Standard 5.1.1.5: Assessment of the Environment at the Site Location

Frequently Asked Questions/CFOC Clarifications

Reference: 5.1.1.5

Date: 10/13/2011

Topic & Location:
Chapter 5
Facilities
Standard 5.1.1.5: Environmental Audit of Site Location

Question:
Has the recommendation for minimum distance between a playground site and hazards, such as electrical transformers and high voltage power lines changed since the CFOC, 2^nd Ed., which stated 30 feet?

Answer:
Yes, specific distances are no longer recommended as distances may differ according to local municipalities and states.
Please consult your local ordinance for appropriate information.

Content in the STANDARD was modified on 8/25/2016,01/23/2020 .

An assessment of the environment at an early care and education site location should be conducted before children receive care at the site. This includes assessment of the site prior to occupying an existing building, before renovating or constructing a building, and after a natural disaster. If an assessment identifies health and safety risks, and the risks cannot be wholly mitigated to protect children’s health, the site should be avoided as an early care and education location.

The assessment of the environment should evaluate safety hazards; potential environmental exposures from air, water, drinking water, and soil contamination; and noise. The assessment should include consideration of

Completed past environmental assessments at the site, if available
Land use or deed restrictions for the site
Previous uses of the site or previous activities in the nearby area and any potential environmental contaminants and safety hazards that may remain
Current nearby businesses or activities that may result in environmental exposures at the early care and education site

Source of drinking water for the early care and education facility and any potential contamination of the drinking water
Naturally occurring sources of potential contamination, such as radon or arsenic in soil or drinking water
Potential noise hazards in the community surrounding the site

Guidance for environmental assessments is available.^1–3 If potential safety hazards or environmental exposures are identified, conduct further assessment or environmental sampling and mitigation, or avoid sites where children’s health could be compromised. Consider consulting with environmental health professionals, such as the state or county health department. State environmental agencies can also be important resources, particularly with regard to assessment, sampling, and mitigation. Keep on file any documentation of the site assessment, sampling, and remediation actions taken.

RATIONALE

Evaluation of environmental health and safety risks associated with the physical location of an early care and education site can identify potential risks to children’s health and development and options for mitigating those risks.

A range of potential environmental exposures may exist. These include air pollution from nearby industries, businesses, or busy roadways; noise from an airport; drinking water contaminants; and contaminants in the soil such as arsenic, lead, or pesticides from past site use. Contamination in the soil or groundwater may enter indoor air spaces through a process known as vapor intrusion. The size of the area to look for possible exposure sources can vary by the route of exposure (air, water, drinking water, or soil) and the emissions’ characteristics. For example, a smelter may affect a larger area than a dry cleaner.

Children can be exposed to harmful substances contained in the indoor and outdoor air they breathe and water they drink. Additionally, children can be exposed to harmful substances in soil or dust when they play on the ground. Children have higher exposures to some harmful substances than adults due to their unique behavior, such as crawling and hand-to-mouth activity. They also eat, drink, and breathe more than adults do relative to their body size. In addition, children are much more vulnerable to harm from exposures to contaminated materials than adults because their bodies and organ systems are still developing. Disruption of this development could result in permanent damage with lifelong health and developmental consequences.⁴

The assessment of the environment at the site can identify issues that may affect children’s health. Methods to identify risks include reviewing the property history and understanding what the site was used for in the past, reviewing maps and records to determine what activities and contaminants may be nearby, visiting the site to look for indications of hazards and potential environmental exposures, reviewing environmental investigation and remediation reports previously prepared for the site, and consulting federal or state environmental agency staff about the regulatory status of the site.

Awareness of site-related environmental health risks and actions to mitigate or avoid those risks can reduce exposure to hazards that adversely affect health and development.¹ For example, if an early care and education facility is considering locating in a building that also has a dry cleaner (or other business that uses hazardous chemicals), contaminated air could migrate into the early care and education site from the adjacent business. Options to reduce risk may include reducing migration of hazardous substances to non-harmful levels or choosing a different location for the early care and education facility. Another example is an early care and education facility proposed to be built on former agricultural land that has soil contamination from past pesticide use. To mitigate the potential exposure to chemicals in the soil, the contaminated soil could be removed, covered with pavement or artificial turf, or made inaccessible to children.

COMMENTS

State or local environmental health programs may be able to help answer questions about identified concerns. In addition, guidance and tools have been created to assist in conducting assessments. The Agency for Toxic Substances and Disease Registry Choose Safe Places for Early Care and Education program has guidance to help ensure that environmental exposures are considered for early care and education facilities where children spend time.¹ The US Environmental Protection Agency School Siting Guidelines, although aimed at schools, provide helpful information on types of environmental issues that are important to address to help protect children from environmental exposures.^3(p53–64) The Environmental Law Institute has identified existing state policies for addressing environmental site hazards at early care and education facilities, highlighting policy considerations to advance safe siting.⁵

ADDITIONAL RESOURCES
Eco-Healthy Child Care. Safe siting of child care facilities. https://cehn.org/wp-content/uploads/2019/05/Safe-Siting-FAQ-FINAL-5.1.19.pdf. Accessed August 21, 2019

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.2 Inspection of Buildings
5.1.1.6 Structurally Sound Facility
5.1.1.7 Use of Basements and Below Grade Areas
5.7.0.7 Structure Maintenance

REFERENCES

Agency for Toxic Substances and Disease Registry. Choose safe places for early care and education. https://www.atsdr.cdc.gov/safeplacesforece/index.html. Reviewed March 6, 2019. Accessed August 21, 2019
Somers TS, Harvey ML, Rusnak SM. Making child care centers SAFER: a non-regulatory approach to improving child care center siting. Public Health Rep. 2011;126(Suppl 1):34–40
US Environmental Protection Agency, Office of Children’s Health Protection. School Siting Guidelines. Washington, DC: US Environmental Protection Agency, Office of Children’s Health Protection; 2011. https://www.epa.gov/schools/view-download-or-print-school-siting-guidelines. Accessed August 21, 2019
American Academy of Pediatrics Council on Environmental Health. Pediatric Environmental Health. Etzel RA, Balk SJ, eds. 4th ed. Itasca, IL: American Academy of Pediatrics; 2019
Environmental Law Institute. Addressing Environmental Site Hazards at Child Care Facilities: A Review of State Policy Strategies.Washington, DC: Environmental Law Institute; 2018. https://www.eli.org/research-report/addressing-environmental-site-hazards-child-care-facilities-review-state-policy-strategies. Published May 2018. Accessed August 21, 2019

NOTES

Content in the STANDARD was modified on 8/25/2016,01/23/2020 .

Standard 5.1.1.7: Use of Basements and Below Grade Areas

Finished basements or areas that are partially below grade may be used for children who independently ambulate and who are two years of age or older, if the space is in compliance with applicable building and fire codes. Environmental health factors may be reviewed with county or city public health departments.

RATIONALE

Basement and partially below grade areas can be quite habitable and should be usable as long as building, fire safety (1), and environmental quality is satisfactory.

COMMENTS

To “independently ambulate” means that children are able to walk from place to place with or without the use of assistive devices.

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.8 Buildings of Wood Frame Construction
5.1.2.1 Space Required per Child
5.1.2.2 Floor Space Beneath Low Ceiling Heights
5.1.4.1 Alternate Exits and Emergency Shelter
5.1.4.2 Evacuation of Children with Special Health Care Needs and Children with Disabilities
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.2.1 Levels of Illumination
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials

REFERENCES

National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.1.1.12: Multiple Use of Rooms

Playing, eating, and napping may occur in the same area (exclusive of diaper changing areas, toilet rooms, kitchens, hallways, and closets), provided that:

The room is of sufficient size to have a defined area for each of the activities allowed there at the time the activity is under way;
The room meets other building requirements;
Programming is such that use of the room for one purpose does not interfere with use of the room for other purposes.

RATIONALE

Except for toilet and diaper changing areas, which must have no other use, the use of common space for different activities for children facilitates close supervision of a group of children, some of whom may be involved simultaneously in more than one of the activities listed in the standard (1).

COMMENTS

Compliance is measured by direct observation.

TYPE OF FACILITY

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

REFERENCES

Olds, A. 2001. Zoning a group room. In Child care design guide, 137-65. New York: McGraw-Hill.

Standard 5.1.2.1: Space Required per Child

In general, the designated area for children’s activities should contain a minimum of forty-two square feet of usable floor space per child. A usable floor space of fifty square feet per child is preferred.

This excludes floor area that is used for:

Circulation (e.g., walkways around the activity area);
Classroom support (e.g., staff work areas and activity equipment storage that may be adjacent to the activity area);
Furniture (e.g., bookcases, sofas, lofts, block corners, tables and chairs);
Center support (e.g., administrative office, washrooms, etc.)

Usable, indoor floor space for the children’s activity area depends on the design and layout of the child care facility, and whether there is an opportunity and space for outdoor activities.

RATIONALE

Numerous studies have explored child care space requirements that are necessary to:

Provide an environment that is highly functional for program delivery and to encourage strong, positive staff-to-child relationships;
Accommodate the recommended group size and staff-to-child ratio; and
Efficiently use space and incorporates ease of supervision.
Recommendations from research studies range between forty-two to fifty-four square feet per child (1).

Studies have shown that the quality of the physical designed environment of early child care centers is related to children’s cognitive, social, and emotional development (e.g., size, density, privacy, well-defined activity settings, modified open-plan space, a variety of technical design features and the quality of outdoor play spaces). In addition to meeting the needs of children, caregivers/teachers require space to implement programs and facilitate interactions with children.

A review of the literature indicates that in the past ten years, there has been growing research and study into how the physical design of child care settings affects child development. Historically, a standard of thirty-five square feet was used. Recommendations from research studies range between forty-two to fifty-four square feet per child. Comments from researchers indicate that other factors must also be considered when assessing the context of usable floor space for child care activities (1,5-8).

Although each child’s development is unique to that child, age groups are often used to categorize developmental needs. To meet these needs, the use of activity space for each age group will be inherently different.

Child behavior tends to be more constructive when sufficient space is organized to promote developmentally appropriate skills. Crowding has been shown to be associated with increased risk of developing upper respiratory infections (2). Also, having sufficient space will reduce the risk of injury from simultaneous activities.

Children with special health care needs may require more space than typically developing children (1).

COMMENTS

The usable floor space for children’s activities in this standard refers to indoor space that is used as the primary play space. Consideration should also be given to the presence or absence of secondary indoor play space that might be shared between programs as well as to outdoor play space.

Staff-child ratios (i.e., the number of staff required per number of children) should also be taken into account since staff consumes floor area space as well as children. Group size for various age groups should also be considered. Since groups of infants are smaller than groups of preschoolers, “infant and toddler rooms tend to be small, while preschool and school-age rooms are a bit generous at full capacity” (1). Infant and toddler rooms often dedicate a considerable amount of inflexible space to cribs and diaper changing areas. Sufficient space to accommodate these activities, space for adult seating to care for infants, and space for safe mobility of infants and toddlers requires that the per child square foot requirements are applied for their areas also.

Square footage estimates should only be intended as guidelines. Especially in child care facilities with fewer than fifty children, “plugging in” the square footage into a formula to calculate space required usually does not work (1).

It is important to keep in mind that state licensing regulations specify minimum space requirements and that they must be legally adhered to. Such requirements vary from state to state (3). For Federal child care centers, the U.S. General Services Administration’s (GSA) child care design standards require a minimum of forty-eight and one-half square feet per child in the classroom (4).

Although providing adequate space for implementing a program of activities that meets the developmental needs of children is important in providing quality child care, how that space is actually used is likely more critical (8). It has been observed that child care facilities operating in older buildings with less than ideal space can still deliver quality child care programs to meet the needs of children. Nevertheless, the amount of activity space required per child should take the known research into consideration.

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.
The Family Child Care Accreditation Project, Wheelock College. 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: National Association for Family Child Care. http://www.nafcc.org/documents/QualStd.pdf.
White, R., V. Stoecklin. 2003. The great 35 square foot myth. http://www.whitehutchinson.com/children/articles/
35footmyth.shtml.
Moore, G. T., T. Sugiyama, L. O’Donnell. 2003. Children’s physical environments rating scale. Paper presented at the Australian Early Childhood Education 2003 Conference, Hobart, Australia. http://sydney.edu.au/architecture/documents/ebs/AECA_2003_paper.pdf.
Beach J., M. Friendly. 2005. Child care centre physical environments. Working Documents, Child Care Resource and Research Unit. http://www.childcarequality.ca/wdocs/QbD
_PhysicalEnvironments.pdf.
U.S. General Services Administration (GSA). 2003. Child care center design guide. New York: GSA Public Buildings Service, Office of Child Care. http://www.gsa.gov/graphics/pbs/designguidesmall.pdf.
National Child Care Information and Technical Assistance Center and the National Association for Regulatory Administration. 2009. The 2007 licensing child care study. http://www.naralicensing.org/associations/4734/files/2007 Licensing Study_full_report.pdf.
Fleming, D. W., S. L. Cochi, A. W. Hightower, et al. 1987. Childhood upper respiratory tract infections: To what degree is incidence affected by daycare attendance? Pediatrics 79:55-60.

Standard 5.1.3.2: Possibility of Exit from Windows

All windows in areas used by children under five years of age should be constructed, adapted, or adjusted to limit the exit opening accessible to children to less than four inches, or be otherwise protected with guards that prevent exit by a child, but that do not block outdoor light. Where such windows are required by building or fire codes to provide for emergency rescue and evacuation, the windows and guards, if provided, should be equipped to enable staff to release the guard and open the window fully when evacuation or rescue is required. Opportunities should be provided for staff to practice opening these windows, and such release should not require the use of tools or keys. Children should be given information about these windows, relevant safety rules, as well as what will happen if the windows need to be opened for an evacuation.

RATIONALE

To prevent children from falling out of windows, standards from the U.S. Consumer Product Safety Commission (CPSC) and the ASTM International (ASTM) require the opening size to be four inches to prevent the child from getting through or the head from being entrapped (1,2). Some children may be able to pass their body through a slightly larger opening but then get stuck and hang from the window opening with their head trapped inside. Caregivers/teachers must not depend on screens to keep children from falling out of windows. Windows to be used as fire exits must be immediately accessible. Staff should supervise children when they are near these windows, and incorporate safety information and relevant emergency procedures and drills into their day-to-day curriculum so that children will better understand the safety issues and what will happen if they need to leave the building through the windows.

COMMENTS

“Screens” are intended to prevent flying insects from coming into the facility whereas window “guards” are the type of devices commonly used to provide building security and prevent intruders.

TYPE OF FACILITY

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

REFERENCES

ASTM International. ASTM F2090-08 Standard specification for window fall prevention devices with emergency escape (egress) release mechanisms. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). New standards for window guards to help protect children from fails. Release #00-126. Washington, DC: CPSC. http://www.cpsc.gov/en/Newsroom/News-Releases/2000/New-Standards-for-Window-Guards-To-Help-Protect-Children-From-Falls-/.

Standard 5.2.1.1: Ensuring Access to Fresh Air Indoors

Content in the STANDARD was modified on 8/25/2016 and 09/23/2021.

COVID-19 Modification as of March 20, 2023.

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

As much fresh outdoor air as possible should be provided in rooms occupied by children. Screened windows should be opened whenever weather and the outdoor air quality permits (1). When windows are not able to be opened, rooms should be ventilated, as specified in Standards 5.2.1.1-5.2.1.6. The specified rates at which outdoor air must be supplied to each room within the facility range from fifteen to sixty cubic feet per minute per person (cfm/p). The rate depends on the activities that normally occur in that room. Indoor air should be kept as free from unnecessary chemicals and fragrances as possible.

Ionizers or products that use UV lights are not recommended. Do not use air cleaner devices with ozonators, ultraviolet (UV) lights, or ionization features, since they are unnecessary and some produce ozone, which can be harmful and trigger respiratory problems such as asthma.

COVID-19 modification as of March 20, 2023:

Improving ventilation is an important COVID-19 prevention strategy that can reduce the number of virus particles in the air. In response to the Centers for Disease Control and Prevention’s guidance on ventilation, it is recommended that staff:

Allow fresh, outdoor air into the building to help keep virus particles from remaining indoors.

Increase the flow of air from outside, using caution in highly polluted areas. See CDC’s webpage for more information about local air quality.
Open all screened doors and windows, when safe to do so. Even slightly opened windows can help.
Do not open windows and doors if doing so is unsafe for children and staff (e.g. risk of falling, triggering asthma symptoms). Have window guards in place on all windows.
When opening windows or doors is unsafe, consider other approaches for reducing the amount of virus particles in the air, such as portable air filters and exhaust fans.
Use child safe portable fans or ceiling fans to 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.
Run heating, ventilation, air conditioning (HVAC) systems at maximum outside airflow for 2 hours before and after the center or home is in use for child care. If units do not have air conditioning, run the “fan” setting.

Ensure exhaust fans in areas such as restroom, kitchens, cooking areas are functional and running at full capacity.

Clean and change filters as recommended by manufacturer. If system allows, ensure filters are MERV 13 (Minimum Efficiency Reporting Value 13) or higher, as recommended by the American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE).
- ASHRAE currently recommends using a minimum MERV 13 filter, which is at least 85% efficient at capturing particles including SARS-CoV-2 virus particles.

Consult with your building’s facility staff or administrators to ensure your ventilation systems operate properly and provide acceptable indoor air quality for the current occupancy level for each space. Work with a ventilation consultant as needed.

See COVID modification to Standard 5.2.1.3: Heating and Ventilation Equipment Inspection and Maintenance for reopening guidance.

If your program does not have an HVAC system, or programs want extra filtration, consider using a portable high-efficiency particulate air (HEPA) cleaner. HEPA cleaners trap particles exhaled when breathing, talking, singing, coughing, and sneezing.

Select HEPA cleaners of the right size for the room(s). For example, select a HEPA fan system with a Clean Air Delivery Rate (CADR) that meets or exceeds the square footage of the room. See EPA’s Guide to Air Cleaners in the Home for more information.

Spend more time outside, as weather permits.

When Transporting Children

Open windows on transport vehicles (cars, vans, etc.) when safe to do so and as weather permits.

For more information see CFOC Standard 6.5.2.3: Child Behavior During Transportation

Additional Resources:

American Society of Heating and Air-Conditioning Engineers (ASHRAE)

California Childcare Health Program

Centers for Disease Control and Prevention

Children’s Environmental Health Network

New Jersey Department of Health

Guidance on Air Cleaning Devices for Indoor Spaces

Environmental Protection Agency (EPA)

Harvard School of Public Health and UC, Colorado Boulder

RATIONALE

The health and well-being of both the staff and the children can be greatly affected by indoor air quality. The air people breathe inside a building can be contaminated with germs shared between people, chemicals emitted from common consumer products and furnishings, and polluted outdoor air entering into the program.^{1, 2}Additionally, the presence of dirt, moisture, and warmth encourages the growth of mold and other contaminants, which can trigger allergic reactions and asthma.³

Children’s exposure to contaminated or polluted air (indoor and outdoor) is associated numerous health effects such as respiratory problems including increased asthma incidence, allergies, preterm birth, low birth weight, neurodevelopmental disorders, some cancers, IQ loss, and risk for adult chronic diseases .^2-5 Children are more vulnerable to air pollution because their organs (respiratory, central nervous system, etc.) are still developing and they breathe in more air relative to their weight than adults.⁵Air circulation is essential to clear infectious disease agents, odors, and toxic substances in the air.

Carbon dioxide levels are an indicator of the quality of ventilation. Higher Oxygen levels and lower Carbon Dioxide from fresh air promotes a better learning environment.⁷ Air circulation can be adjusted by a properly installed and adjusted heating, ventilation, air conditioning, and cooling (HVAC) system as well as by using fans and open windows.

Qualified engineers can ensure heating, ventilation, air conditioning (HVAC) systems are functioning properly and that applicable standards are being met. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) Website includes the qualifications required of its members and the location of the local ASHRAE chapter. The contractor who services the HVAC system should provide evidence of successful completion of ASHRAE or comparable courses.

COMMENTS

ADDITIONAL RESOURCES

National Heart, Lung and Blood Institute.
- How Asthma Friendly is your Child Care Setting?
Asthma and Allergy Foundation of America. New England Chapter.
- ASTHMA – FRIENDLY CHILD CARE: A Checklist for Parents and Providers

The following organizations can provide further information on air quality and on ventilation:

The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE)
The U.S. Environmental Protection Agency (EPA) Public Information Center
The American Gas Association (AGA)
The Edison Electric Institute (EEI)
The American Lung Association (ALA)
The U.S. Consumer Product Safety Commission (CPSC)
The Safe Building Alliance (SBA)

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
3.1.3.3 Protection from Air Pollution While Children Are Outside
5.2.1.2 Indoor Temperature and Humidity
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
5.2.1.4 Ventilation When Using Art Materials
5.2.1.5 Ventilation of Recently Carpeted or Paneled Areas
5.2.1.6 Ventilation to Control Odors
5.2.9.5 Carbon Monoxide Detectors

REFERENCES

Marcotte D. Something in the air? Air quality and children's educational outcomes. Economics of education review. 2017;56. doi:10.1016/j.econedurev.2016.12.003
American Society of Heating, Refrigeration and Air Conditioning Engineers. Standard 62.1 -2019: Ventilation for Acceptable Indoor Air Quality. ISSN 1041-2336. Published October 2019. Accessed July 28, 2021. https://www.ashrae.org/technical-resources/standards-and-guidelines
Brumberg, H. L., Karr, C.J.. Ambient Air Pollution: Health Hazards to Children. Pediatrics. 2021: 147.6.
Danh C. Vu, Thi L. Ho, Phuc H. Vo, et al. Assessment of indoor volatile organic compounds in Head Start child care facilities. Atmospheric Environment. 2019; 215 ( 116900):1352-2310, https://doi.org/10.1016/j.atmosenv.2019.116900
Gaspar, F. W., et al. Ultrafine, fine, and black carbon particle concentrations in California child‐care facilities. Indoor air. 2018;28.1: 102-111. Accessed July 28, 2021. https://onlinelibrary.wiley.com/doi/full/10.1111/ina.12408
United States Environmental Protection Agency. Volatile Organic Compounds' Impact on Indoor Air Quality. Accessed July 28, 2021. https://www.epa.gov/indoor-air-quality-iaq/volatile-organic-compounds-impact-indoor-air-quality
American Lung Association. Ventilation: How Buildings Breathe. Updated April 8, 2020. Accessed July 28, 2021. https://www.lung.org/clean-air/at-home/ventilation-buildings-breathe

NOTES

Content in the STANDARD was modified on 8/25/2016 and 09/23/2021.

COVID-19 Modification as of March 20, 2023.

Standard 5.2.1.2: Indoor Temperature and Humidity

A draft-free temperature of 68°F to 75°F should be maintained at thirty to fifty percent relative humidity during the winter months. A draft-free temperature of 74°F to 82°F should be maintained at thirty to fifty percent relative humidity during the summer months (1,2). All rooms that children use should be heated and cooled to maintain the required temperatures and humidity.

RATIONALE

These requirements are based on the standards of the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), which take both comfort and health into consideration (1,2). High humidity can promote growth of mold, mildew, and other biological agents that can cause eye, nose, and throat irritation and may trigger asthma episodes in people with asthma (3). These precautions are essential to the health and well-being of both the staff and the children. When planning construction of a facility, it is healthier to build windows that open. Some people need filtered air that helps control pollen and other airborne pollutants found in raw outdoor air.

COMMENTS

Simple and inexpensive devices that measure the ambient relative humidity indoors may be purchased in hardware stores or toy stores that specialize in science products. The ASHRAE Website (http://www.ashrae.org) has a list of membership chapters, and membership criteria that help to establish expertise on which caregivers/teachers could rely in selecting a contractor.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance

REFERENCES

U.S. Environmental Protection Agency (EPA). 2008. Care for your air: A guide to indoor air quality. Washington, DC: EPA. http://www.epa.gov/iaq/pdfs/careforyourair.pdf.
American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE). 2007. Standard 55-2007: Thermal conditions for human occupancy. Atlanta: ASHRAE.
American Society of Heating, Refrigeration and Air-Conditioning Engineers, American Institute of Architects, Illuminating Engineering Society of North America, U.S. Green Building Council, U.S. Department of Energy. 2008. Advanced energy design guide for K-12 school buildings, 148. Atlanta, GA: ASHRAE.

Standard 5.2.1.6: Ventilation to Control Odors

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

Odors in toilets, bathrooms, diaper changing areas, and other inhabited areas of the facility should be controlled by ventilation and appropriate cleaning and disinfecting. Toilets and bathrooms, janitorial closets, and rooms with utility sinks or where wet mops and chemicals are stored should be mechanically ventilated to the outdoors with local exhaust mechanical ventilation to control and remove odors in accordance with local building codes. Air fresheners or sanitizers (both manmade and natural) should not be used. Adequate ventilation should be maintained during any cleaning, sanitizing, or disinfecting procedure to prevent children and caregivers/teachers from inhaling potentially toxic fumes.

RATIONALE

Air fresheners or sanitizers (both manmade and natural) may cause nausea, an allergic or asthmatic (airway tightening) response in some children (1). Ventilation and sanitation help control and prevent the spread of disease and contamination. The Safety Data Sheet (SDS) for every chemical product that the facility uses should be checked and available to anyone who uses or who might be exposed to the chemical in the child care facility to be sure that the chemical does not pose a risk to children and adults.

COMMENTS

The SDS gives legally required information about the presence of Volatile Organic Compounds (VOCs) and the risk of exposure from all the chemicals in the product. The Occupational Safety and Health Administration (OSHA) requires the availability of the SDS to the workers who use chemicals (2). In addition these sheets should be available to anyone who might be exposed to the chemical in the child care facility.

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
4.8.0.7 Ventilation Over Cooking Surfaces

REFERENCES

U.S. Occupational Safety and Health Administration. 2009. Hazard communication: Foundation of workplace chemical safety programs. http://www.osha.gov/dsg/hazcom/index.html.
Elliott, L., M. P. Longnecker, G. E. Kissling, S. J. London. 2006. Volatile organic compounds and pulmonary function in the Third National Health and Nutrition Examination Survey, 1988-1994. Environmental Health Perspective 114:1210-14.

NOTES

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

Standard 5.2.1.11: Portable Electric Space Heaters

Portable electric space heaters should:

Be attended while in use and be off when unattended;
Be inaccessible to children;
Have protective covering to keep hands and objects away from the electric heating element;
Bear the safety certification mark of a nationally recognized testing laboratory;
Be placed on the floor only and at least three feet from curtains, papers, furniture, and any flammable object;
Be properly vented, as required for proper functioning;
Be used in accordance with the manufacturer’s instructions;
Not be used with an extension cord.

The heater cord should be inaccessible to children as well.

RATIONALE

Portable electric space heaters are a common cause of fires and burns resulting from very hot heating elements being too close to flammable objects and people (1).

COMMENTS

To prevent burns and potential fires, space heaters must not be accessible to children. Children can start fires by inserting flammable material near electric heating elements. Curtains, papers, and furniture must be kept away from electric space heaters to avoid potential fires. Some electric space heaters function by heating oil contained in a heat-radiating portion of the appliance. Even though the electrical heating element is inaccessible in this type of heater, the hot surfaces of the appliance can cause burns. Cords to electric space heaters should be inaccessible to the children. Heaters should not be placed on a table or desk. Children and adults can pull an active unit off or trip on the cord.

To prevent burns or potential fires, consideration must be given to the ages and activity levels of children in care and the amount of space in a room. Alternative methods of heating may be safer for children. Baseboard electric heaters are cooler than radiant portable heaters, but still hot enough to burn a child if touched.

If portable electric space heaters are used, electrical circuits must not be overloaded. Portable electric space heaters are usually plugged into a regular 120-volt electric outlet connected to a fifteen-ampere circuit breaker. A circuit breaker is an overload switch that prevents the current in a given electric circuit from exceeding the capacity of a line. Fuses perform the same function in older systems. If too many appliances are plugged into a circuit, calling for more power than the capacity of the circuit, the breaker reacts by switching off the circuit. Constantly overloaded electrical circuits can cause electrical fires. If a circuit breaker is continuously switching the electric power off, reduce the load to the circuit before manually resetting the circuit breaker (more than one outlet may be connected to a single circuit breaker). If the problem persists, stop using the circuit and consult an electrical inspector or electrical contractor.

The Occupational Safety and Health Administration (OSHA) has a program that recognizes Nationally Recognized Testing Laboratories. Private sector organizations are listed on their Website at http://www.osha.gov/dts/otpca/nrtl/index
.html#nrtls.

Manufacturer’s instructions should be kept on file.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.13 Barriers/Guards for Heating Equipment and Units

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). 2001. What you should know about space heaters. Washington, DC: CPSC. http://www.nnins.com/documents/WHATYOUSHOULDKNOWABOUTSPACEHEATERS.pdf.

Standard 5.2.6.2: Testing of Drinking Water Not From Public System

Content in the STANDARD was modified on 8/27/2020

If an early care and education program’s drinking water does not come from a public water system, the water source should be approved and tested every year, or as required by the local health department, for bacteriologic quality, nitrates, total dissolved solids, pH levels, and other water quality indicators.^1,2 Early care and education programs with infants 6 months or younger should get water tested for nitrate regularly.²

Drinking water from nonpublic sources includes private or household wells or rainwater collection systems (ie, cisterns).

Testing of private water supplies should be completed by a state-certified laboratory. Most testing laboratories or services supply their own sample containers. Samples for bacteriologic testing must be collected in sterile containers and under sterile conditions. Laboratories may sometimes send a trained technician to collect the sample. For more information, contact the local health authority or view the US Environmental Protection Agency list of state certification programs.³

After a disaster such as a flood, earthquake, or chemical spill, drinking water systems can become contaminated. Routine or new testing should be done to ensure safe drinking water.¹

RATIONALE

Public water systems are responsible for complying with all regulations, including monitoring, reporting, and performing treatment techniques. Environmental Protection Agency and state regulations do not apply to privately owned drinking water systems. Individual owners and operators of the water system are responsible for ensuring the water is safe.⁴

Unsafe water supplies may cause acute illness, such as diarrhea from microorganisms, or other health problems that are harder to identify and have long-lasting health effects. Chemicals can contaminate nonpublic water supplies from a variety of sources, and water quality testing is often the only way to identify the contamination. Some contamination can come from naturally occurring contaminants, such as arsenic, in groundwater. Other chemicals, such as pesticides, can enter drinking water systems from past or adjacent site use.⁵Many of these contaminants cannot be detected via smell, taste, or color.

Infants younger than 6 months who drink water containing nitrate in excess of the maximum concentration limit of 10 mg/L could become seriously ill and, if untreated, may die.²

Regular testing is valuable because it establishes a record of water quality. A water supply that is safe and free of harmful substances and microorganisms and does not spread disease is essential to the health of children enrolled in early care and education programs.

Contamination of nonpublic drinking water supplies may occur after disasters, and additional or repeat testing of water may be necessary to ensure drinking water quality.¹The types of potential drinking water contamination may vary by disaster. State and local health officials may be helpful in determining if water testing is needed after a disaster.

COMMENTS

Public water systems are responsible for complying with all regulations, including monitoring, reporting, and performing treatment techniques. Testing of private water supplies should be completed by a state certified laboratory (1). Most testing laboratories or services supply their own sample containers. Samples for bacteriological testing must be collected in sterile containers and under sterile conditions. Laboratories may sometimes send a trained technician to collect the sample. For further information, contact the local health authority or the U.S. Environmental Protection Agency (EPA).

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.6.1 Water Supply
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.6.4 Water Test Results

REFERENCES

US Environmental Protection Agency. Potential well water contaminants and their impacts. https://www.epa.gov/privatewells/potential-well-water-contaminants-and-their-impacts. Updated August 8, 2019. Accessed May 18, 2020
US Environmental Protection Agency. Protecting your home’s water. Testing wells to safeguard your water. https://www.epa.gov/privatewells/protect-your-homes-water#how. Updated August 8, 2019. Accessed May 18, 2020
US Environmental Protection Agency. Certification of laboratories for drinking water. Contact information for certification programs and certified laboratories for drinking water. https://www.epa.gov/dwlabcert/contact-information-certification-programs-and-certified-laboratories-drinking-water. Updated March 26, 2020. Accessed May 18, 2020
Centers for Disease Control and Prevention. Drinking water. Private water systems. https://www.cdc.gov/healthywater/drinking/private/index.html. Reviewed January 17, 2014. Accessed May 18, 2020
Agency for Toxic Substances and Disease Registry. Choose Safe Places for Early Care and Education (CSPECE) Guidance Manual. https://www.atsdr.cdc.gov/safeplacesforECE/cspece_guidance/index.html. Reviewed October 30, 2018. Accessed May 18, 2020

NOTES

Content in the STANDARD was modified on 8/27/2020

Standard 5.2.6.3: Testing for Lead and Copper Levels in Drinking Water

Drinking water, including water in drinking fountains, should be tested and evaluated in accordance with the assistance of the local health authority or state drinking water program to determine whether lead and copper levels are safe.

RATIONALE

Lead and copper in pipes can leach into water in harmful amounts and present a potential serious exposure. Lead exposure can cause: lower IQ levels, hearing loss, reduced attention span, learning disabilities, hyperactivity, aggressive behavior, coma, convulsion, and even death (2,3). Copper exposure can cause stomach and intestinal distress, liver or kidney damage, and complications of Wilson’s disease. Children’s bodies absorb more lead and copper than the average adult because of their rapid development (2,3).

It is especially important to test and have safe water at child care facilities because of the amount of time children spend in these facilities.

Caregivers/teachers should always run cold water for fifteen to thirty seconds before using for drinking, cooking, and making infant formula (3). Cold water is less likely to leach lead from the plumbing.

COMMENTS

Lead is not usually found in water that comes from wells or public drinking water supply systems. More commonly, lead can enter the drinking water when the water comes into contact with plumbing materials that contain lead (2,4).

Child care facilities that have their own water supply and are considered non-transient, non-community water systems (NTNCWS) are subject to the Environmental Protection Agency’s (EPA) Lead and Copper Rule (LCR) requirements, which include taking water samples for testing (1,2).

Contact your local health department or state drinking water program for information on how to collect samples and for advice on frequency of testing. See also the EPA references below.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.6.2 Testing of Drinking Water Not From Public System
4.2.0.6 Availability of Drinking Water
5.2.6.1 Water Supply
5.2.6.4 Water Test Results
5.2.9.13 Testing for and Remediating Lead Hazards

REFERENCES

Zhang, Y., A. Griffin, M. Edwards. 2008. Nitrification in premise plumbing: Role of phosphate, pH and pipe corrosion. Environ Sci Tech 42:4280-84.
U.S. Environmental Protection Agency (EPA). 2005. 3Ts for reducing lead in drinking water in child care facilities: Revised guidance. Washington, DC: EPA, Office of Water. http://www.epa.gov/safewater/schools/pdfs/lead/toolkit_leadschools_guide_3ts_childcare.pdf.
U.S. Environmental Protection Agency (EPA). 2005. Lead and copper rule: A quick reference guide for schools and child care facilities that are regulated under the safe Drinking Water Act. Washington, DC: EPA, Office of Water. http://www.epa.gov/safewater/schools/pdfs/lead/qrg_lcr_schools.pdf.
U.S. Environmental Protection Agency (EPA). 2009. Drinking water in schools and child care facilities. http://water.epa.gov/infrastructure/drinkingwater/schools/index.cfm.

Standard 5.2.8.1: Integrated Pest Management

Facilities should adopt an integrated pest management program (IPM) to ensure long-term, environmentally sound pest suppression through a range of practices including pest exclusion, sanitation and clutter control, and elimination of conditions that are conducive to pest infestations. IPM is a simple, common-sense approach to pest management that eliminates the root causes of pest problems, providing safe and effective control of insects, weeds, rodents, and other pests while minimizing risks to human health and the environment (2,4).

Pest Prevention: Facilities should prevent pest infestations by ensuring sanitary conditions. This can be done by eliminating pest breeding areas, filling in cracks and crevices; holes in walls, floors, ceilings and water leads; repairing water damage; and removing clutter and rubbish on the premises (5).

Pest Monitoring: Facilities should establish a program for regular pest population monitoring and should keep records of pest sightings and sightings of indicators of the presence of pests (e.g., gnaw marks, frass, rub marks).

Pesticide Use: If physical intervention fails to prevent pest infestations, facility managers should ensure that targeted, rather than broadcast applications of pesticides are made, beginning with the products that pose least exposure hazard first, and always using a pesticide applicator who has the licenses or certifications required by state and local laws.

Facility managers should follow all instructions on pesticide product labels and should not apply any pesticide in a manner inconsistent with label instructions. Safety Data Sheets (SDS) are available from the product manufacturer or a licensed exterminator and should be on file at the facility Facilities should ensure that pesticides are never applied when children are present and that re-entry periods are adhered to.

Records of all pesticides applications (including type and amount of pesticide used), timing and location of treatment, and results should be maintained either on-line or in a manner that permits access by facility managers and staff, state inspectors and regulatory personnel, parents/guardians, and others who may inquire about pesticide usage at the facility.

Facilities should avoid the use of sprays and other volatilizing pesticide formulations. Pesticides should be applied in a manner that prevents skin contact and any other exposure to children or staff members and minimizes odors in occupied areas. Care should be taken to ensure that pesticide applications do not result in pesticide residues accumulating on tables, toys, and items mouthed or handled by children, or on soft surfaces such as carpets, upholstered furniture, or stuffed animals with which children may come in direct contact (3).

Following the use of pesticides, herbicides, fungicides, or other potentially toxic chemicals, the treated area should be ventilated for the period recommended on the product label.

Notification: Notification should be given to parents/guardians and staff before using pesticides, to determine if any child or staff member is sensitive to the product. A member of the child care staff should directly observe the application to be sure that toxic chemicals are not applied on surfaces with which children or staff may come in contact.

Registry: Child care facilities should provide the opportunity for interested staff and parents/guardians to register with the facility if they want to be notified about individual pesticide applications before they occur.

Warning Signs: Child care facilities must post warning signs at each area where pesticides will be applied. These signs must be posted forty-eight hours before and seventy-two hours after applications and should be sufficient to restrict uninformed access to treated areas.

Record Keeping: Child care facilities should keep records of pesticide use at the facility and make the records available to anyone who asks. Record retention requirements vary by state, but federal law requires records to be kept for two years (7). It is a good idea to retain records for a minimum of three years.

Pesticide Storage: Pesticides should be stored in their original containers and in a locked room or cabinet accessible only to authorized staff. No restricted-use pesticides should be stored or used on the premises except by properly licensed persons. Banned, illegal, and unregistered pesticides should not be used.

RATIONALE

Children must be protected from exposure to pesticides (1). To prevent contamination and poisoning, child care staff must be sure that these chemicals are applied by individuals who are licensed and certified to do so. Direct observation of pesticide application by child care staff is essential to guide the pest management professional away from surfaces that children can touch or mouth and to monitor for drifting of pesticides into these areas. The time of toxic risk exposure is a function of skin contact, the efficiency of the ventilating system, and the volatility of the toxic substance. Spraying the grounds of a child care facility exposes children to toxic chemicals. Studies and a recent consensus statement address the risk of neurodevelopmental effects from exposure to pesticides (6). Exposure to pesticides has been linked to learning and developmental disorders. Children are more vulnerable as their metabolic, enzymatic, and immunological systems are immature. Pesticides should only be used as an emergency application to eliminate threats to human health (6).

COMMENTS

Manufacturers of pesticides usually provide product warnings that exposure to these chemicals can be poisonous.

Child care staff should ask to see the license of the pest management professional and should be certain that the individual who applies the toxic chemicals has personally been trained and preferably, individually licensed, i.e., not working in the capacity of a technician being supervised by a licensed pest management professional. In some states only the owner of a pest management company is required to have this training, and s/he may then employ unskilled workers. Child care staff should ensure that the pest management professional is familiar with the pesticide s/he is applying.

Child care staff should contact their state pesticide office and request that their child care facility be added to the state pesticide sensitivity list, in states where such a list exists. When a child care facility is placed on the state pesticide sensitivity list, the child care staff will be notified if there are plans for general pesticide application occurring near the child care facility.

For further information about pest control, contact the state pesticide regulatory agency, the Environmental Protection Agency (EPA), or the National Pesticide Information Center. For possible poison exposure, contact the local poison center at 1-800-222-1222.

TYPE OF FACILITY

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

REFERENCES

South Dakota State University, Department of Plant Science. Restricted use pesticide record keeping: Pesticide recordkeeping is more than just a good idea -- it’s the law! http://www.sdstate.edu/ps/extension/pat/pesticide-record.cfm.
Gilbert, S. G. 2007. Scientific consensus statement on environmental agents associated with neurodevelopmental disorders. Bolinas, CA: Collaborative on Health and the Environment (CHE). http://www.neep.org/uploads/NEEPResources/id27/lddistatement.pdf.
University of California, Agriculture and Natural Resources. UC IPM online: Statewide integrated pest management program. How to manage pests. http://www.ipm.ucdavis.edu.
The IPM Institute of North America. IPM standards for schools. http://ipminstitute.org/school.htm.
U.S. Environmental Protection Agency. Integrated pest management (IPM) in child care.
http://www.epa.gov/pesticides/controlling/childcare-ipm.htm.
U.S. Environmental Protection Agency. Integrated pest management (IPM) in schools. http://www.epa.gov/pesticides/ipm/index.htm.
Tulve, N. S., P. A. Jones, M. G. Nishioka, R. C. Fortmann, C. W. Croghan, J. Y. Zhou, A. Fraser, C. Cave, W. Friedman. 2006. Pesticide measurements from the First National Environmental Health Survey of Child Care Centers using a multi-residue GC/MS analysis method. Environ Sci Tech 40:6269-74.

Standard 5.2.9.4: Radon Concentrations

Content in the STANDARD was modified on 05/17/2016.

Radon concentrations inside a home or building used for child care must be less than four picocuries (pCi) per liter of air. All facilities must be tested for the presence of radon, according to U.S. Environmental Protection Agency (EPA) testing protocols for long-term testing (i.e., greater than ninety days in duration using alpha-track or electret test devices). Radon testing should be conducted after a major renovation to the building or HVAC system (1,2).

RATIONALE

Radon is a colorless, odorless, radioactive gas that comes from the natural breakdown of uranium in soil, rock and water, and gets into the air you breath. It can be found in soil, water, building materials, and natural gas. Radon from the soil is the main cause of radon problems. Radon typically moves up through the ground to the air above and into a home or building through cracks and other holes in the foundation. Radon can get trapped inside the home or building where it can build up. In a small number of homes, the building materials can give off radon, but the materials themselves rarely cause problems. If radon is present in the water supply, most of the risk is related to radon released into the air when water is used for showering or other household purposes (1). When radon gas is inhaled, it can cause lung cancer. Radon levels can be easily measured to determine if acceptable levels have been exceeded. The risk can be reduced by lowering the levels of radon in the home or building. Fixing buildings to reduce radon exposure may entail sealing cracks in the foundation or ventilating the area under the foundation.

COMMENTS

The average indoor radon level is estimated to be about 1.3 pCi per liter of air, and about 0.4 pCi per liter is normally found in the outside air. Most homes today can be reduced to two picocuries per liter or below (1).

Common test kits include: charcoal canisters, e-perm, alpha track detectors, and charcoal liquid scintillation devices. To find radon resources near you, see U.S. EPA Radon Hotlines and Information Resources or contact the National Radon Program Services.

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.7 Use of Basements and Below Grade Areas
5.2.1.3 Heating and Ventilation Equipment Inspection and Maintenance
5.2.9.15 Construction and Remodeling

REFERENCES

U.S. Environmental Protection Agency (EPA). 1993. Radon measurement in schools: Revised edition. https://www.epa.gov/sites/production/files/2014-08/documents/radon_measurement_in_schools.pdf.
U.S. Environmental Protection Agency (EPA). 2012. A citizen’s guide to radon: The guide to protecting yourself and your family from radon. https://www.epa.gov/radon/citizens-guide-radon-guide-protecting-yourself-and-your-family-radon.

NOTES

Content in the STANDARD was modified on 05/17/2016.

Standard 5.2.9.10: Prohibition of Poisonous Plants

Poisonous or potentially harmful plants are prohibited in any part of a child care facility that is accessible to children. All plants not known to be nontoxic should be identified and checked by name with the local poison center (1-800-222-1222) to determine safe use.

RATIONALE

Plants are important to our health and well-being and are a great lesson in learning to understand and respect our environment. However, some plants can be harmful when eaten or touched (1,2). Plants are among the most common household substances that children ingest. Determining the toxicity of every commercially available household plant is difficult. A more reasonable approach is to keep any unknown plant out of the environment that children use. All outdoor plants and their leaves, fruit, and stems should be considered potentially toxic (1).

COMMENTS

Cuttings, trimmings, and leaves from potentially harmful plants must be disposed of safely so children do not have access to them.

For toxic, frequently ingested products and plants, see the American Academy of Pediatrics’ (AAP) Handbook of Common Poisonings in Children, available at http://www.aap.org.

TYPE OF FACILITY

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

RELATED STANDARDS

Appendix Y: Non-Poisonous and Poisonous Plants

REFERENCES

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.
American Academy of Pediatrics. 2011. Handbook of common poisonings in children. 4th ed. Elk Grove Village, IL: AAP.

Standard 5.2.9.13: Testing for and Remediating Lead Hazards

Content in the standard was modified on 08/15/2014 and 04/27/2021.

Lead can be found in all parts of our environment-the air, the soil, the water, and even inside our homes. Because of the highly toxic nature of lead, early care and education (ECE) programs should test and remediate lead hazards in paint and dust, water, soil, and consumer products.

Paint and Dust: Paint and other surface-coating materials used in ECE facilities, including family child care homes (both rental and owned), should be labeled for residential (not industrial) applications only.

All ECE facilities built before 1978

Should be inspected and tested for lead-based paint hazards by a certified lead inspector or certified risk assessor for the following reasons
- If lead is identified in either the interior or exterior paint of the facility, ECE facilities should consult their state or local childhood lead poisoning prevention program, public health agency, and/or a certified risk assessor to determine the best steps for lead hazard control work.
- Surfaces found to have lead-based paint hazards should not be used and should be made inaccessible to children and staff until remediated.
- ECE facilities should hire a certified lead abatement contractor to do lead hazard control work. ECE facilities should be sure to test for lead dust clearance to ensure proper cleanup was done after lead hazard control work.
- ECE facilities should implement an occupant protection plan during lead remediation work.
Should conduct annual inspections of paint and perform routine maintenance to ensure that paint remains intact
Should use an Environmental Protection Agency (EPA)-certified lead-safe contractor (also known as a renovation, repair, and painting, or RRP, contractor) if any repair or renovation work (not lead hazard control work) is needed

Water: ECE facilities should learn the source (public or private) of their water and determine whether the facility has a lead service line or lead-containing pipes, fixtures, or solder. They should test water for lead and take steps to remediate sources if the water contains lead.

Soil: Bare soil around ECE facilities should be tested by an EPA-recognized National Lead Laboratory Accreditation Laboratory (NLLAP) or covered with mulch, plantings, or grass.

Consumer Products: Caregivers/teachers should check the U.S. Consumer Product Safety Commission’s website (http://www.cpsc.gov) for warnings of potential lead exposure to children and recalls of play equipment, toys (especially antique and imported), jewelry used for play, imported vinyl mini-blinds, and food contact materials. If they are found to have lead, the items should be removed from the facility.

Only a certified lab can accurately test toys and products for lead contamination. “Test it yourself” kits or lead wipes (often purchased online or from large home improvement stores) are not recommended. Kits and wipes do not show how much lead is present, and their reliability at detecting low levels of lead has not been established.

Caregivers/teachers should not give children in their care imported candy, herbal remedies, or folk medicines.

RATIONALE

Lead is especially dangerous to children, because their brains and nervous systems are more sensitive to lead’s damaging effects, and their young bodies are able to absorb more lead. Plus, babies and young children often put their hands and other objects in their mouths. These objects may have lead dust on them, particularly if a child is crawling on floors contaminated with lead dust. Once ingested, lead competes with calcium and can be stored in bones, teeth, and organs for decades, making lead poisoning difficult to treat. Lead-based paint is the most common source of lead exposure and poisoning in children.^1,2

Children under the age of 6 are at the greatest risk for lead poisoning. Most children with lead poisoning do not look or act sick. A blood lead test is the only way to know if children are being lead poisoned. The U.S. Centers for Disease Control and Prevention (CDC) uses a blood lead reference value of 5 micrograms per deciliter (mcg/dL) to identify children with blood lead levels that are much higher than most children’s levels.^3,4 Lead is a neurotoxin. Even at low levels of exposure, children can suffer seriously from lead poisoning, leading to behavior and learning problems, lower IQ, hyperactivity, slowed growth, hearing problems, and anemia. There is no safe blood lead level in children.⁵

Lead may be present in paint, dust, water, or soil. It may also be present in consumer products like food, candies, spices, pottery/dishes, traditional medicines, cosmetics, toys, jewelry, and painted furniture.

Paint and Dust:The manufacture of residential lead-based paint was banned in the United States in 1978, but many older homes around the country still contain it. When lead-based paint inside a home deteriorates or is located on a friction surface, chips and dust settle on surfaces children can easily reach, such as windowsills and floors. Contaminated dust can be inhaled or ingested and is hazardous even if the particles are too small to see.

Water:ECE facilities built after 1986 likely do not have a lead service line; however, all ECE facilities, regardless of age, may have pipes and fixtures that contain lead (such as brass fixtures). In addition, unforeseen events (such as the one that occurred in Flint, MI, in 2014) may cause public drinking water to become contaminated with lead.

Soil:Lead can be found in soil as a result of the historic use of lead-based paint on building interiors and exteriors and leaded gasoline for cars, the current use of leaded gas by small airplanes, and industries that put lead into the environment. Soil on the property could be contaminated if the facility is next to a busy highway or high-traffic road or if it was built before 1978. In addition, if the facility is located in or near a current or former industrial area, the soil could be contaminated with lead.

Children may be exposed to lead-contaminated soil by playing in bare dirt. The main way children get lead from soil into their bodies is ingestion, most commonly by touching dirt and putting their hands in their mouths.

Consumer Products: Certain children’s products are known to have a higher risk of containing lead such as inexpensive children’s jewelry, imported pottery, antique toys, and imported toys. The use of lead in plastics has not been banned, so certain plastic toys made with vinyl/ polyvinyl chloride (PVC) [including bath books, teethers, rubber duckies, bath toys, dolls, beach balls, backpacks, pencil cases, and shower curtains] may contain lead. Lead may also be present in certain herbal remedies, folk medicines, and imported spices and foods.

COMMENTS

A state or local childhood lead poisoning prevention program, health department, and/or a certified risk assessment professional can help ECE facilities write a remediation plan to reduce any identified paint, water, or soil hazards. This plan may call for one of two types of lead hazard control work

● Interim Controls: These are measures that minimize lead hazards and include dust removal, paint stabilization, and/or control of friction/abrasion points. These measures ensure no one is exposed to lead-based paint hazards. Some intact lead-based paint may remain in the facility if it will not pose a hazard. These controls have been found to be effective, while less expensive than full abatement.

● Lead Abatement: These are measures that permanently remove lead-based paint and include component replacement (such as windows and windowsills), paint removal, enclosure, or encapsulation of lead-based paint. Lead abatement involves specialized techniques and must be conducted by EPA-certified lead abatement contractors.^6,7

EPA certifies lead abatement contractors to conduct either interim controls or lead abatement. These lead hazard control activities disturb lead-based paint and can create lead dust. Lead clearance testing will determine if contractors properly cleaned up after lead hazard control work and if work areas are safe for reoccupancy.⁷

For RRP work conducted independently from lead hazard control work in pre-1978 homes, EPA certifies lead-safe contractors, also known as RRP contractors. RRP contractors are trained to use lead-safe work practices when conducting tasks that may disturb lead-based paint, but they are not trained to perform lead hazard control work.

State-level programs and local funding resources may be available if financial support is needed for inspection, risk assessment, or remediation services.

Below is a list of general contact information and resources to answer questions, locate lead professionals, and handle other issues:

ADDITIONAL RESOURCES

General Contacts

● EPA regional offices can respond to inquiries about lead and lead poisoning. A list of regional contacts is on at EPA’s Contacts in EPA Regional Offices for Lead Poisoning Prevention Efforts website.

● ECE facilities can call the National Lead Information Center and speak with an information specialist Monday through Friday, 8:00 am to 6:00 pm Eastern, at 800-424-LEAD.

● The CDC has a list of state and local childhood lead poisoning prevention programs.

● More resources available on the Lead-Safe Toolkit for Home-Based Child Care: General ResourcesWeb page.

Lead in Paint Contacts

● An EPA booklet called Protect Your Family from Lead in Your Home explains the dangers of lead and how to protect your family and those in your care from lead-based paint hazards.

● EPA’s webpage, Locate Certified Renovation and Lead Dust Sampling Technician Firms, can help ECE facilities find an inspection or risk assessment firm. This website also contains RRP contractor information.

● A local health department or childhood lead poisoning prevention program may be able to provide information on lead-based paint inspection and testing. The National Association of County and City Health Officials maintains a searchable Directory of Local Health Departments.

● RRP contractors must provide a copy of the EPA pamphlet The Lead-Safe Certified Guide to Renovate Rightto ECE facilities and general renovation information to families whose children attend those ECE facilities.

● A description of steps to identify if ECE facilities have lead in paint hazards and more lead in paint resources are in The Lead-Safety Toolkit for Home-Based Child Care: Lead in Paint.

Lead in Soil Contacts

Labs for soil analysis are on EPA’s list of NLLAP labs. The lab may go to the facility and collect the soil samples, or it may provide instructions, sampling materials, and forms so the facility can collect and submit the samples. State and local lead poisoning prevention programs may have more instructions. A description of steps to identify if ECE facilities have lead in soil hazards and more lead in soil resources are in The Lead-Safe Toolkit for Home-Based Child Care: Lead in Soil.

Lead in Water Contacts

● ECE facilities can call EPA’s Safe Drinking Water Hotline at 800-426-4791 to find local contact information for testing water.

● If facility water comes from a community water system, local water utility staff may be able to test the water or provide a referral to an EPA-accredited lab in your region (see the NLLAP website).

● Module 6 of EPA’s 3Ts: Training, Testing, Taking Action, Remediation and Establishing Routine Practices, lists short- and long-term (permanent) measures to reduce exposures to lead-contaminated drinking water. The document also contains information about how to hire a licensed contractor to replace lead service lines or other lead-containing pipes and fixtures.

● EPA’s pamphlet How to Identify Lead Free Certification Marks for Drinking Water System & Plumbing Products contains information on how to identify lead-free plumbing.

● A description of steps to take when identifying if ECE facilities have lead in water hazards and more lead in water resources can be found in The Lead-Safe Toolkit for Home-Based Child Care: Lead in Drinking Water.

Lead in Consumer Products Contacts

● ECE facilities are encouraged to consult the United States Consumer Product Safety Commission (CPSC)’s web site, www.cpsc.gov, or more information on product recalls.

● ECE programs are encouraged to consult CPSC recall notices, as well as state and local governments, for more information about proper disposal of lead-contaminated consumer products.

● A description of steps to take to identify if ECE facilities have lead in consumer products hazards and a list of additional lead in consumer product resources can be found in The Lead-Safe Toolkit for Home-Based Child Care: Lead in Consumer Products Worksheet.

● The CDC provides more information on potential lead levels in spices, herbal remedies, and ceremonial powders in Lead in Spices, Herbal Remedies, and Ceremonial Powders Sampled from Home Investigations for Children with Elevated Blood Lead Levels — North Carolina, 2011–2018.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.9.15 Construction and Remodeling
5.3.1.2 Product Recall Monitoring

REFERENCES

Centers for Disease Control and Prevention. Blood Lead Levels in Children. Reviewed May 28, 2020. Accessed March 9, 2021. https://www.cdc.gov/nceh/lead/prevention/blood-lead-levels.htm
Advisory Committee on Childhood Lead Poisoning Prevention, Centers for Disease Control and Prevention. Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention. Published January 4, 2012. Accessed March 9, 2021. http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf
National Center for Healthy Housing. Lead-Safe Toolkit for Home-Based Child Care: General Resources. Accessed March 9, 2021. https://nchh.org/tools-and-data/technical-assistance/protecting-children-from-lead-exposures-in-child-care/toolkit/general/
Centers for Disease Control and Prevention. Lead in Paint. Reviewed November 24, 2020. Accessed March 9, 2021. https://www.cdc.gov/nceh/lead/prevention/sources/paint.htm
Centers for Disease Control and Prevention. Lead Poisoning Prevention. Reviewed May 30, 2019. Accessed March 9, 2021. https://www.cdc.gov/nceh/lead/prevention/default.htm
U.S. Environmental Protection Agency. Lead Abatement Versus Lead RRP. Accessed March 9, 2021. https://www.epa.gov/lead/lead-abatement-vs-lead-rrp
Department of Housing and Urban Development. Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing. 2012 Edition. Accessed March 9, 2021. https://www.hud.gov/program_offices/healthy_homes/lbp/hudguidelines

NOTES

Content in the standard was modified on 08/15/2014 and 04/27/2021.

Standard 5.2.9.14: Shoes in Infant Play Areas

Adults and children should remove or cover shoes before entering a play area used by a specific group of infants. These individuals, as well as the infants playing in that area, may wear shoes, shoe covers, or socks that are used only in the play area for that group of infants.

RATIONALE

When infants play, they touch the surfaces on which they play with their hands, and then put their hands in their mouths. Lead and other toxins in soil around a facility can be a hazard when tracked into a facility on shoes (1).

COMMENTS

Facilities can meet this standard in several ways. The facility can designate contained play surfaces for infant play on which no one walks with shoes. Individuals can wear shoes or slippers that are worn only to walk in the infant play area or they can wear clean cloth or disposable shoe covers over shoes that have been used to walk outside the infant play area.

This standard applies to shoes that have been worn outdoors, in the play areas of other groups of children, and in toilet and diaper changing areas. All of these locations are potential sources of contamination.

TYPE OF FACILITY

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

REFERENCES

U.S. Environmental Protection Agency. 2009. Lead in paint, dust and soil: Basic information. http://www.epa.gov/lead/pubs/
leadinfo.htm.

Standard 5.4.1.1: General Requirements for Toilet and Handwashing Areas

Clean toilet and handwashing facilities should be located in the best place to meet the developmental needs of children.

For infant areas, toilets and handwashing facilities are for adult rather than child use. They should be located within the infant area to reduce staff absence.

For toddler areas, toilet and handwashing facilities should be located in or adjacent to the toddler rooms.

For preschool and school-age children, toilet and handwashing facilities should be located near the entrance to the group room and near the entrance to the playground. If both entrances are close to each other, then only one set of toilet and handwashing facilities is needed.

RATIONALE

Young children have poor bowel and bladder control and cannot wait long when they have to use the toilet (1). Young children must be able to get to toilet facilities quickly. Staff must have easy access to hand washing facilities to wash their hands at the times when it is appropriate and still maintain supervision of the children.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.3 Assisting Children with Hand Hygiene

REFERENCES

Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 5.4.1.4: Preventing Entry to Toilet Rooms by Infants and Toddlers

Toilet rooms should have barriers that prevent entry by infants and toddlers who are unattended. Infants and toddlers should be supervised by sight and sound at all times.

RATIONALE

Infants and toddlers can drown in toilet bowls, play in the toilet, have contact with contaminated items or surfaces, or otherwise engage in potentially injurious behavior if they are not supervised in toilet rooms.

TYPE OF FACILITY

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

Standard 6.1.0.1: Size and Location of Outdoor Play Area

The facility or home should be equipped with an outdoor play area that directly adjoins the indoor facilities or that can be reached by a route that is free of hazards and is no farther than one-eighth mile from the facility. The playground should comprise a minimum of seventy-five square feet for each child using the playground at any one time.

The following exceptions to the space requirements should apply:

A minimum of thirty-three square feet of accessible outdoor play space is required for each infant;
A minimum of fifty square feet of accessible outdoor play space is required for each child from eighteen to twenty-four months of age.

There should be separated areas for play for the following ages of children:

Ages six through twenty-three months
Ages two to five years*
Ages five to twelve years**

*These areas may be further sub-divided into ages two to three years and four to five years.

** These areas may be further sub-divided into grades K-1, 2-3, and 4-6.

The outdoor playground should include an open space for running that is free of other equipment (4).

RATIONALE

Play areas must be sufficient to allow freedom of movement without collisions among active children.

Providing more square feet per child may correspond to a decrease in the number of injuries associated with gross motor play equipment (1). An aggregate size of greater than 4,200 square feet that includes all of a facility’s playgrounds has been associated with significantly greater levels of children’s physical activity (5).

In addition, meeting proposed Americans with Disabilities Act (ADA) outdoor play area requirements for accessible routes, and developing natural, outdoor play yards with variety and shade can only be achieved if sufficient outdoor play space is provided.

The space exceptions are based on early childhood and playground professionals’ experience (2). This follows the developmental ages used for the development of the Standards for play equipment for children.

COMMENTS

Children benefit from being outside as much as possible and it is important to provide sufficient outdoor space to accommodate the full enrollment of children (2). If a facility has less than seventy-five square feet of outdoor space per child, then the facility should augment the outdoor space by providing a large indoor play area (see Standard 6.1.0.2).

Additional space beyond the standard of seventy-five square feet per child may be required to meet ADA outdoor play area requirements, depending on the layout and terrain (3). A Certified Playground Safety Inspector (CPSI) can be utilized for guidance in assisting with outdoor play areas. To locate a CPSI, check the National Park and Recreation Association (NPRA) registry at https://ipv.nrpa.org/CPSI_registry/.

Children may play in older children’s areas if the equipment is appropriate for the youngest child present.

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.5 Assessment of the Environment at the Site Location
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
6.1.0.2 Size and Requirements of Indoor Play Area

REFERENCES

Dowda, M., W. H. Brown, C. Addy, K. A. Pfeiffer, K. L. McIver, R. R. Pate. 2009. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 123: e261-66.
Brown, W. H., K. A. Pfeiffer, K. L. Mclver, M. Dowda, C. L. Addy, R. R. Pate. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Devel 80:45-58.
Architectural and Transportation Barriers Compliance Board (U.S. Access Board). 2005. Accessible play areas: A summary of accessibility guidelines for play areas. http://www.access-board.gov/play/guide/guide.pdf.
Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.
Ruth, L. C. 2008. Playground design and equipment. Whole Building Design Guide. http://www.wbdg.org/resources/
playground.php.

Standard 6.1.0.2: Size and Requirements of Indoor Play Area

If a facility has less than seventy-five square feet of accessible outdoor space per child or provides active play space indoors for other reasons, a large indoor activity room that meets the requirement for seventy-five square feet per child may be used if it meets the following requirements:

It provides for types of activities equivalent to those performed in an outdoor play space;
The area is ventilated with fresh, temperate air at a minimum of five cubic feet per minute per occupant when open windows are not possible;
The surfaces and finishes are shock-absorbing, as required for outdoor installations in Standard 6.2.3.1;
The play equipment meets the requirements for outdoor installation as stated in Standards 6.2.1.3-6.2.1.6 and Standards 6.2.2.3-6.2.2.4.

There should be separated areas for play for the following ages of children:

Ages six through twenty-three months
Ages two to five years*
Ages five to twelve years**

*These areas may be further sub-divided into ages two to three years and four to five years.

** These areas may be further sub-divided into grades K-1, 2-3, and 4-6.

RATIONALE

This standard provides facilities located in inner-city areas or areas with extreme weather with an alternative that allows gross motor play when outdoor spaces are unavailable or unusable. Indoor gross motor play must provide an experience like outdoor play, with safe and healthful environmental conditions that match the benefits of outdoor play as closely as possible. These spaces may be interior if ventilation is adequate to prevent undue concentration of organisms, odors, carbon dioxide, humidity and other substances consistent with ASHRAE’s “Standard 62: Ventilation for Acceptable Indoor Air Quality.” This follows the developmental ages used for the development of the Standards for play equipment for children (1,2).

COMMENTS

For days in which weather does not permit outdoor play, the facility is encouraged to provide an alternate place for gross motor activities indoors for children of all ages. This space could be a dedicated gross motor room or a gym, a large hallway, or even a classroom in which furniture has been pushed aside. The room should provide adequate space for children to do vigorous activities including running.

Qualified heating and air conditioning contractors should have a meter to measure the rate of airflow. Before indoor areas are used for gross motor activity, a heating and air conditioning contractor should be called in to make airflow measurements.

TYPE OF FACILITY

Center, Early Head Start, Head Start

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
6.2.1.3 Design of Play Equipment
6.2.1.4 Installation of Play Equipment
6.2.1.5 Play Equipment Connecting and Linking Devices
6.2.1.6 Size and Anchoring of Crawl Spaces
6.2.1.7 Enclosure of Moving Parts on Play Equipment
6.2.1.8 Material Defects and Edges on Play Equipment
6.2.1.9 Entrapment Hazards of Play Equipment
6.2.2.1 Use Zone for Fixed Play Equipment
6.2.2.2 Arrangement of Play Equipment
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 6.1.0.4: Elevated Play Areas

Elevated play areas that have been created using a retaining wall should have a guardrail, protective barrier, or fence running along the top of the retaining wall.

If the exposed side of the retaining wall is higher than two feet, a fence not less than six feet high should be installed. The bottom edge of the fence should be less than three and one-half inches from the base and should be designed to prevent children from climbing it. Fences should be designed so all spaces are less than three and one-half inches (1). If the height of the exposed side of the retaining wall is two feet or lower, a guardrail should be installed if caring for preschool and school-age children. The space between the bottom of the guardrail and the ground should be more than nine inches but less than or equal to twenty-three inches. For school-age children, the space between the bottom of the guardrail and the ground should be more than nine inches but less than or equal to twenty-eight inches. If caring for infants or toddlers, a protective barrier should be installed. The space between the barrier and the ground should be less than three and one-half inches and should be from four to six feet in height.

RATIONALE

Children falling from elevated play areas may suffer fatal head injuries. All spaces in fences or barriers are recommended to be less than three and one-half inches to prevent head entrapment (1,4) and climbing.

Guardrails are designed to protect against falls from elevated surfaces, but do not discourage climbing or protect against climbing through or under. Protective barriers protect against all three and provide greater protection. Guardrails are not recommended to use for infant and toddlers; protective barriers should be used instead.

COMMENTS

If the exposed side of the retaining wall is less than two feet high, additional safety can be provided by placing shock-absorbing material at the base of the exposed side of the retaining wall. A Certified Playground Safety Inspector (CPSI) can be utilized for guidance in assisting with elevated play areas.

According to the U.S. Consumer Product Safety Commission (CPSC), guardrails are not recommended for use with infants and toddlers because they do not discourage climbing or protect against climbing under or through (1). Protective barriers are recommended for infants and toddlers because they provide better protection and protect against all three risks (1).

For a list of shock-absorbing materials, see Appendix Z, the CPSC Public Playground Safety Handbook, and the ASTM International (ASTM) standards “F2223-09: Standard Guide for ASTM Standards on Playground Surfacing” and “F1292-09: Standard Specification for Impact Attenuation of Surfacing Materials within the Use Zone of Playground Equipment” (2,3). To locate a CPSI, check the National Park and Recreation Association (NPRA) registry at https://ipv
.nrpa.org/CPSI_registry/.

TYPE OF FACILITY

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

RELATED STANDARDS

6.1.0.8 Enclosures for Outdoor Play Areas
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment

REFERENCES

ASTM International (ASTM). 2009. Standard safety performance specification for fences/barriers for public, commercial, and multi-family residential use outdoor play areas. ASTM F2049-09b. West Conshohocken, PA: ASTM.
ASTM International (ASTM). 2009. Standard specification for impact attenuation of surfacing materials within the use zone of playground equipment. ASTM F1292-09. West Conshohocken, PA: ASTM.ASTM International (ASTM). 2009. Standard specification for impact attenuation of surfacing materials within the use zone of playground equipment. ASTM F1292-09. West Conshohocken, PA: ASTM.
ASTM International (ASTM). 2009. Standard guide for ASTM standards on playground surfacing. ASTM F2223-09. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.3.1.1: Enclosure of Bodies of Water

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

All water hazards, such as pools, swimming pools, stationary wading pools, ditches, fish ponds, and water retention or detention basins, should be enclosed with a permanent fence, wall, building wall, or combination thereof that is 4 to 6 feet in height or higher. The barrier must measure a distance of 3 feet horizontally from the swimming pool or body of water.¹ The maximum vertical clearance (or gapping) allowed between the ground and the fence shall be 2 inches from surfaces that are not solid, such as grass or gravel, and measured on the side of the barrier that faces away from the vessel.^1(p25)

Openings in the fence should be no greater than 3.5 inches.¹ The fence should be constructed to discourage children and unwanted visitors from climbing and be kept in good repair. A house exterior wall can constitute one side of a fence if the wall has no openings capable of providing direct access to the pool (eg, doors, windows).

If the fence is made of horizontal and vertical members (like a typical wooden fence) and the distance between the tops of the horizontal parts of the fence is less than 45 inches, the horizontal parts should be on the swimming pool side of the fence.^1(p26) The spacing of the vertical members and/or all mesh barriers should not exceed 1.75 inches.^1(p26)

Exit and entrance points should have self-closing, positive latching gates with locking devices a minimum of 54 inches from the ground.^1(p26–27)

If the facility has a water play area, the following requirements should be met:

Water play areas should conform to all state and local health regulations.
Water play areas should not include hidden or enclosed spaces.
Spray areas and water-collecting areas should have a nonslip surface, such as asphalt.
Water play areas, particularly those that have standing water, should not have sudden changes in depth of water.
Drains, streams, waterspouts, and hydrants should not create strong suction effects or water-jet forces.
All toys and other equipment used in and around the water play area should be made of sturdy plastic or metal (no glass should be permitted).
Water play areas in which standing water is maintained for more than 24 hours should be treated according to Standard 6.3.4.1: Pool Water Quality and inspected for glass, trash, animal excrement, and other foreign material.

All areas must be visible to allow caregivers/teachers adequate active supervision of all children.²

RATIONALE

Fenced enclosures around swimming pools and spas provide an adequate barrier to prevent unwanted and unsupervised access.³ Drownings can occur in fresh water, often in home swimming pools within a few feet of safety and in the presence of a supervising adult.⁴ An effective fence is one that prevents a child from getting over, under, or through it and keeps the child from gaining access to the pool or body of water except when supervising adults are present. Fences are not childproof, but they provide a layer of protection for a child who strays from supervision. Fence heights are a matter of local ordinances with minimum heights being 5 feet.

TYPE OF FACILITY

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

RELATED STANDARDS

6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
6.2.5.2 Inspection of Play Area Surfacing
6.3.1.2 Accessibility to Above-Ground Pools
6.3.1.3 Sensors or Remote Monitors
6.3.1.7 Pool Safety Rules
6.3.4.1 Pool Water Quality

REFERENCES

International Code Council, The Association of Pool & Spa Professionals. 2012 International Swimming Pool and Spa Code. Country Club Hills, IL: International Code Council; 2011. https://www.waterparks.org/docs/ISPSC-PV1.pdf. Accessed August 21, 2019
US Department of Health and Human Services, Administration for Children and Families, Head Start Early Childhood Learning and Knowledge Center. Safety practices. Active supervision. https://eclkc.ohs.acf.hhs.gov/safety-practices/article/active-supervision. Updated January 29, 2019. Accessed August 21, 2019
American Red Cross. Swimming and Water Safety. https://www.redcross.org/store/swimming-and-water-safety-manual-rev-04-14/651327.html?cgid=sp-lifeguarding-and-learn-to-swim. Accessed August 21, 2019
Leavy JE, Crawford G, Leaversuch F, Nimmo L, McCausland K, Jancey J. A review of drowning prevention interventions for children and young people in high, low and middle income countries. J Community Health. 2016;41(2):424–441

NOTES

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

Equipment, Materials, and Toys

Facility

Standard 3.4.6.1: Strangulation Hazards

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

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

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

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

RATIONALE

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

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.3.1.1 Indoor and Outdoor Equipment, Materials, and Furnishing

REFERENCES

Window Covering Safety Council. Basic cord safety. http://www.prnewswire.com/news-releases/new-study-released-on-window-cord-safety-awareness-115561629.html.
U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe? Washington, DC: CPSC.
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.
Window Covering Safety Council. 2011. New study released on window covering safety awareness. http://www.windowcoverings.org/about-2/
U.S. Consumer Products Safety Commission. Strings and straps on toys can strangle young children. http://www.cpsc.gov//PageFiles/122499/5100.pdf

Standard 5.1.5.4: Guards at Stairway Access Openings

Securely installed, effective guards (such as gates) should be provided at the top and bottom of each open stairway in facilities where infants and toddlers are in care. Gates should have latching devices that adults (but not children) can open easily in an emergency. “Pressure gates” or accordion gates should not be used. Gate design should not aid in climbing. Gates at the top of stairways should be hardware mounted (e.g., to the wall) for stability. Basement stairways should be shut off from the main floor level by a full door. This door should be self-closing and should be kept locked to entry when the basement is not in use. No door should be locked to prohibit exit at any time.

RATIONALE

Falls down stairs and escape upstairs can injure infants and toddlers. A gate with a difficult opening device can cause entrapment in an emergency (1).

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.6.6 Guardrails and Protective Barriers

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). Old accordion style baby gates are dangerous. http://www.cpsc.gov/CPSCPUB/PUBS/5085.pdf.

Standard 5.1.6.6: Guardrails and Protective Barriers

Guardrails, a minimum of thirty-six inches in height, should be provided at open sides of stairs, ramps, and other walking surfaces (e.g., landings, balconies, porches) from which there is more than a thirty-inch vertical distance to fall. Spaces below the thirty-six inches height guardrail should be further divided with intermediate rails or balusters as detailed in the next paragraph.

For preschoolers, bottom guardrails greater than nine inches but less or equal to twenty-three inches above the floor should be provided for all porches, landings, balconies, and similar structures. For school age children, bottom guardrails should be greater than nine inches but less or equal to twenty inches above the floor, as specified above.

For infants and toddlers, protective barriers should be less than three and one-half inches above the floor, as specified above. All spaces in guardrails should be less than three and a half inches. All spaces in protective barriers should be less than three and one-half inches. If spaces do not meet the specifications as listed above, a protective material sufficient to prevent the passing of a three and one-half inch diameter sphere should be provided.

Where practical or otherwise required by applicable codes, guardrails should be a minimum of forty-two inches in height to help prevent falls over the open side by staff and other adults in the child care facility.

RATIONALE

Structures such as porches, landings, balconies, and other similar structures that are raised more than thirty inches above an adjacent ground or floor, pose increased risk for fall injuries. Spaces between three and one-half inches and nine inches are a head entrapment hazard (1).

Guardrails are designed to protect against falls from elevated surfaces, but do not discourage climbing or protect against climbing through or under. Protective barriers protect against all three and provide greater protection. Guardrails are not recommended to use for infants and toddlers; protective barriers should be used instead.

A top guardrail with a minimum height of forty-two inches serves the needs of all occupants – children as well as adults (2). The minimum thirty-six-inch guardrail height detailed in this standard is based solely on the needs of children.

TYPE OF FACILITY

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

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.2.4.2: Safety Covers and Shock Protection Devices for Electrical Outlets

All electrical outlets accessible to children who are not yet developmentally at a kindergarten grade level of learning should be a type called “tamper-resistant electrical outlets.” These types of outlets look like standard wall outlets but contain an internal shutter mechanism that prevents children from sticking objects like hairpins, keys, and paperclips into the receptacle (2). This spring-loaded shutter mechanism only opens when equal pressure is applied to both shutters such as when an electrical plug is inserted (2,3).

In existing child care facilities that do not have “tamper-resistant electrical outlets,” outlets should have “safety covers” that are attached to the electrical outlet by a screw or other means to prevent easy removal by a child. “Safety plugs” should not be used since they can be removed from an electrical outlet by children (2,3).

All newly installed or replaced electrical outlets that are accessible to children should use “tamper-resistant electrical outlets.”

In areas where electrical products might come into contact with water, a special type of outlet called Ground Fault Circuit Interrupters (GFCIs) should be installed (2). A GFCI is designed to trip before a deadly electrical shock can occur (1). To ensure that GFCIs are functioning correctly, they should be tested at least monthly (2). GFCIs are also available in a tamper-resistant design.

RATIONALE

Tamper-resistant electrical outlets or securely attached safety covers prevent children from placing fingers or sticking objects into exposed electrical outlets and reduce the risk of electrical shock, electrical burns, and potential fires (2). GFCIs provide protection from electrocution when an electric outlet or electric product may come into contact with water (1).

Approximately 2,400 children are injured annually by inserting objects into the slots of electrical outlets (2,3). The majority of these injuries involve children under the age of six (2,3).

Plastic safety plugs inserted into electric outlets are not the safest option since they can easily be removed by children and, depending on their size, present a potential choking hazard if placed in a child’s mouth (3).

COMMENTS

One type of outlet cover replaces the outlet face plate with a plate that has a spring-loaded outlet cover, which will stay in place when the receptacle is not in use. For receptacles where the facility does not intend to unplug the appliance, a more permanent cap-type cover that screws into the outlet receptacle is available. Several effective outlet safety devices are available in home hardware and infant/children stores (4).

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.4.3 Ground-Fault Circuit-Interrupter for Outlets Near Water

REFERENCES

National Electrical Manufacturers Association. Real safety with tamper-resistant receptacles.http://www.childoutletsafety.org.
National Fire Protection Association. National electrical code fact sheet: Tamper-resistant electrical receptacles. http://www.nfpa.org/public-education/by-topic/top-causes-of-fire/electrical/tamper-resistant-electrical-receptacles.
Electrical Safety Foundation International (ESFI). 2008. Know the dangers in your older home Rosslyn, VA: ESFI. http://files.esfi.org/file/Know-The-Dangers-of-Your-Older-Home.pdf
National Fire Protection Association (NFPA). 2010. NFPA 70: National electrical code. 2011 ed. Quincy, MA: NFPA.

Standard 5.2.5.1: Smoke Detection Systems and Smoke Alarms

In centers with new installations, a smoke detection system (such as hard-wired system detectors with battery back-up system and control panel) or monitored wireless battery operated detectors that automatically signal an alarm through a central control panel when the battery is low or when the detector is triggered by a hazardous condition should be installed with placement of the smoke detectors in the following areas:

Each story in front of doors to the stairway;
Corridors of all floors;
Lounges and recreation areas;
Sleeping rooms.

In large and small family child care homes, smoke alarms that receive their operating power from the building electrical system or are of the wireless signal-monitored-alarm system type should be installed. Battery-operated smoke alarms should be permitted provided that the facility demonstrates to the fire inspector that testing, maintenance, and battery replacement programs ensure reliability of power to the smoke alarms and signaling of a monitored alarm when the battery is low and that retrofitting the facility to connect the smoke alarms to the electrical system would be costly and difficult to achieve.

Facilities with smoke alarms that operate using power from the building electrical system should keep a supply of batteries and battery-operated detectors for use during power outages.

RATIONALE

Because of the large number of children at risk in a center, up-to-date smoke detection system technology is needed. Wireless smoke alarm systems that signal and set off a monitored alarm are acceptable. In large and small family child care homes, single-station smoke alarms are acceptable. However, for all new building installations where access to enable necessary wiring is available, smoke alarms should be used that receive their power from the building’s electrical system. These hard-wired detecting systems typically have a battery operated back-up system for times of power outage. The hard-wired and wireless smoke detectors should be interconnected so that occupants receive instantaneous alarms throughout the facility, not just in the room of origin. Single-station batteries are not reliable enough; single-station battery-operated smoke alarms should be accepted only where connecting smoke detectors to existing wiring would be too difficult and expensive as a retrofitted arrangement.

COMMENTS

Some state and local building codes specify the installation and maintenance of smoke detectors and fire alarm systems. For specific information, see the NFPA 101: Life Safety Code (1) and the NFPA 72: National Fire Alarm and Signaling Code from the National Fire Protection Association.

The Federal Emergency Management Agency (FEMA) has an online coloring book that can be printed and used to teach children about fire safety at https://www.usfa.dhs.gov/applications/publications/display.cfm?id=208/.

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.3 Compliance with Fire Prevention Code

REFERENCES

National Fire Protection Association (NFPA). 2009. NFPA 101: Life Safety Code. 2009 ed. Quincy, MA: NFPA.

Standard 5.2.9.1: Use and Storage of Toxic Substances

Content in the STANDARD was modified on 1/12/2017 and 1/31/2023.

Programs should use the following items only in the way the manufacturer recommends, and store them away from children in the labeled, child-proof container they came in:^1–3

Cleaning materials

Detergents (in all forms, including pods)
Automatic dishwasher detergents (liquid or solid, including pods)
Aerosol cans
Paints, solvents, paint removers
Floor polish or stripper, furniture polish
Liquid soap, hand sanitizers, disinfectants
Pesticides
Health and beauty products
Lawn care chemicals

Medications/Substances

Medications (prescription and over-the-counter)
Marijuana –medical and recreational

all forms, including oils, liquids, and edible products and equipment

Liquid nicotine and tobacco products
Alcohol

Other toxic materials

Many of the chemicals and toxic substances listed above will not be found in child care centers. Many of these items may be present in small and large family child care homes. In states that allow recreational or medicinal marijuana, use extra care to store edible marijuana products securely¾and away from other foods and from the children’s medications¾to avoid accidentally giving them to children or children finding and ingesting them. State regulations usually require these products to be clearly labeled as an intoxicating substance and to be stored in the tamper-proof, child-resistant package they came in. In an early childhood program that takes place in a family home, keep all edible, adult medications, including nicotine, marijuana products and other substances, in a locked or child-resistant storage container. Accidentally eating these products can lead to serious adverse events, especially in children.⁴

Early care and education programs should store any potentially toxic substances behind doors/cabinets with child-resistant locks/latches. A locked cabinet or room that children cannot open or enter is best, but it must be locked all the time. Storing potentially toxic substances in child-resistant containers is another level of protection.

Safety data sheets (SDSs) must be available on site for each hazardous chemical that the program has. When you use chemicals, don’t let them contaminate play surfaces, food, or food preparation areas. Don’t use them in a way that is dangerous to children or staff. Chemicals for lawns must be safe for children if children use those areas of the lawn. When you are not using chemicals, keep them away from children by storing all chemicals in a locked room or cabinet with a child-resistant lock or latch. Store them separately from medications and food.

Medications can be toxic if taken by the wrong person or in the wrong dose. Store medications safely in child-resistant containers¾preferably in a locked cupboard or cabinet¾away from children nd discard them properly (see Standard 3.6.3.2).

Post the telephone number for the poison control center in a place where it is immediately available in emergencies. Poison control centers are open 24 hours a day, 7 days a week, and their number is 800-222-1222 (see Standard 5.2.9.2).

RATIONALE

Over 2 million human poisonings are reported to poison centers every year. Children under 6 make up more than half of those poisonings. The most common sources of childhood poisonings are health and beauty products, cleaning products, and medications.⁵A safety data sheet, or SDS, is a standardized document that has occupational safety and health information. The International Hazard Communication Standard (HCS) orders chemical manufacturers to inform the users of a chemical’s potential danger by giving the user an SDS. SDSs usually list chemical properties, health and environmental hazards, protective measures, and safety advice for storing, and handling of chemicals.⁶The SDS explains the risk of exposure to products so that users can be careful.

Many child-resistant locks or latches can be put on doors or cabinets to keep young children from getting to poisons. Many of these devices lock automatically when the door is closed, and they need an adult’s hand or skill to open the door.

Many adult medications, vitamins, marijuana, and other products now look like candy or gummies. Using separate, locked medication cabinets helps prevent child exposure and mistakes that early care and education program staff can make.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.8.1 Integrated Pest Management
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks
5.2.9.2 Use of a Poison Center
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

Jung L, Fan N-C, Yao T-C, et al. Clinical spectrum of acute poisoning in children admitted to the pediatric emergency department. Pediatrics & Neonatology. 2019;60(1):59-67
Davis MG, Casavant MJ, Spiller HA, Chounthirath T, Smith GA. Pediatric exposures to laundry and dishwasher detergents in the United States: 2013–2014. Pediatrics. 2016. doi: 10.1542/peds.2015-4529
http://pediatrics.aappublications.org/content/early/2016/04/21/peds.2015-4529
United States Environmental Protection Agency. Pesticides and their impact on children: key facts and talking points. 2015. https://www.epa.gov/sites/default/files/2015-12/documents/pest-impact-hsstaff.pdf. Accessed August 3, 2022
United States Food and Drug Administration. FDA warns consumers about the accidental ingestion by children of food products containing THC. June 16, 2022. https://www.fda.gov/food/alerts-advisories-safety-information/fda-warns-consumers-about-accidental-ingestion-children-food-products-containing-thc.Accessed August 3, 2022
American Association of Poison Control Centers’ National Poison Data System. Annual Reports. Poison center data snapshots (2012-2020). AAPCC.org Web site. https://www.aapcc.org/annual-reports. Accessed August 3, 2022
Chemical Safety. Safety Data Sheet Search. ChemicalSafety.com Web site. https://chemicalsafety.com/sds-search/. Accessed September 19, 2022

NOTES

Content in the STANDARD was modified on 1/12/2017 and 1/31/2023.

Standard 5.2.9.5: Carbon Monoxide Detectors

Carbon monoxide detector(s) should be installed in child care settings if one of the following guidelines is met:

The child care program uses any sources of coal, wood, charcoal, oil, kerosene, propane, natural gas, or any other product that can produce carbon monoxide indoors or in an attached garage;
If detectors are required by state/local law or state licensing agency.

Facilities must meet state or local laws regarding carbon monoxide detectors. Detectors should be tested monthly. Batteries should be changed at least yearly. Detectors should be replaced at least every five years.

RATIONALE

Carbon monoxide (CO) is a deadly, colorless, odorless, poisonous gas. It is produced by the incomplete burning of various fuels, including coal, wood, charcoal, oil, kerosene, propane, and natural gas. Products and equipment powered by internal combustion engine-powered equipment such as portable generators, cars, lawn mowers, and power washers also produce carbon monoxide. Carbon monoxide detectors are the only way to detect this substance.

Carbon monoxide poisoning causes symptoms that mimic the flu; mild symptoms are typically headache, dizziness, fatigue, nausea, and diarrhea. Prolonged exposure can cause confusion, shortness of breath, unconsciousness, and even death.

On average, about 170 people in the United States die every year from carbon monoxide produced by non-automotive consumer products (1). These products include malfunctioning fuel-burning appliances such as furnaces, ranges, water heaters, and room heaters; engine-powered equipment such as portable generators; fireplaces; and charcoal that is burned in homes and other enclosed areas. In 2005 alone, the U.S. Consumer Product Safety Commission (CPSC) staff was aware of at least ninety-four generator-related carbon monoxide poisoning deaths (1). Still others die from carbon monoxide produced by non-consumer products, such as cars left running in attached garages. The Centers for Disease Control and Prevention (CDC) estimate that several thousand people go to hospital emergency rooms every year to be treated for carbon monoxide poisoning (1).

COMMENTS

Carbon monoxide detectors should be installed according to the manufacturer’s instructions. One carbon monoxide detector should be installed in the hallway outside the bedrooms in each separate sleeping area. Carbon monoxide detectors may be installed into a plug-in receptacle or high on the wall. Hard-wired or plug-in carbon monoxide detectors should have battery backup. Installing carbon monoxide detectors near heating vents, locations that can be covered by furniture or draperies, above fuel-burning appliances or in kitchens should be avoided (1).

There are a number of safety steps that child care programs can do to help prevent carbon monoxide exposure (1-3):

Make sure major appliances are professionally installed and inspected according to local building codes and have older appliances checked for malfunctions and leaks;
Choose vented appliances when possible;
Have heating systems inspected and cleaned by a qualified technician annually and make sure the chimney is clean and with a proper draft control to ensure a proper vent for flue gases;
Check the color of the flame in the burner and pilot light (a yellow-colored flame indicates the fuel is not burning efficiently and could be releasing more carbon monoxide) (4);
Never use a gas oven to heat your facility;
Do not burn charcoal indoors;
Never operate gasoline-powered engines or generators in confined areas in or near the building;
Never leave a vehicle running in a garage or closed area. Even if the garage door is open, normal circulation will not supply enough fresh air to prevent a buildup of CO gas;
If the CO alarm goes off or if you have symptoms of CO poisoning, exit the building and call 9-1-1.

For other questions on CO poisoning call the poison center.

TYPE OF FACILITY

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

REFERENCES

Safe Kids Worldwide. Home Safety Fact Sheet. http://www.safekids.org/fact-sheet/home-safety-fact-sheet-2015-pdf.
Cowling, T. 2007. Safety first: Carbon monoxide poisoning. Healthy Child Care 10(5): 6-7. http://www.safekids.org/safetytips/field_risks/carbon-monoxide.
U.S. Consumer Product Safety Commission (CPSC). 2008. Carbon monoxide questions and answers. Document #466. Bethesda, MD: CPSC. https://www.cpsc.gov/safety-education/safety-guides/home/asbestos-home.
Tremblay, K. R., Jr. 2006. Preventing carbon monoxide problems. Colorado State University Extension. http://www.ext.colostate.edu/pubs/consumer/09939.html.

Standard 5.2.9.6: Preventing Exposure to Asbestos or Other Friable Materials

Any asbestos, fiberglass, or other friable material or any material that is in a dangerous condition found within a facility or on the grounds of the facility should be repaired or removed. Repair usually involves either sealing (encapsulating) or covering asbestos material. Any repair or removal of asbestos should be done by a contractor certified to do in accordance with existing regulations of the U.S. Environmental Protection Agency (EPA). No children or staff should be present until the removal and cleanup of the hazardous condition have been completed.

Pipe and boiler insulation should be sampled and examined in an accredited laboratory for the presence of asbestos in a friable or potentially dangerous condition.

Non-friable asbestos should be identified to prevent disturbance and/or exposure during remodeling or future activities.

RATIONALE

Removal of significant hazards will protect the staff, children, and families who use the facility. Asbestos dust and fibers that are inhaled and reach the lungs can cause lung disease (1,2).

COMMENTS

The mere presence of asbestos in a child care facility, home, or a building is not hazardous. The danger is that asbestos materials may become damaged over time. Damaged asbestos may release asbestos fibers and become a health hazard (2,3). The best thing to do with asbestos material that is in good condition is to leave it alone. Disturbing it may create a health hazard where none existed before (1).

Asbestos that is in a friable condition means that it is easily crumbled (2).

The National Asbestos School Hazard Abatement Act of 1984 specifies requirements for removal of asbestos. Contact your local health department for additional information on asbestos regulations in your area. For more information regarding asbestos and applicable EPA regulations, contact regional offices of the EPA.

TYPE OF FACILITY

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

REFERENCES

U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry. 2001. Toxicological profile for asbestos. http://www.atsdr.cdc.gov/ToxProfiles/tp61-p.pdf.
U.S. Consumer Product Safety Commission (CPSC). Asbestos in the home. http://www.cpsc.gov/cpscpub/pubs/453.html.
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.

Standard 5.3.1.1: Indoor and Outdoor Equipment, Materials, and Furnishing

Standard was last updated on September 13, 2022.

Early care and education programs should make sure that equipment, materials, and furnishings, accessible to children both indoors and outdoors, are sturdy, in good condition, safe to use, and used only as intended by the manufacturer. The equipment, materials, and furnishings in the program should meet the safety recommendations of the U.S. Consumer Product Safety Commission and ASTM International.

Program leadership and staff should:

Prevent children from accessing equipment, materials, and furnishings that are unsafe, such as items that
- Are known to be hazardous (e.g., infant walkers, inclined sleepers, trampolines)
- Are not developmentally appropriate for a child’s age or size (e.g., intended for older children)
- Are raised above the ground or floor (e.g., playground platforms, step stools) and have neither guardrails nor protective barriers
- Have sharp corners or points
- Have openings that could entrap a child’s body parts (e.g., head or fingers)
- Have small parts that may detach and be choking, breathing or swallowing hazards
- Can pinch, sheer, or crush body parts
Remove or make tip-over hazards secure, including
- Unstable furnishings or unsecured equipment (e.g., bookshelves, dressers, televisions, indoor climbing equipment)
- Playground equipment that is loosely anchored to the ground
Remove tripping hazards (e.g., rugs, electrical extension cords).
Remove strangulation hazards (e.g., cords, straps, strings), or make them secure or inaccessible to children.
Remove or repair equipment, materials, and furnishings that are worn, damaged, or in poor condition, such as items with
- Loose, rusty, or cracked parts
- Rotted or split wood or plastic pieces that can cause splinters or other injuries
- Protruding nails, bolts, or other components that could cause injury
- Missing or damaged protective caps or plugs
- Flaking paint or paint that may have lead or other hazardous materials
Prevent children from playing with or on
- Outdoor equipment, materials, and furnishings that are too hot or cold to use
- Equipment that is spaced too closely together for safety
- Climbing equipment or swings installed on surfaces that cannot absorb the impact of a fall
Inspect newly acquired equipment and furnishings carefully to decide if they meet this standard before allowing children to use the items.
Check that the U.S. Consumer Product Safety Commission (CPSC) for safety hazards has not recalled toys and equipment (see Standard 5.3.1.2: Product Recall Monitoring) by
- Reading the CPSC recall list regularly, and/or subscribing to an email notification list from the CPSC.

RATIONALE

Young children in early care and education programs are at risk for unintentional injuries indoors and outdoors. Awareness of potential hazards and proper choice, use, and maintenance of equipment, materials, and furnishings can help prevent injuries. The CPSC collaborates with ASTM International, an international organization that develops and communicates technical standards, in determining safety and testing standards for many products for children.¹ This standard lists hazards often associated with injury and death by CPSC.^2,3,4

Equipment and furnishings that are not sturdy, safe, or in good condition may cause falls, trap a child’s head or limbs, or contribute to other injuries.^2,3,4 Regardless of their condition, some types of equipment are simply dangerous to use in early care and education programs (e.g., baby walkers, trampolines, inclined sleepers).^5.6 Others are dangerous when used in ways the manufacturer did not intend or when directions are not followed (e.g., not buckling safety belts, using infant bouncers or car seats for napping).^7,8 Although emergency department visits due to tip-overs of televisions and furniture declined in recent years, tip-overs are still an important risk for injury of children younger than 6.⁹

Playground equipment and materials have many potential hazards.¹⁰More than a third of emergency visits for playground injuries involve pre-school children.¹¹ Falls from climbing structures cause the most serious injuries in early care and education programs.^11,12However, knowing the surface temperature of outdoor playground equipment (metal and plastic) is also important to make sure children are playing safely. Staff should also pay attention to the temperature of other materials or furnishings (e.g., slides, steps, railings, metal picnic tables). Metal and other surfaces exposed to sun can quickly reach high temperatures that can burn a child’s skin in seconds.³ (See Burn Safety Awareness on Playgrounds, a CPSC factsheet about preventing thermal burns.¹³)

Young children’s intake of lead dust and particles from artificial turf, playground surfaces, and lead-based paint on older playground equipment and furnishings is very hazardous to their health and development.¹⁴(See Standard 5.2.9.13: Testing for and Remediating Lead Hazards.. Directors and program staff need to pay attention to the safety and condition of new and existing equipment, materials, and furnishings to remove or fix potential hazards.

COMMENTS

For more information on specific requirements and safety considerations for many types of equipment, materials, and furnishings (e.g., infant equipment, playground surfaces, and inspections), see the Related Standards below. The CCHP Health and Safety Checklist,¹⁵a CFOC-based resource from the California Childcare Health program, has sections on indoor and outdoor equipment and furnishings that may help programs assess hazards in this standard and related standards. Child care health consultants or other appropriately trained staff can help find resources to review the safety of equipment, materials, and furnishings in programs.

The National Program for Playground Safety (NPPS) at the University of Northern Iowa offers the Playground Safety Report Card.¹⁰ The tool is useful to assess the safety of playground equipment and what to correct or improve.¹⁰

For more information on lead hazards, visit the Environmental Protection Agency (EPA) Web page, Protect Your Family from Sources of Lead.¹⁶Also see Standard 5.2.9.13: Testing for and Remediating Lead Hazards and Standard 5.2.9.15: Building Construction and Renovation Safety. Home-based early care and education programs may refer to The Lead-Safe Toolkit for Home-Based Child Care.¹⁷

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.9.13 Testing for and Remediating Lead Hazards
6.1.0.4 Elevated Play Areas
3.4.6.1 Strangulation Hazards
5.1.5.4 Guards at Stairway Access Openings
5.1.6.6 Guardrails and Protective Barriers
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition
4.5.0.2 Tableware and Feeding Utensils
5.1.1.4 Accessibility of Facility
5.1.3.5 Finger-Pinch Protection Devices
5.1.5.1 Balusters
5.2.9.15 Construction and Remodeling
5.3.1.2 Product Recall Monitoring
5.3.1.3 Size of Furniture
5.3.1.5 Placement of Equipment and Furnishings
5.3.1.6 Floors, Walls, and Ceilings
5.3.1.8 High Chair Requirements
5.3.1.9 Carriage, Stroller, Gate, Enclosure, and Play Yard Requirements
5.3.1.10 Restrictive Infant Equipment Requirements
5.3.1.11 Exercise Equipment
5.3.1.12 Availability and Use of a Telephone or Wireless Communication Device
5.3.2.1 Therapeutic and Recreational Equipment
5.3.2.2 Special Adaptive Equipment
5.3.2.3 Storage for Adaptive Equipment
5.3.2.4 Orthotic and Prosthetic Devices
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.5 Bunk Beds
5.7.0.1 Maintenance of Exterior Surfaces
9.2.6.1 Policy on Use and Maintenance of Play Areas
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

REFERENCES

Earls A. The CPSC and ASTM Collaboration: the consensus process plays a growing role in ensuring child-safe products. Standardization News. 2011;January/February. Accessed May 2, 2022. https://sn.astm.org/?q=features/cpsc-and-astm-collaboration-jf11.html
California Childcare Health Program. CCHP health and safety checklist. University of California San Francisco Web site. Updated July 2020. Accessed April 18, 2022. https://cchp.ucsf.edu/content/cchp-health-and-safety-checklist
Council on Environmental Health. Prevention of childhood lead toxicity. Pediatrics. 2016;138(1):e20161493. doi:10.1542/peds.2016-1493
Consumer Product Safety Commission. CPSC Fact Sheet: Burn Safety Awareness on Playgrounds. U.S. Consumer Product Safety Commission Publication 3200 042012. Published April 2012. Accessed May 2, 2022. https://www.cpsc.gov/s3fs-public/3200.pdf
Hashikawa AN, Newton MF, Cunningham RM, Stevens MW. Unintentional injuries in child care centers in the United States: a systematic review. J Child Health Care. 2015;19(1):93-105. doi:10.1177/1367493513501020
Nabavizadeh B, Hakam N, Holler JT, et al. Epidemiology of child playground equipment-related injuries in the USA: emergency department visits, 1995-2019. J Paediatr Child Health. 2022;58(1):69-76. doi:10.1111/jpc.15644
National Program for Playground Safety. Safety Report Card. National Program for Playground Safety Web site. Published 2004. Accessed April 18, 2022. https://playgroundsafety.org/sites/default/files/2020-08/blank-report-card.pdf
U.S. Environmental Protection Agency. Protect your family from sources of lead: soil, yards and playgrounds. U.S. Environmental Protection Agency Web site. Accessed April 18, 2022. https://www.epa.gov/lead/protect-your-family-sources-lead#soil
Lu C, Badeti J, Mehan TJ, Zhu M, Smith GA. Furniture and television tip-over injuries to children treated in United States emergency departments. Inj Epidemiol. 2021;8(1):53. Published 2021 Aug 27. doi:10.1186/s40621-021-00346-6
Liaw P, Moon RY, Han A, Colvin JD. Infant deaths in sitting devices. Pediatrics. 2019;144(1):e20182576. doi:10.1542/peds.2018-2576
Smith GA. Injuries to children in the United States related to trampolines, 1990-1995: a national epidemic. Pediatrics. 1998;101(3 Pt 1):406-412. doi:10.1542/peds.101.3.406
Sims A, Chounthirath T, Yang J, Hodges NL, Smith GA. Infant walker-related injuries in the United States. Pediatrics. 2018;142(4):e20174332. doi:10.1542/peds.2017-4332
O’Brien C. Injuries and investigated deaths associated with playground equipment, 2001–2008. U.S. Consumer Product Safety Commission. Published October 29, 2009. Accessed April 18, 2022. https://www.cpsc.gov/s3fs-public/pdfs/playground.pdf
U.S. Consumer Product Safety Commission. Public playground safety handbook. U.S. Consumer Product Safety Commission Web site. Published December 2015. Accessed April 18, 2022. https://www.cpsc.gov/s3fs-public/325.pdf
U.S. Consumer Product Safety Commission. Toys & children products: injury statistics. National Electronic Injury Surveillance System (NEISS). U.S. Consumer Product Safety Commission Web site. Published December 13, 2021. Accessed April 18. 2022. https://www.cpsc.gov/Research--Statistics/Toys-and-Childrens-Products
Chaudhary S, Figueroa J, Shaikh S, et al. Pediatric falls ages 0-4: understanding demographics, mechanisms, and injury severities. Inj Epidemiol. 2018;5(Suppl 1):7. Published 2018 Apr 10. doi:10.1186/s40621-018-0147-x
Children’s Environmental Health Network, National Center for Healthy Housing, and National Association for Family Child Care. Lead-safe toolkit for home-based child care. National Center for Health Housing Web site. Published 2019. Accessed April 18, 2022. https://nchh.org/tools-and-data/technical-assistance/protecting-children-from-lead-exposures-in-child-care/hbcc-toolkit/

NOTES

Standard was last updated on September 13, 2022.

Standard 5.3.1.3: Size of Furniture

Furniture should be durable and child-sized or adapted for children’s use. Tables should be between waist and mid-chest level of the intended child-user and allow the child’s feet to rest on a firm surface while seated for eating.

RATIONALE

Children cannot safely or comfortably use furnishings that are not sized for their use. When children eat or work at tables that are above mid-chest level, they must reach up to get their food or do their work instead of bringing the food from a lower level to their mouth and having a comfortable arrangement when working to develop their fine-motor skills. When eating, this leads to scooping food into the mouth instead of eating more appropriately. When working, this leads to difficulty succeeding with hand-eye coordination. When children do not have a firm surface on which to rest their feet, they cannot reposition themselves easily if they slip down. This can lead to poor posture and increased risk of choking. When children use chairs that are too high for them, they are at risk for falling.

TYPE OF FACILITY

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

Standard 5.3.1.4: Surfaces of Equipment, Furniture, Toys, and Play Materials

Frequently Asked Questions/CFOC Clarifications

Reference: 5.3.1.4

Date: 10/13/2011

Topic & Location:
Chapter 5
Facilities
Standard 5.3.1.4: Surfaces of Equipment, Furniture, Toys, and Play Materials

Question:
Do all pressed wood items contain formaldehyde?

Answer:
All pressed wood items do not contain added formaldehyde; however, all wood naturally contains some formaldehyde. Pressed wood products that have the highest formaldehyde emissions are those that are made with urea-formaldehyde resins. Products designed for interior use, such as hardwood plywood, medium density fiberboard, and particleboard, are more likely to contain urea-formaldehyde than those designed for exterior use such as oriented strand board or structural plywood. However, hardwood plywood, medium density fiberboard, and particleboard don't necessarily contain added formaldehyde; they are sometimes made with no added formaldehyde based resins. Many companies are choosing to make products with no added formaldehyde (NAF) based resins as well as ultra low-emitting formaldehyde (ULEF) based resins both to market their products as green and to comply with California regulations on composite wood products. Some products are currently labeled as made with NAF or ULEF resins under the California regulations, and once EPA regulations are proposed and go into effect, more products will be labeled to inform consumers about formaldehyde content.

Equipment, furnishings, toys, and play materials should have smooth, nonporous surfaces or washable fabric surfaces that are easy to clean and sanitize, or be disposable.

Walls, ceilings, floors, furnishings, equipment, and other surfaces should be suitable to the location and the users. They should be maintained in good repair, free from visible soil and in a clean condition. Programs should choose materials with the least probability of containing materials that off-gas toxic elements such as volatile organic compounds (VOCs), formaldehyde, or toxic flame retardants (polybrominated diphenylethers [PBDE]). Carpets, porous fabrics, and other surfaces that trap soil and potentially contaminated materials should not be used in toilet rooms, diaper change areas, and areas where food handling occurs (1).

Areas used by staff or children who have allergies to dust mites or components of furnishings or supplies should be maintained according to the recommendations of primary care providers.

RATIONALE

Few young children practice good hygiene. Messy play is developmentally appropriate in all age groups, and especially among very young children, the same group that is most susceptible to infectious disease. These factors lead to soiling and contamination of equipment, furnishings, toys, and play materials. To avoid transmission of disease within the group, these materials must be easy to clean and sanitize.

Formaldehyde and toxic flame retardants are the toxins of most concern in household furnishings, as they are both commonly found in furniture and carpets. Formaldehyde is a flammable, colorless gas that has a pungent odor. It is a human carcinogen, an asthma trigger, and a suspected neurological, reproductive, and liver toxin. People are exposed by breathing contaminated air from pressed wood furniture, flooring, and after application of certain paints, fabrics, and household cleaners. Toxic Flame Retardants (PBDEs) are widely used in furniture foam, carpet padding, back coatings for draperies and upholstery, plastics, building materials, and electrical appliances. It is believed that more than 80% of PBDE exposure is from house dust. PBDEs persist in the environment and accumulate in living things. Health concerns associated with PBDE exposure include liver, thyroid, and neurodevelopmental toxicity.

Carpets and porous fabrics are not appropriate for some areas because they are difficult to clean and sanitize. Disease-causing microorganisms have been isolated from carpets. Caregivers/teachers must remove illness-causing materials. Many allergic children have allergies to dust mites, which are microscopic insects that ingest the tiny particles of skin that people shed normally every day. Dust mites live in carpeting and fabric but can be killed by frequent washing and use of a clothes dryer or mechanical, heated dryer. Restricting the use of carpeting and furnishings to types that can be laundered regularly helps. Other children may have allergies to animal products such as those with feathers, fur, or wool, while some may be allergic to latex.

COMMENTS

Toys that can be washed in a mechanical dishwasher that meets the standard for cleaning and sanitizing dishes can save labor, if the facility has a dishwasher. Otherwise, after the children have used them, these toys can be placed in a tub of detergent water to soak until the staff has time to scrub, rinse, and sanitize the surfaces of these items. Except for fabric surfaces, nonporous surfaces are best because porous surfaces can trap organic material and soil. Fabric surfaces that can be laundered provide the softness required in a developmentally appropriate environment for young children. If these fabrics are laundered when soiled, the facility can achieve cleanliness and sanitation. When a material cannot be cleaned and sanitized it should be discarded.

One way to measure compliance with the standard for cleanliness is to wipe the surface with a clean mop or clean rag, and then insert the mop or rag in cold rinse water. If the surface is clean, no residue will appear in the rinse water.

Disposable gloves are commonly made of latex or vinyl. If latex-sensitive individuals are present in the facility, only vinyl or nitrile disposable gloves should be used.

Tips for Reducing Exposure to Formaldehyde and PBDEs:

Avoid wall-to-wall carpets;
Limit use of pressed wood products that are made with adhesives that contain urea-formaldehyde (UF) resins; choose solid-wood furniture;
Do not leave foam exposed (this includes furniture and toys, such as stuffed animals);
Keep dust levels down;
Vacuum often – use a high efficiency particulate air (HEPA) filter vacuum cleaner;
Ventilate while cleaning;
Except in emergency situations, remove shoes prior to going indoors;
Clean area rugs with biodegradable cleaners;
Choose floor coverings that are made with natural fibers (cotton, hemp, and wool) that are naturally fire-resistant and contain fewer chemicals (2).

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.9.15 Construction and Remodeling

REFERENCES

Eco-Healthy Child Care (EHCC). Furniture and carpets. Washington, DC: EHCC. http://www.oeconline.org/resources/publications/factsheetarchive/Furniture and carpets.pdf.
U.S. Environmental Protection Agency. Polybrominated diphenylethers (PBDEs). http://www.epa.gov/oppt/pbde/.

Standard 5.3.1.7: Facility Arrangements to Minimize Back Injuries

The child care setting should be organized to reduce the risk of back injuries for adults provided that such measures do not pose hazards for children or affect the implementation of developmentally appropriate practice. Furnishings and equipment should enable caregivers/teachers to hold and comfort children and enable their activities while minimizing the need for bending and for lifting and carrying heavy children and objects. Caregivers/teachers should not routinely be required to use child-sized chairs, tables, or desks.

RATIONALE

Back strain can arise from adult use of child-sized furniture. Analysis of worker compensation claims shows that employees in the service industries, including child care, have an injury rate as great as or greater than that of workers employed in factories. Back injuries are the leading type of injury (1). Appropriate design of work activities and training of workers can prevent most back injuries. The principles to support these recommendations (see Comments) are standard principles of ergonomics, in which jobs and workplaces are designed to eliminate biomechanical hazards.

In a statewide (Wisconsin) survey of health status, behaviors, and concerns, 446 randomly selected early childhood professionals, directors, center teachers, and family providers, reported dramatic changes in frequency of backache and fatigue symptoms since working in child care (2).

COMMENTS

Some approaches to reduce risk are:

Adult-height changing tables;
Small, stable stepladders, stairs, and similar equipment to enable children to climb to the changing table or other places to which they would otherwise be lifted, without creating a fall hazard;
Convenient equipment for moving children, reducing the necessity of carrying them;
Adult furniture that eliminates awkward sitting or working positions in all areas where adults work.

This standard is not intended to interfere with child-adult interactions or to create hazards for children. Modifications can be made in the environment to minimize hazards and injuries for both children and adults. Adult furniture has to be available at least for break times, staff meetings, etc.

TYPE OF FACILITY

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

RELATED STANDARDS

1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization
1.7.0.2 Daily Staff Health Check
1.7.0.3 Staff Health Guidelines for Return to Work
1.7.0.4 On-Site Occupational Hazards
1.7.0.5 Stress Management for Staff

REFERENCES

Grantz, R. R., A. Claffey. 1996. Adult health in child care: Health status, behaviors, and concerns of teachers, directors, and family child care providers. Early Child Res Q. 11:243-67.
Brown, M. Z., S. G. Gerberich. 1993. Disabling injuries to childcare workers in Minnesota, 1985 to 1990: An analysis of potential risk factors. J Occup Med 1993 35:1236-43.

Standard 5.4.1.6: Ratios of Toilets, Urinals, and Hand Sinks to Children

Toilets and hand sinks should be easily accessible to children and facilitate adult supervision. The number of toilets and hand sinks should be subject to the following minimums:

Toddlers:
1. If each group size is less than ten children, provide one sink and one toilet per group.
Preschool-age children:
1. If each group size is less than ten children, provide one sink and one toilet per group;
2. If each group size is between ten to sixteen children, provide two sinks and two flush toilets for each group.
School-age children:
1. If each group size is less than ten children, provide one sink and one toilet per group;
2. If each group size is between ten to twenty children, provide two sinks and two toilets per group. Provide separation of male and female toilets.

For toddlers and preschoolers, the maximum toilet height should be eleven inches, and maximum height for hand sinks should be twenty-two inches. Urinals should not exceed 30% of the total required toilet fixtures and should be used by one child at a time. For school-age children, standard height toilet, urinal, and hand sink fixtures are appropriate.

Non-flushing equipment in toilet learning/training should not be counted as toilets in the toilet:child ratio.

RATIONALE

The environment can become contaminated more easily with multiple simultaneous users of urinals, because at least one of the children must assume an off-center position in relationship to the fixture during voiding.

Young children use the toilet frequently and cannot wait long when they have to use the toilet. The ratio of 1:10 is based on best professional experience of early childhood educators who are facility operators (1). This ratio also limits the group that will be sharing facilities (and infections).

COMMENTS

The ratios of toilets and hand sinks to children provided above takes into consideration the maximum group size specified under Standard 1.1.1.2. Local building codes also dictate toilet and sink requirements based on number of children utilizing them.

State licensing regulations have often applied a ratio of 1:10 for toddlers and preschool children, and 1:15 for school-age children. The ratios used in this standard correspond to the maximum group sizes for each age group specified in Standard 1.1.1.2.

A ratio of one toilet to every ten children may not be sufficient if only one toilet is accessible to each group of ten, so a minimum of two toilets per group is preferable when the group size approaches ten. However, a large toilet room with many toilets used by several groups is less desirable than several small toilet rooms assigned to specific groups, because of the opportunities such a large room offers for transmitting infectious disease agents.

When providing bathroom fixtures for a mixed group of preschool and school-age children, requiring a school-age child to use bathroom fixtures designed for preschoolers may negatively impact the self-esteem of the school-age child.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.2 Ratios for Large Family Child Care Homes and Centers

REFERENCES

Olds, A. R. 2001. Child care design guide. New York: McGraw-Hill.

Standard 5.4.1.7: Toilet Learning and Training Equipment

Content in the standard was modified on 12/20/2022.

Children who are learning to use the toilet should have the right training equipment. Programs should use child-sized toilets; or safe step aids that can be cleaned, and modified toilet seats (for adult-sized toilets). Children should use this equipment only with direct supervision. Staff should clean and disinfect soiled toilets immediately and at the end of each day. Non-flushing toilets (i.e., potty chairs) are strongly discouraged.

Children with special health care needs may need other training equipment, accommodations, and learning strategies to be successful during toilet training. Early care and education programs should be sensitive to each child’s special needs (i.e., sensory, regulatory, developmental, physical accommodations, etc.).

RATIONALE

Child-sized toilets that are flushable, step aids that can be cleaned, and modified toilet seats are easier to use and clean. Flushable toilets are better than any type of equipment that exposes the staff to contact with feces or urine. Many infectious diseases can be prevented with proper hygiene and disinfection.¹ Research surveys of surfaces in early care and education settings have shown presence of fecal contamination. Fecal contamination has been used to measure the degree of effectiveness in cleaning and disinfecting procedures. Sanitary touching and cleaning of potty chairs is difficult and therefore not recommended.

When early care and education programs think about children with special health care needs by having the proper support and resources, children can overcome any challenges they might face and be successful in toilet training.²

COMMENTS

ADDITIONAL RESOURCES

American Academy of Pediatrics. Virtual Early Education Center. https://veec.aap.org/index.html

Child Care Resource and Referral Network. Supporting the Development of Toileting Skills in Children with Special Needs. https://childcareanswers.org/resources/toileting-the-exceptional-child/

TYPE OF FACILITY

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

REFERENCES

Minnesota Department of Health. Ways to prevent diarrheal illness from spreading at child care and preschool. https://www.health.state.mn.us/diseases/foodborne/daycarepre.html. Accessed September 19, 2022
Child Care Resource and Referral Network. Toileting supports for children with special needs. https://childcareanswers.org/wp-content/uploads/2021/06/Toileting-Special-Needs-Network.pdf. Accessed September 19, 2022

NOTES

Content in the standard was modified on 12/20/2022.

Standard 5.4.2.1: Diaper Changing Tables

Content in the standard was modified on 12/20/2022.

Early care and education programs should have at least one diaper changing table per infant group or toddler group. Diaper changing stations should follow the Safety Standard for Baby Changing Products within 16 CFR Part 1235 (effective June 26, 2019), and American Society for Testing and Materials’ (ASTM) F2388-21 Standard Consumer Safety Specification for Baby Changing Products for Domestic Use.¹

Also, program staff should:

Be properly trained on diaper changing procedures and proper cleaning and disinfecting of diapering surfaces. They should clean and disinfect surfaces after each use.
Allow enough time for changing diapers.
Not allow more than one group or cohort of children to share diaper changing tables and sinks.
Not place the diaper changing tables and sinks between two classrooms.
Only use the diaper changing table for changing diapers.

Diaper changing tables should be high enough for staff to use comfortably without bending over, and for older toddlers to use stairs if necessary . Staff should actively supervise children during diaper changing.

RATIONALE

Diaper changing takes time, as does cleaning and disinfecting diaper-changing surfaces. Early care and education programs that follow proper diapering and hand hygiene practices decrease illnesses among children and staff.² Also, when program staff from different groups use the same diaper changing surface without proper cleaning and disinfecting of surfaces, illnesses may spread more easily among children.

Following the Safety Standard for Baby Changing Products decreases injuries to children from normal use as well as misuse or abuse of diaper changing tables. Specifically, it decreases injuries and deaths of children from falling from changing tables, structural or mechanical failure, instability, getting trapped in openings in the table, and suffocation.¹

COMMENTS

ADDITIONAL RESOURCES

American Academy of Pediatrics. Virtual Early Education Center. https://veec.aap.org/index.html

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
3.2.1.3 Checking For the Need to Change Diapers
3.2.1.4 Diaper Changing Procedure
3.2.2.1 Situations that Require Hand Hygiene
5.2.7.4 Containment of Soiled Diapers
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.2.5 Changing Table Requirements
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

U.S. Consumer Safety Product Commission. Baby changing products business guidance and small entity compliance guide. CPSC.gov Web site. https://www.cpsc.gov/Business--Manufacturing/Business-Education/Business-Guidance/Baby-Changing-Products-Business-Guidance-and-Small-Entity-Compliance-Guide. Accessed September 19, 2022
Collins JP, Shane AL. Infections associated with group childcare. Principles and Practice of Pediatric Infectious Diseases. 2018:25–32.e3. doi: 12 16/B978-0-323-40181-4.00003-7. Epub 2017 Jul 18. PMCID: PMC7152033. Accessed August 3, 2022

NOTES

Content in the standard was modified on 12/20/2022.

Standard 5.4.2.4: Use, Location, and Setup of Diaper Changing Areas

Infants and toddlers should be diapered only in the diaper changing area. Children should be discouraged from remaining in or entering the diaper changing area. The contaminated surfaces of waste containers should not be accessible to children.

Diaper changing areas and food preparation areas should be physically separated. Diaper changing should not be conducted in food preparation areas or on surfaces used for other purposes. Food and drinking utensils should not be washed in sinks located in diaper changing areas.

The diaper changing area should be set up so that no other surface or supply container is contaminated during diaper changing. Bulk supplies should not be stored on or brought to the diaper changing surface. Instead, the diapers, wipes, gloves, a thick layer of diaper cream on a piece of disposable paper, a plastic bag for soiled clothes, and disposable paper to cover the table in the amount needed for a specific diaper change will be removed from the bulk container or storage location and placed on or near the diaper changing surface before bringing the child to the diaper changing area.

Conveniently located, washable, plastic-lined, tightly covered, hands-free receptacles, should be provided for soiled cloths and linen containing body fluids.

Where only one staff member is available to supervise a group of children, the diaper changing table should be positioned to allow the staff member to maintain constant sight and sound supervision of children.

RATIONALE

The use of a separate area for diaper changing or changing of soiled underwear reduces contamination of other parts of the child care environment (1-2). Children cannot be expected to avoid contact with contaminated surfaces in the diaper changing area. They should be in this area only for diaper changing and be protected as much as possible from contact with contaminated surfaces. The separation of diaper changing areas and food preparation areas prevents transmission of disease. Using diaper changing surfaces for any other purpose increases the likelihood of contamination and spreading of infectious disease agents.

Bringing storage containers for bulk supplies to the diaper changing table is likely to result in their contamination during the diaper changing process. When these containers stay on the table or are replaced in a storage location, they become conduits for transmitting disease agents. Bringing to the table only the amount of each supply that will be consumed in that specific diaper changing will prevent contamination of diapering supplies and the environment.

Hands-free receptacles prevent environmental contamination so the children do not come into contact with disease-bearing body fluids.

Often, only one staff person is supervising children when a child has to be changed. Orienting the diaper changing table so the staff member can maintain direct observation of all children in the room allows adequate supervision.

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
5.2.7.4 Containment of Soiled Diapers
5.4.2.5 Changing Table Requirements

REFERENCES

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.
Aronson, S. S. 1999. The ideal diaper changing station. Child Care Information Exchange 130:92.

Standard 5.4.2.5: Changing Table Requirements

Changing tables should meet the following requirements:

Have impervious, nonabsorbent, smooth surfaces that do not trap soil and are easily disinfected;
Be sturdy and stable to prevent tipping over;
Be at a convenient height for use by caregivers/teachers (between twenty-eight and thirty-two inches high);
Be equipped with railings or barriers that extend at least six inches above the change surface.

RATIONALE

This standard is designed to prevent disease transmission and falls and to provide safety measures during diapering. Commercial diaper change tables vary as much as ten inches in height. Many standard-height thirty-six inch counters are used as the diaper change area. When a railing or barrier is attached, shorter staff members cannot change diapers without standing on a step.

Back injury is a common occupational injury for caregivers/teachers (3,5). Using changing tables that are sized for caregiver/teacher comfort and convenience can help prevent back injury (1,3-4). Railings of two inches or less in height have been observed in some diaper change areas and when combined with a moisture-impervious diaper changing pad approximately one inch thick, render the railing ineffective. A change table height of twenty-eight inches to thirty-two inches (standard table height) plus a six-inch barrier will reduce back strain on staff members and provide a safe barrier to prevent children from falling off the changing table.

Data from the U.S. Consumer Product Safety Commission (CPSC) show that falls are a serious hazard associated with infant changing tables (2). Safety straps on changing tables are provided to prevent falls but they trap soil and they are not easily disinfected. Therefore, diaper changing tables should not have safety straps.

COMMENTS

An impervious surface is defined as a smooth surface that does not absorb liquid or retain soil. While changing a child, the adult must hold onto the child at all times.

The activity of diaper changing presents an opportunity for adult interaction with the child whose diaper is being changed.

TYPE OF FACILITY

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

REFERENCES

Gratz, R., A. Claffey, P. King, G. Scheuer. 2002. The physical demands and ergonomics of working with young children. Early Child Devel Care 172:531-37.
ASTM International. 2008. ASTM F2388-08. Baby changing tables for domestic use. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 1997. The safe nursery. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/202.pdf.
Aronson, S. S. 1999. The ideal diaper changing station. Child Care Info Exch 130:92.
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.

Standard 5.4.1.10: Handwashing Sinks

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

A handwashing sink should be accessible without barriers (such as doors) to each child care area. In areas for toddlers and preschoolers, the sink should be located so the caregiver/teacher can visually supervise the group of children washing their hands. Sinks should be placed at the child’s height or be equipped with a stable step platform to make the sink available to children. If a platform is used, it should have slip-proof steps and platform surface. In addition, each sink should be equipped so that the user has access to:

Clean, running water (1);
A foot-pedal operated, electric-eye operated, open, self-closing, slow-closing, or metering faucet that provides a flow of water for at least thirty seconds without the need to reactivate the faucet;
A supply of hand-cleansing non-antibacterial, unscented liquid soap;
Disposable single-use cloth or paper towels or a heated-air hand-drying device with heat guards to prevent contact with surfaces that get hotter than 120°F.

A steam tap or a water tap that provides water that is hotter than 120°F may not be used at a handwashing sink.

RATIONALE

Transmission of many infectious diseases can be prevented through handwashing (1). To facilitate routine handwashing at the many appropriate times, sinks must be close at hand and permit caregivers/teachers to provide continuous supervision while children wash their hands. The location, access, and supporting supplies to enable adequate handwashing are important to the successful integration of this key routine. Foot-pedaled operated or electric-eye operated handwashing sinks and liquid soap dispensers are preferable because they minimize hand contamination during and after handwashing. The flow of water must continue long enough for the user to wet the skin surface, get soap, lather for at least twenty seconds, and rinse completely.

Comfortably warm water helps to release soil from hand surfaces and provides comfort for the person who is washing the hands. When the water is too cold or too hot for comfort, the person is less likely to wet and rinse long enough to lather and wash off soil. Having a steam tap or a super-heated hot water tap available at a handwashing sink poses a significant risk of scald burns.

COMMENTS

Shared access to soap and disposable towels at more than one sink is acceptable if the location of these is fully accessible to each person. There is no evidence that antibacterial soap reduces the incidence of illness among children in child care.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.2 Handwashing Procedure
3.6.2.2 Space Requirements for Care of Children Who Are Ill
4.8.0.4 Food Preparation Sinks
4.8.0.5 Handwashing Sink Separate from Food Zones
5.2.1.14 Water Heating Devices and Temperatures Allowed
5.2.6.9 Handwashing Sink Using Portable Water Supply

REFERENCES

Centers for Disease Control and Prevention (CDC). 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.

NOTES

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

Standard 5.4.1.11: Prohibited Uses of Handwashing Sinks

Handwashing sinks should not be used for rinsing soiled clothing, for cleaning equipment that is used for toileting, or for the disposal of any waste water used in cleaning the facility.

RATIONALE

The sink used to wash/rinse soiled clothing or equipment used for toileting becomes contaminated during this process and can be a source of transmission of disease to those who wash their hands in that sink (1).

TYPE OF FACILITY

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

REFERENCES

Laborde, D. J., K. A. Weigle, D. J. Weber, J. B. Kotch. 1993. Effect of fecal contamination on the diarrheal illness rates in day-care centers. Am J Epidemiol 138:243-55.

Standard 5.4.2.2: Handwashing Sinks for Diaper Changing Areas in Centers

Handwashing sinks in centers should be provided within arm’s reach of the caregiver/teacher to diaper changing tables and toilets. A minimum of one handwashing sink should be available for every two changing tables. Where infants and toddlers are in care, sinks and diaper changing tables should be assigned for use to a specific group of children and used only by children and adults who are in the assigned group as defined by Standard 5.4.2.1. Handwashing sinks should not be used for bathing or removing smeared fecal material.

RATIONALE

Sinks must be close to where the diapering takes place to avoid transfer of contaminants to other surfaces en route to washing the hands of staff and children. Having sinks close by will help prevent the spread of contaminants and disease.

When sinks are shared by multiple groups, cross-contamination occurs. Many child care centers put the diaper changing tables and sinks in a buffer zone between two classrooms, effectively joining the groups through cross-contamination.

COMMENTS

Shared access to soap and disposable towels at more than one sink is acceptable if the location of these is fully accessible to each person.

TYPE OF FACILITY

Center, Early Head Start, Head Start

RELATED STANDARDS

5.4.2.1 Diaper Changing Tables
5.4.2.4 Use, Location, and Setup of Diaper Changing Areas

REFERENCES

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.

Standard 5.4.2.3: Handwashing Sinks for Diaper Changing Areas in Homes

Handwashing sinks in large and small family child care homes should be supplied for diaper changing, as specified in Standard 5.4.2.2, except that they should be within ten feet of the changing table if the diapering area cannot be set up so the sink is adjacent to the changing table. If diapered toddlers and preschool-age children are in care, a stepstool should be available at the handwashing sink, as specified in Standard 5.4.1.10, so smaller children can stand at the sink to wash their hands. Handwashing sinks should not be used for bathing or removing smeared fecal material.

RATIONALE

When children from more than one family are in care, the diaper changing area should be arranged to be as close as possible to a non-food sink to avoid fecal-oral transmission of infection.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.2.4 Use, Location, and Setup of Diaper Changing Areas
5.4.1.10 Handwashing Sinks
5.4.2.2 Handwashing Sinks for Diaper Changing Areas in Centers

Standard 5.4.5.1: Sleeping Equipment and Supplies

Content in the STANDARD was modified on 3/31/2017 and 1/31/2023.

Programs should have a separate crib, cot, sleeping bag, bed, mat, or pad for each child who spends more than 4 hours a day in care. No child should share a crib, bed, or bedding with another child at the same time. Each child should have clean linens once a week; more often if soiled. Regardless of age group, bed linens should not be used as rest equipment in place of cots, beds, pads, or similar approved equipment. Bed linens used under children on cots, cribs, futons, and playpens should be tight-fitting. See Standard 5.4.5.2 for crib specifications.

Store each child’s pillow, blanket, sheet, and any special sleep item separately, and label it. The sleeping surfaces of one child’s rest equipment should not touch the sleeping surfaces of another child’s rest equipment in storage.

Sleeping pads or other sleep equipment should not be placed directly on a floor that is cooler than 65°F when children are resting. Cribs, cots, beds, mats, or pads that children are sleeping in or on should be at least 3 feet apart. If the room used for sleeping is too small to have 3 feet between children, it is recommended that caregivers and teachers space children as far as possible from one another, and/or alternate children head to toe. Screens to separate sleeping children are not recommended. If empty sleep equipment is used to separate children, place the equipment so that the staff can watch and have immediate access to each child.

No child should sleep on a bare, uncovered surface. Seasonally appropriate covering, such as sheets, sleeping garments, or infant sleep sacks that are sufficient to maintain adequate warmth, should be available and used by each child below school age. Caregivers and teachers may ask parents or guardians to bring in bedding that will be washed at home at least weekly, or sooner if soiled.

Toddlers and Older Children

Canvas cots are not recommended for toddlers. If toddlers and older children use pillows, pillows should have removable cases that can be laundered, assigned to a child, and used only by that child while enrolled in the program. When pads are used, they should be enclosed in washable covers and long enough, so the child’s head or feet do not rest off the pad. Mats and cots should be:

Lead-safe, BPA-free, phthalate-free, have no fire-retardant chemical, and meet all Consumer Products Safety Commission rules and regulations for foam cots^1,2
Made with a waterproof material that can be easily cleaned. Plastic bags or loose plastic material should never be used as a covering.

Infants

Infants should not use pillows, nursing pillows, blankets, and sleep positioners.^3,4 Programs should make sure that cribs, bassinets, portable cribs, or play yards used for safe sleeping meet the current U.S. Consumer Product Safety Commission (CPSC) and American Society for Testing and Materials (ASTM) safety standards and have not been recalled by the manufacturer.^5,6 Programs can read and file complaints about thousands of consumer products at https://www.saferproducts.gov/. Canvas cots are not recommended for infants.

Programs should use only sleep equipment for sleeping. Couches, futons, and armchairs are extremely dangerous for infants and should never be used for infant sleep.⁷ When infants wake up, remove them from their cribs and return them to the play area. Do not use sleep equipment in play, feeding, or diaper-changing areas.⁸ The ends of cribs are not enough to separate sleeping children.

Infant monitors with dangling cords or other electric wires should never be in the crib or sleeping equipment. Caregivers and teachers should never use strings to hang objects (mobiles, toys, diaper bags, etc.) on or near a child’s sleep area.⁹

RATIONALE

Using screens to separate sleeping children is not recommended because screens can limit supervision, can interfere with immediate access to a child, and could injure children if pushed over on them. Keep each child’s sleeping and resting surfaces away from others’ to reduce the risk of spreading disease. Solid crib ends between sleeping children can be barriers if they are 3 feet from each other.

Children freely interact and can contaminate one another while awake, but reducing the risk of spreading germs during sleep will reduce the number of germs the child is exposed to overall. Because respiratory illnesses can spread through the air¾and children don’t cover their coughs and sneezes while sleeping¾keep at least 3 feet between cots, cribs, sleeping bags, beds, mats, or pads used for resting or sleeping.

Three feet between equipment will also allow staff to get to a child in an emergency. Many caregivers and teachers find that placing children in alternating positions (i.e., one child’s head is next to the other’s feet) reduces interaction, promotes settling during rest periods, and may help reduce the spread of infections.

Sometimes children drool, spit up, or spread other body fluids on their sleeping surfaces. Using cleanable, waterproof, nonabsorbent rest equipment lets the staff wash and disinfect the sleeping surfaces that have touched body fluids. Plastic bags may not be used to cover rest and sleep surfaces or equipment because they can suffocate the child if the material clings to the child’s face.

COMMENTS

ADDITIONAL RESOURCES

American Academy of Pediatrics

Safe Sleep Campaign Toolkit. https://www.aap.org/en/news-room/campaigns-and-toolkits/safe-sleep/
Virtual Early Education Center. https://veec.aap.org/index.html

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.6.1 Strangulation Hazards
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.3.0.4 Cleaning Individual Bedding
5.4.5.2 Cribs
9.2.4.5 Emergency and Evacuation Drills Policy

REFERENCES

Ford A, Moore E, Stebbins J. Chemicals and all: the health risks posed by crib mattresses. National Center for Health Research. November 22, 2013. https://www.center4research.org/rock-bye-baby-chemicals-health-risks-posed-crib-mattresses/. Accessed September 19, 2022
Consumer Product Safety Commission. Standard for the flammability (open flame) of mattress sets; final rule. March 15, 2006. https://www.cpsc.gov/s3fs-public/pdfs/blk_media_mattsets.pdf. Accessed September 19, 2022
Consumer Product Safety Commission. CPSC warns parents not to use nursing pillows for sleep; agency is investigating infant deaths that may be associated with pillow-like products. October 7, 2020. CPSC.gov Web site. https://www.cpsc.gov/Newsroom/News-Releases/2021/CPSC-Warns-Parents-Not-to-Use-Nursing-Pillows-for-Sleep-Agency-Is-Investigating-Infant-Deaths-that-May-Be-Associated-with-Pillow-Like-Products. Accessed May 25, 2022
U.S. Food and Drug Administration. Do not use infant sleep positioners due to the risk of suffocation. FDA.gov Web site. https://www.fda.gov/consumers/consumer-updates/do-not-use-infant-sleep-positioners-due-risk-suffocation. Updated April 18, 2019. Accessed May 25, 2022
Federal Register. Safety standard for infant sleep products. FederalRegister.gov Web site. https://www.federalregister.gov/documents/2021/06/23/2021-12723/safety-standard-for-infant-sleep-products
Consumer Product Safety Commission. CPSC approves major new federal safety standard for infant sleep products. June 2, 2021. CPSC.gov Web site. https://www.cpsc.gov/Newsroom/News-Releases/2021/CPSC-Approves-Major-New-Federal-Safety-Standard-for-Infant-Sleep-Products. Accessed May 20, 2022
American Academy of Pediatrics. Tips for keeping infants safe during sleep from the American Academy of Pediatrics. February 2022. AAP.org Web site. https://www.aap.org/en/news-room/news-releases/aap/2020/tips-for-keeping-infants-safe-during-sleep-from-the-american-academy-of-pediatrics/. Accessed August 2, 2022
National Institute of Food and Agriculture. USDA. Cooperative Extension. Creating safe and appropriate napping areas in child care. August 15, 2019. https://childcare.extension.org/creating-safe-and-appropriate-napping-areas-in-child-care/. Accessed May 25, 2022
Moon RY, Carlin RF, Hand I, The Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. Sleep-related infant deaths: updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics. 2022; e2022057990. 10.1542/peds.2022-057990

NOTES

Content in the STANDARD was modified on 3/31/2017 and 1/31/2023.

Standard 5.4.5.2: Cribs

Facilities should check each crib before its purchase and use to ensure that it is in compliance with the current U.S. Consumer Product Safety Commission (CPSC) and ASTM safety standards.

Recalled or “second-hand” cribs should not be used or stored in the facility. When it is determined that a crib is no longer safe for use in the facility, it should be dismantled and disposed of appropriately.

Staff should only use cribs for sleep purposes and should ensure that each crib is a safe sleep environment. No child of any age should be placed in a crib for a time-out or for disciplinary reasons. When an infant becomes large enough or mobile enough to reach crib latches or potentially climb out of a crib, they should be transitioned to a different sleeping environment (such as a cot or sleeping mat).

Each crib should be identified by brand, type, and/or product number and relevant product information should be kept on file (with the same identification information) as long as the crib is used or stored in the facility.

Staff should inspect each crib before each use to ensure that hardware is tightened and that there are not any safety hazards. If a screw or bolt cannot be tightened securely, or there are missing or broken screws, bolts, or mattress support hangers, the crib should not be used.

Safety standards document that cribs used in facilities should be made of wood, metal, or plastic. Crib slats should be spaced no more than two and three-eighths inches apart, with a firm mattress that is fitted so that no more than two fingers can fit between the mattress and the crib side in the lowest position. The minimum height from the top of the mattress to the top of the crib rail should be twenty inches in the highest position. Cribs with drop sides should not be used. The crib should not have corner post extensions (over one-sixteenth inch). The crib should have no cutout openings in the head board or footboard structure in which a child’s head could become entrapped. The mattress support system should not be easily dislodged from any point of the crib by an upward force from underneath the crib. All cribs should meet the ASTM F1169-10a Standard Consumer Safety Specification for Full-Size Baby Cribs, F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards, or the CPSC 16 CFR 1219, 1220, and 1500 – Safety Standards for Full-Size Baby Cribs and Non-Full-Size Baby Cribs; Final Rule.

Cribs should be placed away from window blinds or draperies.

As soon as a child can stand up, the mattress should be adjusted to its lowest position. Once a child can climb out of his/her crib, the child should be moved to a bed. Children should never be kept in their crib by placing, tying, or wedging various fabric, mesh, or other strong coverings over the top of the crib.

Cribs intended for evacuation purpose should be of a design and have wheels that are suitable for carrying up to five non-ambulatory children less than two years of age to a designated evacuation area. This crib should be used for evacuation in the event of fire or other emergency. The crib should be easily moveable and should be able to fit through the designated fire exit.

RATIONALE

Standards have been developed to define crib safety, and staff should make sure that cribs used in the facility meet these standards to protect children and prevent injuries or death (1-3). Significant changes to the ATSM and CPSC standards for cribs were published in December 2010. As of June 28, 2011 all cribs being manufactured, sold or leased must meet the new stringent requirements. Effective December 28, 2012 all cribs being used in early care and education facilities including family child care homes must also meet these standards. For the most current information about these new standards please go to http://www.cpsc.gov/info/cribs/index.html.

More infants die every year in incidents involving cribs than with any other nursery product (4). Children have become trapped or have strangled because their head or neck became caught in a gap between slats that was too wide or between the mattress and crib side.

An infant can suffocate if its head or body becomes wedged between the mattress and the crib sides (6).

Corner posts present a potential for clothing entanglement and strangulation (5). Asphyxial crib deaths from wedging the head or neck in parts of the crib and hanging by a necklace or clothing over a corner post have been well-documented (6).

Children who are thirty-five inches or taller in height have outgrown a crib and should not use a crib for sleeping (4). Turning a crib into a cage (covering over the crib) is not a safe solution for the problems caused by children climbing out. Children have died trying to escape their modified cribs by getting caught in the covering in various ways and firefighters trying to rescue children from burning homes have been slowed down by the crib covering (6).

CPSC has received numerous reports of strangulation deaths on window blind cords over the years (7).

COMMENTS

For more information on articles in cribs, see Standard 5.4.5.1: Sleeping Equipment and Supplies and Standard 6.4.1.3: Crib Toys.

A “safety-approved crib” is one that has been certified by the Juvenile Product Manufacturers Association (JPMA).

If portable cribs and those that are not full-size are substituted for regular full-sized cribs, they must be maintained in the condition that meets the ASTM F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards. Portable cribs are designed so they may be folded or collapsed, with or without disassembly. Although portable cribs are not designed to withstand the wear and tear of normal full-sized cribs, they may provide more flexibility for programs that vary the number of infants in care from time to time.

Cribs designed to be used as evacuation cribs, can be used to evacuate infants, if rolling is possible on the evacuation route(s).

To keep window blind cords out of the reach of children, staff can use tie-down devices or take the cord loop and cut it in half to make two separate cords. Consumers can call 1-800-506-4636begin_of_the_skype_highlighting 1-800-506-4636 end_of_the_skype_highlighting or visit the Window Covering Safety Council Website at http://windowcoverings.org to receive a free repair kit for each set of blinds.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.4.5.3 Stackable Cribs
6.4.1.3 Crib Toys

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe?http://www.cpsc.gov/cpscpub/pubs/5009a.pdf.
Juvenile Products Manufacturers Association. 2007. Safe and sound for baby: A guide to juvenile product safety, use, and selection. 9th ed. Moorestown, NJ: JPMA. http://www.jpma.org/content/retailers/safe-and-sound/.
U.S. Consumer Product Safety Commission (CPSC). 1996. CPSC warns parents about infant strangulations caused by failure of crib hardware. http://www.ridgevfd.org/content/prevent/sleepwear.pdf
U.S. Consumer Product Safety Commission (CPSC). 1997. The safe nursery. Washington, DC: CPSC.http://www.cpsc.gov/cpscpub/pubs/202.pdf.
U.S. Consumer Product Safety Commission (CPSC). 2010. Safety standards for full-size baby cribs and non-full-size baby cribs; final rule. 16 CFR 1219, 1220, and 1500.http://www.cpsc.gov/businfo/frnotices/fr11/cribfinal.pdf.
ASTM International. 2010. ASTM F406-10b: Standard consumer safety specification for non-full-size baby cribs/play yards. West Conshohocken, PA: ASTM.
ASTM International. 2010. ASTM F1169-10a: Standard consumer safety specification for full-size baby cribs. West Conshohocken, PA: ASTM.

Standard 5.4.5.3: Stackable Cribs

Use of stackable cribs (i.e., cribs that are built in a manner that there are two or three cribs above each other that do not touch the ground floor) in facilities is not advised. In older facilities, where these cribs are already built into the structure of the facility, staff should develop a plan for phasing out the use of these cribs.

If stackable cribs are used, they must meet the current Consumer Product Safety Commission’s (CPSC) federal standard for non-full-size cribs, 16 CFR 1220. In addition they should be three feet apart and staff placing or removing a child from a crib that cannot reach from standing on the floor, should use a stable climbing device such as a permanent ladder rather than climbing on a stool or chair. Infants who are able to sit, pull themselves up, etc. should not be placed in stackable cribs.

RATIONALE

Stackable cribs are designed to save space by having one crib built on top of another. Although they may be practical from the standpoint of saving space, infants on the top level of stackable cribs will be positioned at a height that will be several feet from the floor. Infants who fall from several feet or more can have an intracranial hemorrhage (i.e., serious bleed inside of the skull). While no injury reports have been filed, there is a potential for injury as a result of either latch malfunction or a caregiver/teacher who slips or falls while placing or removing a child from a crib. It is best practice to place an infant to sleep in a safe sleep environment (safety-approved crib with a firm mattress and a tight-fitting sheet) at a level that is close to the floor.

A minimum distance of three feet between cribs is required because respiratory infections are transmitted by large droplets of respiratory secretions, which usually are limited to a range of less than three feet from the infected person (1,2).

Young children placed to sleep in stackable cribs may have difficulties falling asleep because they may not be used to sleeping in this type of equipment. In addition, requiring staff to use stackable cribs may cause them concern and fear regarding their liability if an injury occurs.

COMMENTS

Many state child care licensing regulations prohibit the use of stackable cribs. If stackable cribs are not prohibited in the caregiver’s/teacher’s state and they are used, parents/guardians should be informed and extreme care should be taken to ensure that no infant falls from the higher level cribs due to the potential for injury. Any injury that is suspected to be related to the use of stackable cribs should be reported to the U.S. Consumer Product Safety Commission (CPSC) at 1-800-638-2772 or http://www.cpsc.gov.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs

REFERENCES

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.
Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red book: 2015 report to the committee of infectious diseases. 30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 5.4.5.4: Futons

Child-sized futons should be used only if they meet the following requirements:

Not on a frame;
Easily cleanable;
Encased in a tight-fitting waterproof cover;
Meet all other standards on sleep and rest areas (Section 5.4.5).

RATIONALE

Frames pose an entrapment hazard. Futons that are easy to clean can be kept sanitary. Supervision is necessary to maintain adequate spacing of futons and ensure that bedding is not shared, thereby reducing transmission of infectious diseases and keeping children out of traffic areas.

TYPE OF FACILITY

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

Standard 5.5.0.7: Storage of Plastic Bags

Plastic bags, whether intended for storage, trash, diaper disposal, or any other purpose, should be stored out of reach of children.

RATIONALE

Plastic bags have been recognized for many years as a cause of suffocation. Warnings regarding this risk are printed on diaper-pail bags, dry-cleaning bags, and so forth. The U.S. Consumer Product Safety Commission (CPSC) has received average annual reports of twenty-five deaths per year to children due to suffocation from plastic bags. Nearly 90% of the reported deaths were to children under the age of one (1).

TYPE OF FACILITY

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

REFERENCES

U.S. Consumer Safety Commission (CPSC). Children still suffocating with plastic bags. Document #5604. Bethesda, MD: CPSC. http://nurse.png.woodcrest.schoolfusion.us/modules/locker/files/get_group_file.phtml?fid=2333676&gid=572924&sessionid=e71cb1192f18078f5dbd2fbf4f1f63bb

Standard 5.5.0.8: Firearms

Centers should not have any firearms, pellet or BB guns (loaded or unloaded), darts, bows and arrows, cap pistols, stun guns, paint ball guns, or objects manufactured for play as toy guns within the premises at any time. If present in a small or large family child care home, these items must be unloaded, equipped with child protective devices, and kept under lock and key with the ammunition locked separately in areas inaccessible to the children. Parents/guardians should be informed about this policy.

RATIONALE

The potential for injury to and death of young children due to firearms is apparent (1-5). These items should not be accessible to children in a facility (2,3).

COMMENTS

Compliance is monitored via inspection.

TYPE OF FACILITY

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

REFERENCES

Hemenway, D., D. Weil. 1990. Phasers on stun: The case for less lethal weapons. J Policy Analysis Management 9:94-98.
Katcher, M. L., A. N. Meister., C. A. Sorkness, A. G. Staresinic, S. E. Pierce, B. M. Goodman, N. M. Peterson, P. M. Hatfield, J. A. Schirmer. 2006. Use of the modified Delphi technique to identify and rate home injury hazard risks and prevention methods for young children. Injury Prev 12:189-94.
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.
DiScala, C., R. Sege. 2004. Outcomes in children and young adults who are hospitalized for firearms-related injuries. Pediatrics 113:1306-12.
American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2004. Policy statement: Firearm-related injuries affecting the pediatric population. Pediatrics 114:1126.

Standard 6.3.3.4: Pool Water Temperature

Water temperatures should be maintained at no less than 82°F and no more than 88°F while the pool is in use.

RATIONALE

Because of their relatively larger surface area to body mass, young children can lose or gain body heat more easily than adults. Water temperature for swimming and wading should be warm enough to prevent excess loss of body heat and cool enough to prevent overheating.

COMMENTS

Learner pools in public swimming centers are usually at least two degrees warmer than the main pool.

Caregivers/teachers should be advised about the length of time infants should usually spend in the water and how to recognize when an infant is cold so that temperature control should not be problem (1). Signs that an infant is cold are that the infant has cold skin, becomes unhappy, has low energy or becomes less responsive.

TYPE OF FACILITY

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

REFERENCES

Coleman, H., F. D. Finlay. 1995. When is it safe for babies to swim? Profess Care Mother Child 5:85-86.

Standard 6.3.5.1: Hot Tubs, Spas, and Saunas

Children should not be permitted in hot tubs, spas, or saunas in child care. Areas should be secured to prevent any access by children.

RATIONALE

Any body of water, including hot tubs, pails, and toilets, presents a drowning risk to young children (1-3). Toddlers and infants are particularly susceptible to overheating.

TYPE OF FACILITY

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

RELATED STANDARDS

6.3.1.1 Enclosure of Bodies of Water
6.3.1.4 Safety Covers for Swimming Pools
6.3.1.6 Pool Drain Covers

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.
U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of in-home drowning dangers with bathtubs, bath seats, buckets. Release #10-008. http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html.
Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported fatalities, 2008 report. Atlanta: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/poolsub2008.pdf.

Standard 6.3.5.2: Water in Containers

Bathtubs, buckets, diaper pails, and other open containers of water should be emptied immediately after use.

RATIONALE

In addition to home swimming and wading pools, young children drown in bathtubs and pails (4). Bathtub drownings are equally distributed in both sexes. Any body of water, including hot tubs, pails, and toilets, presents a drowning risk to young children (1,2,4,5).

From 2003-2005, eleven children under the age of five died from drowning in buckets or containers that were being used for cleaning (4). Of all buckets, the five-gallon size presents the greatest hazard to young children because of its tall straight sides and its weight with even just a small amount of liquid. It is nearly impossible for top-heavy infants and toddlers to free themselves when they fall into a five-gallon bucket head first (3).

TYPE OF FACILITY

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

REFERENCES

Rivera, F. P. 1999. Pediatric injury control in 1999: Where do we go from here? Pediatrics 103:883-88.
U.S. Consumer Safety Commission (CPSC). How to plan for the unexpected: Preventing child drownings. Document #359. https://www.cpsc.gov/s3fs-public/359.pdf.
U.S. Consumer Products Safety Commission (CPSC). In home danger: CPSC warns of children drowning in bathtubs, bath seats and buckets more than 400 deaths estimated over a five-year. period. 2012. https://www.cpsc.gov/Newsroom/News-Releases/2012/In-Home-Danger-CPSC-Warns-of-Children-Drowning-in-Bathtubs-Bath-Seats-and-Buckets-More-than-400-deaths-estimated-over-a-five-year-period/.
U.S. Consumer Products Safety Commission (CPSC). Submersions related to non-pool and non-spa products, 2009 report. 2010. https://www.cpsc.gov/s3fs-public/pdfs/nonpoolsub2009.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.

Standard 6.4.1.5: Balloons

Infants, toddlers, and preschool children should not be permitted to inflate balloons, suck on or put balloons in their mouths nor have access to uninflated or underinflated balloons. Children under eight should not have access to latex balloons or inflated latex objects that are treated as balloons and these objects should not be permitted in the child care facility.

RATIONALE

Balloons are an aspiration hazard (1). The U.S. Consumer Product Safety Commission (CPSC) reported eight deaths from balloon aspiration with choking between 2006 and 2008 (1). Aspiration injuries occur from latex balloons or other latex objects treated as balloons, such as inflated latex gloves. Latex gloves are commonly used in child care facilities for diaper changing, but they should not be inflated (2). When children bite inflated latex balloons or gloves, these objects may break suddenly and blow an obstructing piece of latex into the child’s airway. Exposure to latex balloons could trigger an allergic reaction in children with latex allergies.

Underinflated or uninflated balloons of all types could be chewed or sucked and pieces potentially aspirated.

TYPE OF FACILITY

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

RELATED STANDARDS

6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
Garland, S. 2009. Toy-related deaths and injuries, calendar year 2008. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/toymemo08.pdf.

Standard 6.5.2.2: Child Passenger Safety

When children are driven in a motor vehicle other than a bus, school bus, or a bus operated by a common carrier, the following should apply:

A child should be transported only if the child is restrained in developmentally appropriate car safety seat, booster seat, seat belt, or harness that is suited to the child’s weight, age, and/or psychological development in accordance with state and federal laws and regulations and the child is securely fastened, according to the manufacturer’s instructions, in a developmentally appropriate child restraint system.
Age and size-appropriate vehicle child restraint systems should be used for children under eighty pounds and under four-feet-nine-inches tall and for all children considered too small, in accordance with state and federal laws and regulations, to fit properly in a vehicle safety belt. The child passenger restraint system must meet the federal motor vehicle safety standards contained in the Code of Federal Regulations, Title 49, Section 571.213 (especially Federal Motor Vehicle Safety Standard 213), and carry notice of such compliance.
For children who are obese or overweight, it is important to find a car safety seat that fits the child properly. Caregivers/teachers should not use a car safety seat if the child weighs more than the seat’s weight limit or is taller than the height limit. Caregivers/teachers should check the labels on the seat or manufacturer’s instructions if they are unsure of the limits. Manufacturer’s instructions that include these specifications can also be found on the manufacturer’s Website.
Child passenger restraint systems should be installed and used in accordance with the manufacturer’s instructions and should be secured in back seats only.
All children under the age of thirteen should be transported in the back seat of a car and each child not riding in an appropriate child restraint system (i.e., a child seat, vest, or booster seat), should have an individual lap-and-shoulder seat belt (2).
For maximum safety, infants and toddlers should ride in a rear-facing orientation (i.e., facing the back of the car) until they are two years of age or until they have reached the upper limits for weight or height for the rear-facing seat, according to the manufacturer’s instructions (1). Once their seat is adjusted to face forward, the child passenger must ride in a forward-facing child safety seat (either a convertible seat or a combination seat) until reaching the upper height or weight limit of the seat, in accordance with the manufacturer’s instructions (10). Plans should include limiting transportation times for young infants to minimize the time that infants are sedentary in one place.
A booster seat should be used when, according to the manufacturer’s instructions, the child has outgrown a forward-facing child safety seat, but is still too small to safely use the vehicle seat belts (for most children this will be between four feet nine inches tall and between eight and twelve years of age) (1).
Car safety seats, whether provided by the child’s parents/guardians or the child care program, should be labeled with the child passenger’s name and emergency contact information.
Car safety seats should be replaced if they have been recalled, are past the manufacturer’s “date of use” expiration date, or have been involved in a crash that meets the U.S. Department of Transportation crash severity criteria or the manufacturer’s criteria for replacement of seats after a crash (3,11).
The temperature of all metal parts of vehicle child restraint systems should be checked before use to prevent burns to child passengers.

If the child care program uses a vehicle that meets the definition of a school bus and the school bus has safety restraints, the following should apply:

The school bus should accommodate the placement of wheelchairs with four tie-downs affixed according to the manufactures’ instructions in a forward-facing direction;
The wheelchair occupant should be secured by a three-point tie restraint during transport;
At all times, school buses should be ready to transport children who must ride in wheelchairs;
Manufacturers’ specifications should be followed to assure that safety requirements are met.

RATIONALE

According to the National Center for Health Statistics, motor vehicle crashes are the leading cause of death among children ages three to fourteen in the United States (4). Safety restraints are effective in reducing death and injury when they are used properly. The best car safety seat is one that fits in the vehicle being used, fits the child being transported, has never been in a crash, and is used correctly every time. The use of restraint devices while riding in a vehicle reduces the likelihood of any passenger suffering serious injury or death if the vehicle is involved in a crash. The use of child safety seats reduces risk of death by 71% for children less than one year of age and by 54% for children ages one to four (4). In addition, booster seats reduce the risk of injury in a crash by 45%, compared to the use of an adult seat belt alone (5).

The safest place for all infants and children under thirteen years of age is to ride in the back seat. Head-on crashes cause the greatest number of serious injuries. A child sitting in the back seat is farthest away from the impact and less likely to be injured or killed. Additionally, new cars, trucks and vans have had air bags in the front seats for many years. Air bags inflate at speeds up to 200 mph and can injure small children who may be sitting too close to the air bag or who are positioned incorrectly in the seat. If the infant is riding in the front seat, a rapidly inflating air bag can hit the back of a rear-facing infant seat behind a baby’s head and cause severe injury or death. For this reason, a rear-facing infant must NEVER be placed in the front seat of a vehicle with active passenger air bags.

Infants under one year of age have less rigid bones in the neck. If an infant is placed in a child safety seat facing forward, a collision could snap the infant’s head forward, causing neck and spinal cord injuries. If an infant is placed in a child safety seat facing the rear of the car, the force of a collision is absorbed by the child restraint and spread across the infant’s entire body. The rigidity of the bones in the neck, in combination with the strength of connecting ligaments, determines whether the spinal cord will remain intact in the vertebral column. Based on physiologic measures, immature and incompletely ossified bones will separate more easily than more mature vertebrae, leaving the spinal cord as the last link between the head and the torso (6). After twelve months of age, more moderate consequences seem to occur than before twelve months of age (7). However, rear-facing positioning that spreads deceleration forces over the largest possible area is an advantage at any age. Newborns seated in seat restraints or in car beds have been observed to have lower oxygen levels than when placed in cribs, as observed over a period of 120 minutes in each position (8).

As of March 1, 2010, all but three states required booster seat use for children up to as high as nine years of age. Child passenger restraints are recommended increasingly for older children. State child restraint requirements are listed by state at: http://www.iihs.org/laws/ChildRestraint.aspx. Booster seats are recommended for use only with both lap and shoulder belts; NEVER install a booster seat with the lap belt only. When the vehicle safety belts fit properly, the lap belt lies low and tightly across the child’s upper thighs (not the abdomen) and the shoulder belt lies flat across the chest and shoulder, away from the neck and face.

COMMENTS

A Child Passenger Safety Technician may be able to help find a car safety seat that fits a larger child. Car safety seat manufacturers increasingly are making car safety seats that fit larger children. To locate a Child Passenger Safety Technician see https://ssl13.cyzap.net/dzapps/dbzap.bin/apps/assess/webmembers/tool?pToolCode=TAB9&pCategory1=TAB9_CERTSEARCH&Webid=SAFEKIDSCERTSQL. See http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats
-Product-Listing-2010.aspx for a list of available car safety seats. For toddlers or young children whose behavior will not yet allow safe use of a booster seat but who are too large for a forward-facing seat with a harness, caregivers/teachers can consider using a travel vest (9).

When school buses meet current standards for the transport of school-age children, containment design features help protect children from injury, although the use of seat belts would provide additional protection. The U.S. Department of Transportation and U.S. Federal Motor Vehicle Safety standards for school buses apply only to vehicles equipped with factory-installed seat belts after 1967. To obtain the Federal Regulations, contact the Superintendent of Documents at the Government Printing Office.

Written transportation policy that is communicated to parents/guardians, staff, and all who transport children can help assure understanding of requirements/recommendations for child passenger safety as well as decisions about the value/necessity of the trip.

Car seat manufacturer’s the National Highway Traffic Safety Administration (NHTSA) guidance on car seat replacement after a crash is available at http://www.nhtsa.gov/people/injury/childps/ChildRestraints/ReUse/index.htm.

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.5.1 Transportation Policy for Centers and Large Family Homes
9.2.5.2 Transportation Policy for Small Family Child Care Homes
2.2.0.2 Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.
6.5.3.1 Passenger Vans

REFERENCES

Durbin, D. R., American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2011. Policy statement: Child passenger safety. Pediatrics 127:788-93.
Child Restraint Safety. Manufacture and expiration. http://www.childrestraintsafety.com/manufacture-expiration.html.
American Academy of Pediatrics. 2015. Car safety seats: Information for families for 2015. http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx
American Academy of Pediatrics. Obese children and car safety seats: Suggestions for parents. http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-and-Obese-Children-Suggestions-for-Parents.aspx
Cerar, L. K., C. V. Scirica, I. S. Gantar, D. Osredkar, D. Neubauer, T. B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in car safety seats and beds. Pediatrics 124: e396-e402.
Weber, K., D. Dalmotas, B. Hendrick. 1993. Investigation of dummy response and restraint configuration factors associated with upper spinal cord injury in a forward-facing child restraint. Warrendale, PA: Society of Automotive Engineers.
Huelke, D. F., G. M. Mackay, A. Morris, M. Bradford. 1993. Car crashes and non-head impact cervical spine injuries in infants and children. Warrendale, PA: Society of Automotive Engineers.
Arbogast, K. B., J. S. Jermakian, M. J. Kallan, D. R. Durbin. 2009. Effectiveness of belt positioning booster seats: An updated assessment. Pediatrics 124:1281-86
National Highway Traffic Safety Administration’s National Center for Statistics and Analysis 2008. Traffic safety facts, 2008, Children. http://www-nrd.nhtsa.dot.gov/Pubs/811157.PDF.
National Highway Traffic Safety Administration. Child restraint re-use after minor crashes.http://www.nhtsa.dot.gov/people/injury/childps/ChildRestraints/ReUse/index.htm.
National Highway Trafic Safety Administration. Questions and answers about air bag safety. Safe and Sober Campaign. http://www.nhtsa.gov/people/injury/alcohol/Archive/Archive/safesobr/12qp/airbag.html.

Standard 6.5.2.4: Interior Temperature of Vehicles

The interior of vehicles used to transport children should be maintained at a temperature comfortable to children. When the vehicle’s interior temperature exceeds 82°F and providing fresh air through open windows cannot reduce the temperature, the vehicle should be air-conditioned. When the interior temperature drops below 65°F and when children are feeling uncomfortably cold, the interior should be heated. To prevent hyperthermia, all vehicles should be locked when not in use, head counts of children should be taken after transporting to prevent a child from being left unintentionally in a vehicle, and children should never be intentionally left in a vehicle unattended.

RATIONALE

Some children have problems with temperature variations. Whenever possible, opening windows to provide fresh air to cool a hot interior is preferable before using air conditioning. Over-use of air conditioning can increase problems with respiratory infections and allergies. Excessively high temperatures in vehicles can cause neurological damage in children (1).

Children’s bodies overheat three to five times faster than
adults because the hypothalamus regions of their brains, which control body temperature, are not as developed (1).

About thirty-seven children die every year from hyperthermia when they’re left in cars and the cars quickly heat up. Even with comfortable temperatures outdoors, the temperature in an enclosed car climbs rapidly.

Temperature increase inside a car with an outside temperature of 80°F (elapsed time in minutes) (2):

After ten minutes: 99°F inside car;
After twenty minutes: 109°F;
After thirty minutes 114°F;
After forty minutes: 118°F;
After fifty minutes: 120°F;
After sixty minutes: 123°F.

COMMENTS

In geographical areas that are prone to very cold or very hot weather, a small thermometer should be kept inside the vehicle. In areas that are very cold, adults tend to wear very warm clothing and children tend to wear less clothing than might actually be required. Adults in a vehicle, then, may be comfortable while the children are not. When air conditioning is used, adults might find the cool air comfortable, but the children may find that the cool air is uncomfortably cold. To determine whether the interior of the vehicle is providing a comfortable temperature to children, a thermometer should be used and children in the vehicle should be asked if they are comfortable. Non-verbal children and infants should be assessed by an adult for signs of hypo- or hyperthermia. Signs of hypothermia include: cold skin, very low energy, and may be non-responsive. Young infants do not shiver when cold. Signs of hyperthermia include: dizziness, disorientation, agitation, confusion, sluggishness, seizure, hot dry skin that is flushed but not sweaty, loss of consciousness, rapid heartbeat, hallucinations (2).

TYPE OF FACILITY

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

REFERENCES

Guard, A., S. S. Gallagher. 2005. Heat related deaths to young children in parked cars: An analysis of 171 fatalities in the United States, 1995-2002. Injury Prevention 11:33-37.
McLaren, C., J. Null, J. Quinn. 2005. Heat stress from enclosed vehicles: Moderate ambient temperatures cause significant temperature rise in enclosed vehicles. Pediatrics 116: e109-12.

Food Preparation and Feeding Area

Standard 4.5.0.2: Tableware and Feeding Utensils

Tableware and feeding utensils should meet the following requirements:

Dishes should have smooth, hard, glazed surfaces and should be free from cracks or chips. Sharp-edged plastic utensils (intended for use in the mouth) or dishes that have sharp or jagged edges should not be used;
Imported dishes and imported ceramic dishware or pottery should be certified by the regulatory health authority to meet U.S. standards and to be safe from lead or other heavy metals before they can be used;
Disposable tableware (such as plates, cups, utensils made of heavy weight paper, food-grade medium- weight or BPA- or phthalates-free plastic) should be permitted for single service if they are discarded after use. The facility should not use foam tableware for children under four years of age (1,2);
Single-service articles (such as napkins, paper placemats, paper tablecloths, and paper towels) should be discarded after one use;
Washable bibs, placemats, napkins, and tablecloths, if used, should be laundered or washed, rinsed, and sanitized after each meal. Fabric articles should be sanitized by being machine-washed and dried after each use;
Highchair trays, plates, and all items used in food service that are not disposable should be washed, rinsed, and sanitized. Highchair trays that are used for eating should be washed, rinsed, and sanitized just before and immediately after they are used for eating. Children who eat at tables should have disposable or washed and sanitized plates for their food;
All surfaces in contact with food should be lead-free (3);
Tableware and feeding utensils should be child-sized and developmentally appropriate.

RATIONALE

Clean food service utensils, napkins, bibs, and tablecloths prevent the spread of microorganisms that can cause disease. The surfaces that are in contact with food must be sanitary.

Food should not be put directly on the table surface for two reasons. First, even washed and sanitized tables are more likely to be contaminated than disposable plates or washed and sanitized dishes. Second, eating from plates reduces contamination of the table surface when children put down their partially eaten food while they are eating.

Although highchair trays can be considered tables, they function as plates for seated children. The tray should be washed and sanitized before and after use (4). The use of disposable items eliminates the spread of contamination and disease and fosters safety and injury prevention. Single-service items are usually porous and should not be washed and reused. Items intended for reuse must be capable of being washed, rinsed, and sanitized.

Medium-weight plastic should be chosen because lighter-weight plastic utensils are more likely to have sharp edges and break off small pieces easily. Sharp-edged plastic spoons can cut soft oral tissues, especially when an adult is feeding a child and slides the spoon out of the child’s closed mouth. Older children can cut their mouth tissues in the same way.

Foam can break into pieces that can become choking hazards for young children.

Imported dishware may be improperly fired and may release toxic levels of lead into food. U.S. government standards prevent the marketing of domestic dishes with lead in their glazes. There is no safe level of lead in dishware.

COMMENTS

Ideally, food should not be placed directly on highchair trays, as studies have shown that highchair trays can be loaded with infectious microorganisms. If the highchair tray is made of plastic, is in good repair, and is free from cracks and crevices, it can be made safe if it is washed and sanitized before placing a child in the chair for feeding and if the tray is washed and sanitized after each child has been fed. Food must not be placed directly on highchair trays made of wood or metal, other than stainless steel, to prevent contamination by infectious microorganisms or toxicity from metals.

If there is a question about whether tableware is safe and sanitary, consult the regulatory health authority 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

4.9.0.9 Cleaning Food Areas and Equipment
5.2.9.9 Plastic Containers and Toys

REFERENCES

Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red Book: 2015 Report to the Committee of Infectious Diseases. 30^th Ed. Elk Grove Village, IL: American Academy of Pediatrics.
Center for Disease Control and Prevention. 2017. Lead. https://www.cdc.gov/nceh/lead/.
Safer Chemicals, Healthy Families. 2017. Styrene and styrofoam 101.
http://saferchemicals.org/2014/05/26/styrene-and-styrofoam-101-2/.
Eco-Healthy Child Care. 2016. Plastics & plastic toys. http://cehn.org/wpcontent/uploads/2015/12/Plastics_Plastic_Toys_6_16.pdf.

Standard 4.8.0.1: Food Preparation Area

The food preparation area of the kitchen should be separate from eating, play, laundry, toilet, and bathroom areas and from areas where animals are permitted. The food preparation area should not be used as a passageway while food is being prepared. Food preparation areas should be separated by a door, gate, counter, or room divider from areas the children use for activities unrelated to food, except in small family child care homes when separation may limit supervision of children.

Infants and toddlers should not have access to the kitchen in child care centers. Access by older children to the kitchen of centers should be permitted only when supervised by staff members who have been certified by the nutritionist/registered dietitian or the center director as qualified to follow the facility’s sanitation and safety procedures.

In all types of child care facilities, children should never be in the kitchen unless they are directly supervised by a caregiver/teacher. Children of preschool-age and older should be restricted from access to areas where hot food is being prepared. School-age children may engage in food preparation activities with adult supervision in the kitchen or the classroom. Parents/guardians and other adults should be permitted to use the kitchen only if they know and follow the food safety rules of the facility. The facility should check with local health authorities about any additional regulations that apply.

RATIONALE

The presence of children in the kitchen increases the risk of contamination of food and the risk of injury to children from burns. Use of kitchen appliances and cooking techniques may require more skill than can be expected for children’s developmental level. The most common burn in young children is scalding from hot liquids tipped over in the kitchen (1).

The kitchen should be used only by authorized individuals who have met the requirements of the local health authority and who know and follow the food safety rules of the facility so they do not contaminate food and food surfaces for food-related activities. Under adult supervision, school-age children may be encouraged to help with developmentally appropriate food preparation, which increases the likelihood that they will eat new foods.

TYPE OF FACILITY

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

RELATED STANDARDS

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES

Ring, L. M. 2007. Kids and hot liquids–A burning reality. J Pediatric Health Care 21:192-94.

Standard 4.8.0.8: Microwave Ovens

Microwave ovens should be inaccessible to all children, with the exception of school-age children under close adult supervision. Any microwave oven in use in a child care facility should be manufactured after October 1971 and should be in good condition. While the microwave is being used, it should not be left unattended.

If foods need to be heated in a microwave:

Avoid heating foods in plastic containers;
Avoid transferring hot foods/drinks into plastic containers;
Do not use plastic wrap or aluminum foil in the microwave;
Avoid plastics for food and beverages labeled “3” (PVC), “6” (PS), and “7” (polycarbonate);
Stir food before serving to prevent burns from hot spots.

RATIONALE

Young children can be burned when their faces come near the heat vent. The issues involved with the safe use of microwave ovens (such as no metal and steam trapping) make use of this equipment by preschool-age children too risky. Older ovens made before the Federal standard went into effect in October 1971 can expose users or passers-by to microwave radiation. If adults or school-age children use a microwave, it is recommended that they do not heat food in plastic containers, plastic wrap or aluminum foil due to concerns of releasing toxic substances even if the container is specified for use in a microwave (1).

COMMENTS

If school-age children are allowed to use a microwave oven in the facility, this use should be closely supervised by an adult to avoid injury. See Standard 4.3.1.9 for prohibition of use of microwave ovens to warm infant feedings.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

Institute for Agriculture and Trade Policy (IATP), Food and Health Program. 2005. Smart plastics guide: Healthier food uses of plastics for parents and children. Minneapolis, MN: IATP.

Standard 5.3.1.8: High Chair Requirements

High chairs, if used, should have a wide base and a securely locking tray, along with a crotch bar/guard to prevent a child from slipping down and becoming entrapped between the tray and the seat. High chairs should also be equipped with a safety strap to prevent a child from climbing out of the chair. The safety strap should be fastened with every use. Caps or plugs on tubing should be firmly attached. Folding high chairs should have a locking device that prevents the high chair from collapsing. High chairs should be labeled or warranted by the manufacturer in documents provided at the time of purchase or verified thereafter by the manufacturer as meeting the ASTM International current Standard F404-08 Consumer Safety Specification for High Chairs. High chairs should be used in accordance with manufacturer’s instructions including following restrictions based on age and minimum/maximum weight of children.

Highchairs should be kept far enough away from a table, counter, wall or other surface so that the child can’t use them to push off or to grab potentially dangerous cords or objects.

RATIONALE

High chairs offer potential for entrapment, falls and other injuries. Current ASTM Standard F404-08 Consumer Safety Specifications for High Chairs covers:

Sharp edges;
Locking devices;
Drop tests of the tray;
Disengagement of the tray;
Load and stability of the chair;
Protection from coil springs and scissoring;
Maximum size of holes;
Restraining system tests;
Labeling;
Instructional literature.

COMMENTS

The general age of high chair users is about six-months- to three-years-old (1). Caregivers/teachers should transition children from high chairs to small tables and chairs as soon as they are capable of using them.

Manufacturers and vendors also may indicate a weight restriction for use by children who do not exceed thirty-seven pounds (2). The Juvenile Products Manufacturers Association (JPMA) has a testing and certification program for highchairs, play yards, carriages, strollers, walkers, gates, and expandable enclosures. When purchasing such equipment, consumers can look for labeling that certifies that these products meet the standards. ASTM also maintains a Website at http://www.astm.org with the latest standards on high chair specifications.

TYPE OF FACILITY

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

REFERENCES

Lerner, N. D., R. W. Huey, B. M. Kotwal. 2001. Product profile report, 19. Rockville, MD: Westat.
U.S. Consumer Product Safety Commission (CPSC). Tips for your baby's safety. http://www.nchh.org/Portals/0/Contents/CPSC_Baby_Safety_Checklist.pdf

Play Areas

Standard 5.2.9.7: Proper Use of Art and Craft Materials

Only art and craft materials that are approved by the Art and Creative Materials Institute (ACMI) should be used in the child care facility. Art and craft materials should conform to all applicable ACMI safety standards. Materials should be labeled in accordance with the chronic hazard labeling standard, ASTM D4236.

The facility should prohibit use of unlabeled, improperly labeled old, or donated materials with potentially harmful ingredients.

Caregivers/teachers should closely supervise all children using art and craft materials and should make sure art and craft materials are properly used, cleaned up, and stored in original containers that are fully labeled. Materials should be age-appropriate. Children should not eat or drink while using art and craft materials.

Caregivers/teachers should have emergency protocols in place in the event of an injury, poisoning, or allergic reaction. If caregivers/teachers suspect a poisoning may have occurred they should call their poison center at 1-800-222-1222. Rooms should be well ventilated while using art and craft materials.

Only ACMI-approved unscented water-based markers should be used for children’s art projects and work.

RATIONALE

Contamination and injury may occur if art and craft materials are improperly used or labeled. Labels are required on art supplies to identify any hazardous ingredients, risks associated with their use, precautions, first aid, and sources of further information (1).

Art material, approved by the ACMI, has been tested for both chronic and acute health hazards. The ACMI AP (Approved Product) Seal, with or without Performance Certification, identifies art materials that are safe and that are certified in a toxicological evaluation by a medical expert to contain no materials in sufficient quantities to be toxic or injurious to humans, including children, or to cause acute or chronic health problems. This seal is currently replacing the previous non-toxic seals: CP (Certified Product), AP (Approved Product), and HL Health Label (Non-Toxic) over a ten-year phase-in period. Such products are certified by ACMI to be labeled in accordance with the chronic hazard labeling standard, ASTM D4236, and the U.S. Labeling of Hazardous Art Materials Act (LHAMA). Additionally, products bearing the AP Seal with Performance Certification or the CP Seal are certified to meet specific requirements of material, workmanship, working qualities, and color developed by ACMI and others through recognized standards organizations, such as the American National Standards Institute (ANSI) and ASTM International. Some products cannot attain this performance certification because no quality standard currently exists for certain types of products (1).

Children have been known to try and eat fruit-scented markers. Solvent-based/permanent markers can trigger headaches and/or asthma (3).

COMMENTS

Non-toxic art and craft supplies intended for children are readily available.

Some products labeled “non-toxic” are not necessarily a safer alternative; thus the need to check for the proper labeling.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.4 Ventilation When Using Art Materials

REFERENCES

Art and Creative Materials Institute. 2010. Safety - what you need to know. http://www.acminet.org/Safety.htm.
U.S. Consumer Product Safety Commission (CPSC). Art and craft safety guide. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/5015.pdf.
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.

Standard 5.3.1.9: Carriage, Stroller, Gate, Enclosure, and Play Yard Requirements

Each carriage, stroller, gate, enclosure, and play yard used should meet the corresponding ASTM International standard and should be so labeled on the equipment.

Carriages/strollers: ASTM F833-10 Standard Consumer Safety Performance Specification for Carriages and Strollers;
Gates/enclosures: ASTM F1004-10 Consumer Safety Specification for Expansion Gates and Expandable Enclosures;
Play yards: ASTM F406-10 Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards.

RATIONALE

The presence of a Juvenile Products Manufacturers Association (JPMA) certification seal on products that are made for children ensures that the product is in compliance with the requirements of the current safety standard for that product at the time of manufacture.

COMMENTS

ASTM also maintains a website at http://www.astm.org with the latest standards on high chair specifications. For more information, contact the JPMA or the ASTM.

TYPE OF FACILITY

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

Standard 6.2.1.1: Play Equipment Requirements

Play equipment and materials in the facility should meet the recommendations of the U.S. Consumer Product Safety Commission (CPSC) and the ASTM International (ASTM) for public playground equipment. Equipment and materials intended for gross-motor (active) play should conform to the recommendations in the CPSC Public Playground Safety Handbook and the provisions in the ASTM “Standard F1487-07ae1: Consumer Safety Performance Specifications for Playground Equipment for Public Use.”

All play equipment should be constructed, installed, and made available to the intended users in such a manner that meets CPSC guidelines and ASTM standards, as warranted by the manufacturers’ recommendations. A Certified Playground Safety Inspector (CPSI) who has been certified by the National Recreation and Park Association (NRPA) should conduct an inspection of playground plans for new installations. Previously installed playgrounds should be inspected at least once each year, by a CPSI or local regulatory agency, and whenever changes are made to the equipment or intended users.

Inspectors should specifically test wooden play equipment structures for chromated copper arsenate (CCA). The wood in many playground sets can contain potentially hazardous levels of arsenic due to the use of CCA as a wood preservative.

Play equipment and materials should be deemed appropriate to the developmental needs, individual interests, abilities, and ages of the children, by a person with at least a master’s degree in early childhood education or psychology, or identified as age-appropriate by a manufacturer’s label on the product package. Enough play equipment and materials should be available to avoid excessive competition and long waits.

The facility should offer a wide variety of age-appropriate portable play equipment (e.g., balls, jump ropes, hoops, ribbons, scarves, push/pull toys, riding toys, rocking and twisting toys, sand and water play toys) in sufficient quantities that multiple children can play at the same time (1-5).

Children should always be supervised when playing on playground equipment.

RATIONALE

The active play areas of a child care facility are associated with frequent and severe injuries (8). Many technical design and installation safeguards are addressed in the ASTM and CPSC standards. Manufacturers who guarantee that their equipment meets these standards and provide instructions for use to the purchaser ensure that these technical requirements will be met under threat of product liability. Certified Playground Safety Inspectors (CPSI) receive training from the NPRA in association with the National Playground Safety Institute (NPSI). Since the training received by CPSIs exceeds that of most child care personnel, obtaining a professional inspection to detect playground hazards before they cause injury is highly worthwhile.

Playgrounds designed for older children might present intrinsic hazards to preschool-age children. Equipment that is sized for larger and more mature children poses challenges that younger, smaller, and less mature children may not be able to meet.

The health effects related to arsenic include: irritation of the stomach and intestines, birth or developmental effects, cancer, infertility, and miscarriages in women. CCA is a wood preservative and insecticide that is made up of 22% arsenic, a known carcinogen. Much of the wood in playground equipment contains high levels of this toxic substance. In 2004, CCA was phased-out for residential uses; however, older, treated wood is a still a health concern, particularly for children (6).

COMMENTS

Compliance should be measured by structured observation.

A general guideline for establishing play equipment heights is one foot per year of age of the intended users. In some states, height limitations for playground equipment are:

Thirty-two inches for infants and toddlers (six months to twenty-three months) (7);
Forty-eight inches for preschoolers (thirty months to five years of age);
Six and one-half feet for school-age children (six through twelve years of age).

Consult with your regulatory health authority for any local or state requirements.

Check the ASTM Website – http://www.astm
.org – for up-to-date standards. To obtain the publications listed above, contact the ASTM or the CPSC.

To locate a CPSI, check the NPRA registry at https://
ipv.nrpa.org/CPSI_registry/.

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.1 Methods of Supervision of Children
3.3.0.2 Cleaning and Sanitizing Toys
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment

REFERENCES

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.
ASTM International (ASTM). 2007. Standard consumer safety performance specification for playground equipment for public use. ASTM F1487-07ae1. West Conshohocken, PA: ASTM.
American Academy of Pediatrics (AAP), Committee on Environmental Health. 2003. Arsenic. In Pediatric environmental health, ed. R. A. Etzel. Elk Grove Village, IL: AAP.
Dowda, M., W. H. Brown, et al. 2009. Policies and characteristics of the preschool environment and physical activity of young children. Pediatrics 123: e261-66.
Brown, W. H., K. A. Pfeiffer, et al. 2009. Social and environmental factors associated with preschoolers’ nonsedentary physical activity. Child Development 80:45-58.
Bower, J. K., D. P. Hales, et al. 2008. The childcare environment and children’s physical activity. Am J Prev Med 34:23-29.
Ammerman, A. S., D. S. Ward, et al. 2007. An intervention to promote healthy weight: Nutrition and physical activity self-assessment for child care (NAP SACC) theory and design. Prev Chronic Dis 4 (July).
Ammerman, A., S. E. Benjamin, et al. 2004. The nutrition and physical activity self assessment for child care (NAP SACC). Raleigh and Chapel Hill, NC: Division of Public Health, Center for Health Promotion and Disease Prevention.

Standard 6.2.1.7: Enclosure of Moving Parts on Play Equipment

All pieces of play equipment should be designed so moving parts (swing components, teeter-totter mechanism, spring-ride springs, and so forth) will be shielded or enclosed. Teeter-totters should not be used by preschool-age children unless they are equipped with a spring centering device and have an appropriate shock-absorbing material underneath the seats. Use of teeter totters is prohibited for infants and toddlers (1-3).

RATIONALE

Playground injuries often involve pinching, catching, or crushing of body parts or clothing by equipment mechanisms (4).

COMMENTS

For more information on play equipment with moving parts, see the U.S. Consumer Product Safety Commission (CPSC) Public Playground Safety Handbook and ASTM International (ASTM) standards “F1487-07ae1: Standard Consumer Safety Performance Specification for Playground Equipment for Public Use” and “F2373-08: Standard Consumer Safety Performance Specification for Public Use Play Equipment for Children 6 Months through 23 Months.”

TYPE OF FACILITY

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

REFERENCES

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.
ASTM International (ASTM). 2008. Standard consumer safety performance specification for public use play equipment for children 6 months through 23 months. ASTM F2373-08. West Conshohocken, PA: ASTM.
ASTM International (ASTM). 2007. Standard consumer safety performance specification for playground equipment for public use. ASTM F1487-07ae1. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.2.1.9: Entrapment Hazards of Play Equipment

All openings in pieces of play equipment should be designed too large for a child’s head to get stuck in or too small for a child’s body to fit into, in order to prevent entrapment and strangulation. Openings in exercise rings (overhead hanging rings such as those used in a ring trek or ring ladder) should be smaller than three and one-half inches or larger than nine inches in diameter. Rings on long chains are prohibited. A play structure should have no openings with a dimension between three and one-half inches and nine inches. In particular, side railings, stairs, and other locations where a child might slip or try to climb through should be checked for appropriate dimensions.

Protrusions such as pipes, wood ends, or long bolts that may catch a child’s clothing are prohibited. Distances between two vertical objects that are positioned near each other should be less than three and one-half inches to prevent entrapment of a child’s head. No opening should have a vertical angle of less than fifty-five degrees. To prevent entrapment of fingers, openings should not be larger than three-eighths inch or smaller than one inch. A Certified Playground Safety Inspector (CPSI) is specially trained to find and measure various play equipment hazards.

RATIONALE

Any equipment opening between three and one-half inches and nine inches in diameter presents the potential for head entrapment. Similarly, openings between three-eighths inch and one inch can cause entrapment of the child’s fingers (1-2).

COMMENTS

To locate a CPSI, check the National Park and Recreation Association (NPRA) registry at https://ipv
.nrpa.org/CPSI_registry/.

TYPE OF FACILITY

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

REFERENCES

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.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.2.4.3: Sensory Table Materials

All materials used in a sensory table should be nontoxic and should not be of a size or material that could cause choking. Sensory table activities should not be used with children under eighteen months of age. For toddlers, materials should be limited to water, sand and fixed plastic objects. All sensory table activities should be supervised for toddlers and preschool children. When water is used in a sensory table, the requirements of Standard 6.2.4.2, Water Play Tables should be met.

RATIONALE

According to the federal government’s small parts standard on safe-size toys for children under three years of age, a prohibited small part is any object that fits completely into a specially designed test cylinder two and one-quarter inches long by one and one-quarter inches wide, which approximates the size of the fully expanded throat of a child under three-years-old. Since round objects are more likely to choke children because they can completely block a child’s airway, balls and toys with parts that are spheroid, ovoid, or elliptical with a diameter smaller than one and three-quarter inches should be banned for children under three years old (4,5); any part smaller than this is a potential choking hazard (5). Injury and fatality from aspiration of small parts is well-documented (4). Eliminating small parts from children’s environment will greatly reduce this risk.

According to the U.S. Food and Drug Administration (FDA), eating as few as four or five uncooked kidney beans can cause severe nausea, vomiting, and diarrhea. In addition to their toxicity, raw kidney beans are small objects that could be inserted by a child into his nose or ear; beans can potentially get stuck, swell, and be difficult to remove (1). Styrofoam peanuts could cause choking. Flour could be aspirated and affect breathing; if spilled on the floor, flour could cause slipping. If soil is used, it must be free from chemicals such as fertilizer or pesticides.

Sensory table activities/materials are not developmentally appropriate for children under the age of eighteen months; the potential health and safety hazards outweigh the benefits for use with this age group. Supervision is required for toddlers and preschool-age children to ensure that they are using materials appropriately (2,3).

Sand used in sensory tables should be new “sterilized” natural sand that is labeled for use in children’s sandboxes or labeled as play sand. Water used in sensory tables must be potable and clean.

COMMENTS

Children’s hands should be washed before and after using the sensory table. Children with open areas (cuts/sores) should not be allowed to use the sensory table.

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
3.3.0.2 Cleaning and Sanitizing Toys
6.2.4.1 Sandboxes
6.2.4.2 Water Play Tables
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
U.S. Consumer Product Safety Commission (CPSC). 2004. CPSC warns parents about choking hazards to young children, announces new recall of toys posing choking hazards. Release #04-216. http://www.cpsc.gov/cpscpub/prerel/prhtml04/04216.html.
Cryer, D., T. Harms, C. Riley. 2004. All about the ITERS-R. Lewisville, NC: Kaplan Early Learning.
Harms, T., D. Cryer, R. M. Clifford. 2006. Infant/toddler environment rating scale. Rev ed. New York: Teachers College Press. http://ers.fpg.unc.edu/
infanttoddler-environment-rating-scales-iters-r/.
California Childcare Health Program, University of California San Francisco School of Nursing. Health and safety tip. Child Care Health Connections 16:1. http://www.ucsfchildcarehealth.org/pdfs/newsletters/2003/CCHPJul_Aug03.pdf.

Standard 6.4.1.2: Inaccessibility of Toys or Objects to Children Under Three Years of Age

Small objects, toys, and toy parts available to children under the age of three years should meet the federal small parts standards for toys. The following toys or objects should not be accessible to children under three years of age:

Toys or objects with removable parts with a diameter less than one and one-quarter inches and a length between one inch and two and one-quarter inches;
Balls and toys with spherical, ovoid (egg shaped), or elliptical parts that are smaller than one and three-quarters inches in diameter;
Toys with sharp points and edges;
Plastic bags;
Styrofoam objects;
Coins;
Rubber or latex balloons;
Safety pins;
Marbles;
Magnets;
Foam blocks, books, or objects;
Other small objects;
Latex gloves;
Bulletin board tacks;
Glitter.

RATIONALE

Injury and fatality from aspiration of small parts is well-documented (1,2). Eliminating small parts from children’s environment will greatly reduce the risk (2). Objects should not be small enough to fit entirely into a child’s mouth.

According to the federal government’s small parts standard on a safe-size toy for children under three years of age, a small part should be at least one and one-quarter inches in diameter and between one inch and two and one-quarter inches long; any part smaller than this has a potential choking hazard.

Magnets generally are small enough to pass through the digestive tract, however, they can attach to each other across intestinal walls, causing obstructions and perforations within the gastrointestinal tract (5).

Glitter, inadvertently rubbed in eyes, has been known to scratch the surface of the eye and is especially hazardous in children under three years of age (3).

Toys can also contain many chemicals of concern such as lead, phthalates found in many polyvinylchloride (PVC) plastics, cadmium, chlorine, arsenic, bromine, and mercury. When children put toys in their mouths, they may be exposed to these chemicals.

COMMENTS

Toys or games intended for use by children three to five years of age and that contain small parts should be labeled “CHOKING HAZARD--Small Parts. Not for children under three.” Because choking on small parts occurs throughout the preschool years, small parts should be kept away from children at least up to three years of age. Also, children occasionally have choked on toys or toy parts that meet federal standards, so caregivers/teachers must constantly be vigilant (2).

The federal standard that applies is Code of Federal Regulations, Title 16, Part 1501 – “Method for Identifying Toys and Other Articles Intended for Use by Children Under 3 Years of Age Which Present Choking, Aspiration, or Ingestion Hazards Because of Small Parts” – which defines the method for identifying toys and other articles intended for use by children under three years of age that present choking, aspiration, or ingestion hazards because of small parts. To obtain this publication, contact the Superintendent of Documents of the U.S. Government Printing Office or access online at http://www.access.gpo.gov/nara/cfr/waisidx_04/16cfr1501_04.html. This information also is described in the U.S. Consumer Product Safety Commission (CPSC) document, “Small Parts Regulations: Toys and Products Intended for Use by Children Under 3 Years Old,” available online at http://www.cpsc.gov/businfo/
regsumsmallparts.pdf. Also note the ASTM International (ASTM) standard “F963-08: Standard Consumer Safety Specification on Toy Safety.” To obtain this publication, contact the ASTM at http://www.astm.org.

CPSC has produced several useful resources regarding safety and toys based on age group, see: “Which Toy for Which Child Ages Birth to Five” at http://www.cpsc.gov/cpscpub/pubs/285.pdf and “Which Toy for Which Child Ages Six through Twelve” at http://www.cpsc.gov/cpscpub/pubs/286.pdf.

New technologies have become smaller and smaller. Caregivers/teachers should be aware of items such as small computer components, batteries in talking books, mobile phones, portable music players, etc. that fall under item a) in the list of prohibited items.

HealthyToys.org is a good resource for information on chemical contents in toys (4).

TYPE OF FACILITY

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

REFERENCES

Centers for Disease Control and Prevention. 2006. Gastrointestinal injuries from magnet ingestion in children — United States, 2003-2006. MMWR 55:1296-1300.
HealthyStuff.org. Chemicals of concern: Introduction. http://www.healthystuff.org/departments/toys/chemicals.introduction.php.
Southern Daily Echo. 2009. Dr. John Heyworth from Southampton General Hospital warns about festive injuries. http://www.dailyecho.co.uk/news/4814667.City_doctor_warns_about_bizarre_Christmas_injuries/.
Chowdhury, R. T., U.S. Consumer Product Safety Commission. 2008. Toy-related deaths and injuries, calendar year 2007. Washington, DC: CPSC. http://www.cpsc.gov/LIBRARY/toymemo07.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Standard 6.4.1.3: Crib Toys

Crib gyms, crib toys, mobiles, mirrors, and all objects/toys are prohibited in or attached to an infant’s crib. Items or toys should not be hung from the ceiling over an infant’s crib.

RATIONALE

Falling objects could cause injury to an infant lying in a crib.

The presence of crib gyms presents a potential strangulation hazard for infants who are able to lift their head above the crib surface. These children can fall across the crib gym and not be able to remove themselves from that position (1).

The presence of mobiles, crib toys, mirrors, etc. present a potential hazard if the objects can be reached and/or pulled down by an infant (1). Some stuffed animals and other objects that dangle from strings can wrap around a child’s neck (2).

Soft objects/toys can cause suffocation.

COMMENTS

Ornamental or small toys are often hung over an infant to provide stimulation; however, the crib should be used for sleep only. The crib is not recommended as a place to entertain an infant or to “contain” an infant. If an infant is not content in a crib, the infant should be removed.

Even though this is best practice for infants in any environment, the recommendation for prohibiting all crib gyms, mobiles, and all toys/objects in or attached to cribs may differ from what is done at an infant’s home. Caregivers/teachers have a professional responsibility to ensure a safe environment for children; therefore, child care settings are held at a higher standard, warranting the removal of these potential hazards.

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

American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. 2005. Policy statement: The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics 116:1245-55.
U.S. Consumer Product Safety Commission (CPSC). CPSC warns of strangulation with crib toys. Consumer Product Safety Alert. http://www.cpsc.gov/cpscpub/pubs/5024.pdf.

Standard 6.4.2.1: Riding Toys with Wheels and Wheeled Equipment

Riding toys (such as tricycles) and wheeled equipment (such as scooters) used in the child care setting should:

Be spokeless;
Be capable of being steered;
Be of a size appropriate for the child;
Have a low center of gravity;
Be in good condition, work properly, and free of sharp edges or protrusions that may injure the children;
Be non-motorized (excluding wheelchairs).

All riders should wear properly fitting helmets. See Standard 6.4.2.2 Helmets, regarding proper usage and type of helmet. Helmets should be removed once children are no longer using wheeled riding toys or wheeled equipment. Children should wear knee and elbow pads in addition to helmets when using wheeled equipment such as scooters, skateboards, rollerblades, etc.

Children should be closely supervised when using riding toys or wheeled equipment.

When not in use, riding toys with wheels and wheeled equipment should be stored in a location where they will not present a physical obstacle to the children and caregivers/teachers. The staff should inspect riding toys and wheeled equipment at least monthly for loose or missing hardware/parts, protrusions, cracks, or rough edges that can lead to injury.

RATIONALE

Riding toys can provide much enjoyment for children. However, because of their high center of gravity and speed, they often cause injuries in young children. Wheels with spokes can potentially cause entrapment injuries. Wearing helmets when children are learning to use riding toys or wheeled equipment teaches children the practice of wearing helmets while using any riding toy or wheeled equipment. Children should remove their helmets when they are no longer using a riding toy or wheeled equipment because helmets can be a potential strangulation hazard if they are worn for other activities (such as playing on playground equipment, climbing trees, etc.) and/or worn incorrectly.

Motorized wheeled equipment (excluding wheelchairs) used by children in a child care setting does not promote good physical activity (2). Vehicles used by children in child care need to be child propelled rather than battery propelled.

The U.S. Consumer Product Safety Commission (CPSC) and Centers for Disease Control and Prevention (CDC) reported in 2000 that 23% of children treated in emergency departments for scooter-related injuries were age eight or under (1).

Helmet use is associated with a reduction in the risk of any head injury by 69%, brain injury by 65%, and severe brain injuries by 74%, and recommended for all children one year of age and over (3).

COMMENTS

Concern regarding the spreading of head lice in sharing helmets should not override the practice of using helmets. The prevention of a potential brain injury heavily outweighs a possible case of head lice. While it is best practice for each child to have his/her own helmet, this may not be possible. If helmets need to be shared, it is recommended to clean the helmet between users. Wiping the lining with a damp cloth should remove any head lice, nits, or fungal spores. More vigorous washing of helmets, using detergents, cleaning chemicals, and sanitizers, is not recommended because these chemicals may cause the physical structure of the impact-absorbing material to deteriorate inside the helmet. The use of these chemicals can also deteriorate the straps used to hold the helmet on the head.

TYPE OF FACILITY

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

RELATED STANDARDS

6.4.1.5 Balloons
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
6.4.1.3 Crib Toys
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
6.4.1.4 Projectile Toys
6.4.2.2 Helmets
Appendix II: Bike and Multi-Sport Helmets: Quick-Fit Check

REFERENCES

Thompson, D. C., F. P. Rivara, R. S. Thompson. 1996. Effectiveness of bicycle safety helmets in preventing head injuries: A case-control study. JAMA 276:1968-73.
Griffin, R., C. T. Parks, L. W. Rue, III, G. McGwin, Jr. 2008. Comparison of severe injuries between powered and nonpowered scooters among children age 2 to 12 in the United States. Academic Pediatrics 8:379-82.
Kubiak, R., T. Slongo. 2003. Unpowered scooter injuries in children. Acta Paediatrics 92:50-54.

Standard 6.4.2.2: Helmets

Content in the STANDARD was modified on 3/31/2017.

All children one year of age and over should wear properly fitted and approved helmets while riding toys with wheels (tricycles, bicycles, etc.) or using any wheeled equipment (rollerblades, skateboards, etc.). Helmets should be removed as soon as children stop riding the wheeled toys or using wheeled equipment. Approved helmets should meet the standards of the U.S. Consumer Product Safety Commission (CPSC) (1). The standards sticker should be located on the bike helmet. Bike helmets should be replaced if they have been involved in a crash, the helmet is cracked, when straps are broken, the helmet can no longer be worn properly, or according to recommendations by the manufacturer (usually after three years).
It is not recommended that infants (children under the age of one year) wear helmets or ride as a passenger on wheeled equipment (2).

RATIONALE

Injuries occur when riding tricycles, bicycles, and other riding toys or wheeled equipment. Helmet use is associated with a reduction in the risk of any head injury by 69%, brain injury by 65%, and severe brain injuries by 74%, and recommended for all children one year of age and over (2-4).

Helmets can be a potential strangulation hazard if they are worn for activities other than when using riding toys or wheeled equipment and/or when worn incorrectly.

Infants are just learning to sit unsupported at about nine months of age. Until this age, infants have not developed sufficient bone mass and muscle tone to enable them to sit unsupported with their backs straight. Pediatricians advise against having infants sitting in a slumped or curled position for prolonged periods due to the underdevelopment of their neck muscles (5). This situation may even be exacerbated by the added weight of a bicycle helmet on the infant’s head.

COMMENTS

The CPSC helmet standard was published in March 1998 (6). Bike helmets manufactured or imported for sale in the U.S. after January 1999 must meet the CPSC standard. Helmets made before this date will not have a CPSC approval label. However, helmets made before this date should have an ASTM International (ASTM) approval label. The American National Standard Institute (ANSI) standard for helmet approval has been withdrawn, and ANSI approval labels will no longer appear on helmets. The Snell Memorial Foundation also no longer certifies bike helmets.

Concern regarding the spreading of head lice when sharing helmets should not override the practice of using helmets. The prevention of a potential brain injury heavily outweighs a possible case of head lice. While it is best practice for each child to have his/her own helmet, this may not be possible. If helmets need to be shared, it is recommended to clean the helmet between users. Helmets should be cleaned according to manufacturer's instructions.

TYPE OF FACILITY

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

RELATED STANDARDS

6.4.2.1 Riding Toys with Wheels and Wheeled Equipment

REFERENCES

ADDITIONAL REFERENCE:

Centers for Disease Control and Prevention. 2015. Head injuries and bicycle safety. http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/headinjuries.html.
U.S. Consumer Product Safety Commission (CPSC). 2017. CPSC’s Bicycle Helmet Standard. http://www.helmets.org/cpscstd.htm.
Bicycle Helmet Safety Institute. 2016. Should you take your baby along? http://www.helmets.org/little1s.htm.
Head Start. An Office of the Administration of Children and Families Early Childhood Learning & Knowledge Center (ECLKC). 2014. Play it safe: Walking and biking safely. https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family/for-families/safety/safety-prevention/PlayitSafeWal.htm.
Thompson, D. C., F. P. Rivara, R. S. Thompson. 1996. Effectiveness of bicycle safety helmets in preventing head injuries: A case-control study. JAMA 276:1968-73.
U.S. Consumer Product Safety Commission. 2016. CPSC guidelines for age-related activities. Bicycle Helmet Safety Institute. http://www.helmets.org/ageguide.htm.
U.S. Consumer Product Safety Commission (CPSC). 1998. Safety standard for bicycle helmets. http://www.bhsi.org/cpscstd.pdf.

NOTES

Content in the STANDARD was modified on 3/31/2017.

Program Activities for Healthy Development

Developmentally Appropriate Practice

Standard 2.1.1.4: Monitoring Children’s Development/Obtaining Consent for Screening

Child care settings provide daily indoor and outdoor opportunities for promoting and monitoring children’s development. Caregivers/teachers should monitor the children’s development, share observations with parents/guardians, and provide resource information as needed for screenings, evaluations, and early intervention and treatment. Caregivers/teachers should work in collaboration to monitor a child’s development with parents/guardians and in conjunction with the child’s primary care provider and health, education, mental health, and early intervention consultants. Caregivers/teachers should utilize the services of health and safety, education, mental health, and early intervention consultants to strengthen their observation skills, collaborate with families, and be knowledgeable of community resources.

Programs should have a formalized system of developmental screening with all children that can be used near the beginning of a child’s placement in the program, at least yearly thereafter, and as developmental concerns become apparent to staff and/or parents/guardians. The use of authentic assessment and curricular-based assessments should be an ongoing part of the services provided to all children (5-9). The facility’s formalized system should include a process for determining when a health or developmental screening or evaluation for a child is necessary. This process should include parental/guardian consent and participation.

Parents/guardians should be explicitly invited to:

Discuss reasons for a health or developmental assessment;
Participate in discussions of the results of their child’s evaluations and the relationship of their child’s needs to the caregivers’/teachers’ ability to serve that child appropriately;
Give alternative perspectives;
Share their expectations and goals for their child and have these expectations and goals integrated with any plan for their child;
Explore community resources and supports that might assist in meeting any identified needs that child care centers and family child care homes can provide;
Give written permission to share health information with primary health care professionals (medical home), child care health consultants and other professionals as appropriate;

The facility should document parents’/guardians’ presence at these meetings and invitations to attend.

If the parents/guardians do not attend the screening, the caregiver/teacher should inform the parents/guardians of the results, and offer an opportunity for discussion. Efforts should be made to provide notification of meetings in the primary language of the parents/guardians. Formal evaluations of a child’s health or development should also be shared with the child’s medical home with parent/guardian consent.

Programs are encouraged to utilize validated screening tools to monitor children’s development, as well as various measures that may inform their work facilitating children’s development and providing an enriching indoor and outdoor environment, such as authentic-based assessment, work sampling methods, observational assessments, and assessments intended to support curricular implementation (5,9). Programs should have clear policies for using reliable and valid methods of developmental screening with all children and for making referrals for diagnostic assessment and possible intervention for children who screen positive. All programs should use methods of ongoing developmental assessment that inform the curricular approaches used by the staff. Care must be taken in communicating the results. Screening is a way to identify a child at risk of a developmental delay or disorder. It is not a diagnosis.

If the screening or any observation of the child results in any concern about the child’s development, after consultation with the parents/guardians, the child should be referred to his or her primary care provider (medical home), or to an appropriate specialist or clinic for further evaluation. In some situations, a direct referral to the Early Intervention System in the respective state may also be required.

RATIONALE

Seventy percent of children with developmental disabilities and mental health problems are not identified until school entry (10). Daily interaction with children and families in early care and education settings offers an important opportunity for promoting children’s development as well as monitoring developmental milestones and early signs of delay (1-3). Caregivers/teachers play an essential role in the early identification and treatment of children with developmental concerns and disabilities (6-8) because of their knowledge in child development principles and milestones and relationship with families (4). Coordination of observation findings and services with children’s primary care providers in collaboration with families will enhance children’s outcomes (6).

COMMENTS

Parents/guardians need to be included in the process of considering, identifying and shaping decisions about their children, (e.g., adding, deleting, or changing a service). To provide services effectively, facilities must recognize parents’/guardians’ observations and reports about the child and their expectations for the child, as well as the family’s need of child care services. A marked discrepancy between professional and parent/guardian observations of, or expectations for, a child necessitates further discussion and development of a consensus on a plan of action.

Consideration should be given to utilizing parent/guardian-completed screening tools, such as the Ages and Stages Questionnaire (ASQ) (for a list of validated developmental screening tools, see the American Academy of Pediatric’s [AAP] list of developmental screening tools at http://www
.medicalhomeinfo.org/downloads/pdfs/DPIPscreeningtool
grid.pdf). The caregiver/teacher should explain the results to parents/guardians honestly, with sensitivity, and without using technical jargon (11).

Resources for implementing a program that involves a formalized system of developmental screening are available at the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncbddd/actearly/ and the AAP at http://www.healthychildcare.org.

Scheduling meetings at times convenient for parent/guardian participation is optimal. Those conducting an evaluation, and when subsequently discussing the findings with the family, should consider parents’/guardians’ input. Parents/guardians have both the motive and the legal right to be included in decision-making and to seek other opinions.

A second, independent opinion could be provided by the program’s child care health consultant or the child’s primary care provider.

TYPE OF FACILITY

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

RELATED STANDARDS

1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
3.1.4.5 Unscheduled Access to Rest Areas
9.4.1.3 Written Policy on Confidentiality of Records

REFERENCES

O’Connor, S., et al. 1996. ASQ: Assessing school age child care quality. Wellesly, MA: Center for Research on Women.
Glascoe, F. P. 2005. Screening for developmental and behavioral problems. Mental Retardation Develop Disabilities 11:173-79.
Gilliam, W. S., S. Meisels, L. Mayes. 2005. Screening and surveillance in early intervention systems. In A developmental systems approach to early intervention: National and international perspectives, ed. M. J. Guralnick, 73-98. Baltimore, MD: Brookes Publishing.
American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. 2006. Identifying infants and young children with developmental disorders in the medical home: An alogorithm for developmental surveillance and screening. Pediatrics 118:405-20.
Squires, J., D. Bricker. 2009. Ages and stages questionnaires. Baltimore: Brookes Publishing.
Kostelnik, M. J., A. K. Soderman, A. P. Whiren. 2006. Developmentally appropriate curriculum best practices in early childhood education. Upper Saddle River, NJ: Prentice Hall.
Brothers, K. l., F. Glascoe, N. Robertshaw. 2008. PEDS: Developmental milestones - An accurate brief tool for surveillance and screening. Clinical Pediatrics 47:271-79.
Dworkin, P. H. 1989. British and American recommendations for developmental monitoring: The role of surveillance. Pediatrics 84:1000-1010.
Copple, C., S. Bredekamp. 2009. Developmentally appropriate practice in early childhood programs serving children at birth through age 8. 3rd ed. Washington, DC: National Association for the Education of Young Children.
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.
Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.

Standard 2.1.1.5: Helping Families Cope with Separation

The staff of the facility should engage strategies to help a child and parents/guardians cope with the experience of separation and reunion, such as death of family members, divorce, or placement in foster care.

For the child, this should be accomplished by:

Encouraging parents/guardians to spend time in the facility with the child and supporting the separation transition;
Providing a comfortable setting both indoors and outdoors for parents/guardians to be with their children to transition or to have conversation with staff;
Having established routines for drop-off and pick-up times to assist with transition;
Enabling the child to bring to child care tangible reminders of home/family (such as a favorite toy or a picture of self and parent/guardian);
Encouraging parents/guardians to reassure the child of their return and to calmly say “goodbye”;
Helping the child play out themes of separation and reunion;
Frequently exchanging information between the child’s parents/guardians and caregivers/teachers, including activities and routine care information particularly during greeting and departing;
Reassuring the child about the parent’s/guardian’s return;
Ensuring the caregivers/teachers are consistent both within the parts of a day and across days;
Requesting assistance from early childhood mental health consultants, mental health professionals, developmental-behavioral pediatricians, parent/guardian counselors, etc. when a child’s adjustment continues to be problematic over time;
When a family is experiencing separation due to a military deployment, explore changes in children’s behavior that may be related to feelings of anger, fear, sadness, or uncertainty related to changes in family structure as a result of deployment. Work with the parent/guardian at home to help the child adjust to these changes, including providing activities that help the child remain connected to the deployed parent/guardian and manage their emotions throughout the deployment cycle.

For the parents/guardians, this should be accomplished by:

Validating their feelings as a universal human experience;
Providing parents/guardians with information about the positive effects for children of high quality facilities with strong parent/guardian participation;
Encouraging parents/guardians to discuss their feelings;
Providing parents/guardians with evidence, such as photographs, that their child is being cared for and is enjoying the activities of the facility;
Ask parents/guardians to bring pictures from home that may be placed in the room or cubby and displayed throughout the indoor and outdoor learning/play environment at the child’s eye level;
Where a family is experiencing separation due to a military deployment, collaborate with the parent/guardian at home to address changes in children’s behavior that may be related to the deployment, providing parents/guardians with information about activities in care and at home may help promote their child’s positive adjustment throughout the deployment cycle (connect parents/guardians with services/resources in the community that can help to support them);
Requesting assistance from early childhood mental health consultants, mental health professionals, developmental-behavioral pediatricians, parent/guardian counselors, etc. when a child’s adjustment continues to be problematic over time.

RATIONALE

In childhood, some separation experiences facilitate psychological growth by mobilizing new approaches for learning and adaptation. Other separations are painful and traumatic. The way in which influential adults provide support and understanding, or fail to do so, will shape the child’s experience (1).

Many parents/guardians who prefer to care for their young children only at home may have no other option than to place their children in out-of-home child care before three months of age. Some parents/guardians prefer combining out-of-home child care with parental/guardian care to provide good experiences for their children and support for other family members to function most effectively. Whether parents/guardians view out-of-home child care as a necessary accommodation to undesired circumstances or a benefit for their family, parents/guardians and their children need help from the caregivers/teachers to accommodate the transitions between home and out-of-home settings (2).

Many parents/guardians experience distress at separation. For most parents/guardians, the younger their child and the less experience they have had with sharing the care of their children with others, the more intense their distress at separation (3).

Although children’s responses to deployment separation will vary depending on age, personality, and support received, children will be aware of a parent’s/guardian’s long-term absence and may mourn. Children may feel uncertain, sad, afraid, or angry. These feelings can manifest as increased clinginess, aggression, withdrawal, changes in sleeping or eating patterns, regression or other behaviors. Young children don’t often have the vocabulary to express their emotions, and may need support to express their feelings in healthy and safe ways (2). Additionally, the parent/guardian at home may be experiencing stress, anxiety, depression, or fear. These parents/guardians may benefit from additional outreach from caregivers/teachers, who are part of their community support system, and can help them with strategies to promote children’s adjustment and connect them with resources in the community (3).

COMMENTS

Depending on the child’s developmental stage, the impact of separation on the child and parent/guardian will vary. Child care facilities should understand and communicate this variation to parents/guardians and work with parents/guardians to plan developmentally appropriate coping strategies for use at home and in the child care setting. For example, a child at eighteen to twenty-four months of age is particularly vulnerable to separation issues and may show visible distress when experiencing separation from parents/guardians. Entry into child care at this age may trigger behavior problems, such as difficulty sleeping. Even for the child who has adapted well to a child care arrangement before this developmental stage, such difficulties can occur as the child continues in care and enters this developmental stage. For younger children, who are working on understanding object permanence (usually around nine to twelve months of age), parents/guardians who sneak out after bringing their children to the child care facility may create some level of anxiety in the child throughout the day. Sneaking away leaves the child unable to discern when someone the child trusts will leave without warning. Parents/guardians and caregivers/teachers reminding a child that the parent/guardian returned as promised reinforces truthfulness and trust. Parents/guardians of children of any age should be encouraged to visit the facility together before the child care officially begins. Parents/guardians of infants may benefit from feeling assured by the caregivers/teachers themselves. Depending on the child’s temperament and prior care experience, several visits may be recommended before enrolling as well opportunities to practice the process and consistency of a separation experience in the first weeks of entering the child care. Using a phasing-in period can also be helpful (e.g., spend only a part of the day with parents/guardians on the first day, half-day on the second day, and parents/guardians leave earlier, etc.)

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.2.1 Minimum Age to Enter Child Care
1.6.0.3 Infant and Early Childhood Mental Health Consultants
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff

REFERENCES

Gonzalez-Mena, J. 2007. Separation: Helping children and families. In 50 Early childhood strategies for working and communicating with diverse families, 96-97. Upper Saddle River, NJ: Prentice Hall.
Kim, A. M., J. Yeary. 2008. Making long-term separations easier for children and families. Young Children 63:32-37.
Blecher-Sass, H. 1997. Good-byes can build trust. Young Child 52:12-14.

Standard 2.1.1.6: Transitioning within Programs and Indoor and Outdoor Learning/Play Environments

Caregivers/teachers should take into consideration the individual needs of children when transitioning them to a new indoor and outdoor learning/play environment. The transitioning child/children should be offered the opportunity to visit the new space with a familiar caregiver/teacher with enough time to allow them to display comfort in the new space. The program should allow time for communication with the families regarding the process and for each child to follow through a comfortable time line of adaptation to the new indoor and outdoor learning/play environment, caregiver/teachers, and peers.

Children need time to manipulate, explore and familiarize themselves with the new space and caregivers/teachers. This should be done before they are part of a new group to allow them time to explore to their personal satisfaction. Eating is a primary reinforcer and need. The opportunity to share food within the new space will help reassure a child and help adults assess how the transition is going. Toileting involves another level of trust. Diapering/toileting should be introduced in the new space with a familiar teacher.

New routines should be introduced by the new staff with a familiar caregiver/teacher present to support the child/children. Transitions to the indoor and outdoor learning/play environment, especially if the space is different than the one from which they are familiar, should follow similar procedures as moving to another indoor space. Parents/guardians should be part of the transition as they too are in the process of learning to trust a new indoor and outdoor learning/play environment for their child. Primary needs need to be met to support a smooth transition.

Transitions should be planned in advance, based on the child’s readiness. A written plan should be developed and shared with parents/guardians, describing how and when the transition will occur. Children should not be moved to a new indoor and outdoor learning/play environment for the sole purpose of maintaining child: staff ratios.

RATIONALE

Supporting the achievement of developmental tasks for young children is essential for their social and emotional health. Establishing trust with caregivers/teachers and successful adaptation to a new indoor and outdoor learning/play environment is a critical component of quality care. Young children need predictability and routine. They need to feel secure and to understand the expectations of their environment. By taking time to allow them to familiarize themselves with their new caregivers/teachers and environment, they are better able to handle the emotional, cognitive, and social requirements of their new space (1-5).

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.2.5 Toilet Learning/Training

REFERENCES

Maslow, A. 1943. A theory of human motivation. Psychological Review 50:370-96
Mahler, M., F. Pine, A. Bergman. 1975. The Psychological birth of the human infant. New York: Basic Books.
Lally, R. L., L. Y. Torres, P. C. Phelps. 1994. Caring for infants and toddlers in groups: Necessary considerations for emotional, social, and cognitive development. Zero to Three 14:1-8.
Gorski, P. A., S. P. Berger. 2005. Emotional health in child care. In Health in child care: A manual for health professionals, ed. J. R. Murph, S. D. Palmer, D. Glassy, 173-86. Elk Grove Village, IL: American Academy of Pediatrics.
Erikson, E. H. 1950. Childhood and society. New York: W.W. Norton and Co.

Standard 2.1.1.7: Communication in Native Language Other Than English

At least one member of the staff should be able to communicate with the parents/guardians and children in the family’s native language (sign or spoken), or the facility should work with parents/guardians to arrange for a translator to communicate with parents/guardians and children. Efforts should be made to support a child’s and family’s native language while providing resources and opportunities for learning English (2). Children should not be used as translators. They are not developmentally able to understand the meaning of all words as used by adults, nor should they participate in all conversations that may be regarding the child.

RATIONALE

The future development of the child depends on his/her command of language (1). Richness of language increases as a result of experiences as well as through the child’s verbal interaction with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. Learning English while maintaining a family’s native language enriches child development and strengthens family cultural traditions.

COMMENTS

For resources on bilingual and dual language learning, see the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics (SODBP) at http://www.aap.org/sections/dbpeds/.

TYPE OF FACILITY

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

REFERENCES

Olsen, L. 2006. Ensuring academic success of English learners. 2006. U.C. Linguistic Minority Research Institute 15:1-7.
Moerk, E. L. 2000. The guided acquisition of first language skills. Advances Applied Dev Psychol 20:248.

Standard 2.1.1.9: Verbal Interaction

The child care facility should assure that a rich environment of spoken language by caregivers/teachers surrounds and includes all children with opportunities to expand their language communication skills. Each child should have at least one speaking adult person who engages the child in frequent verbal exchanges linked to daily events and experiences. To encourage the development of language, the caregiver/teacher should demonstrate skillful verbal communication and interaction with the child.

For infants, these interactions should include responses to, and encouragement of, soft infant sounds, as well as identifying objects, feelings, and desires by the caregiver/teacher.
For toddlers, the interactions should include naming of objects, feelings, listening to the child and responding, along with actions and supporting, but not forcing, the child to do the same.
For preschool and school-age children, interactions should include respectful listening and responses to what the child has to say, amplifying and clarifying the child’s intent, and not reinforcing mispronunciations (e.g., Wambulance instead of Ambulance).
Frequent interchange of questions, comments, and responses to children, including extending children’s utterances with a longer statement, by teaching staff.
For children with special needs, alternative methods of communication should be available, including but not limited to: sign language, assistive technology, picture boards, picture exchange communication systems (PECS), FM systems for hearing aids, etc. Communication through methods other than verbal communication can result in the same desired outcomes.
Profanity should not be used at any time.

RATIONALE

Conversation with adults is one of the main channels through which children learn about themselves, others, and the world in which they live. While adults speaking to children teaches the children facts and relays information, the social and emotional communications and the atmosphere of the exchange are equally important. Reciprocity of expression, response, and the initiation and enrichment of dialogue are hallmarks of the social function and significance of the conversations (1-4).

The future development of the child depends on his/her command of language (5). Research suggests that language experiences in a child’s early years have a profound influence on that child’s language and vocabulary development, which in turn has an impact on future school success (6). Richness of the child’s language increases as it is nurtured by verbal interactions and learning experiences with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. Discussing the impact of actions on feelings for the child and others helps to develop empathy.

TYPE OF FACILITY

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

REFERENCES

Pikulski, J. J., Templeton, S. 2004. Teaching and developing vocabulary: Key to long-term reading success. Geneva, IL: Houghton Mifflin Company. http://www.eduplace.com/state/author/pik_temp.pdf.
Moerk, E. L. 2000. The guided acquisition of first language skills. Advances in Applied Dev Psychol 20:248.
Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: Why are they so important? Young Child 52:4-12.
Szanton, E. S., ed. 1997. Creating child-centered programs for infants and toddlers, birth to 3 year olds, step by step: A Program for children and families. New York: Children’s Resources International, Inc.
Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, IL: Learning Seed.
Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Education 7:229-39.

Standard 2.1.2.1: Personal Caregiver/Teacher Relationships for Infants and Toddlers

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

The facility should practice a relationship-based philosophy that promotes consistency and continuity of caregivers/teachers for infants and toddlers (1-3). Facilities should implement continuity of care practices into established policies and procedures as a means to foster strong, positive relationships that will act as a secure basis for exploration and learning in the classroom (1-4). Child–caregiver relationships based on high-quality care are central to brain development, emotional regulation, and overall learning (5). The facility should encourage practices of continuity of care that give infants and toddlers the added benefit of the same caregiver for the first three years of life of the child or during the time of enrollment (6). The facility should limit the number of caregivers/teachers who interact with any one infant or toddler (1).

The caregiver/teacher should:

Use a variety of safe and appropriate individualized soothing methods of holding and comforting infants and toddlers who are upset (7).
Engage in frequent, multiple, and rich social interchanges, such as smiling, talking, appropriate forms of touch, singing, and eating.
Be play partners as well as protectors.
Be attuned to infants’ and toddlers’ feelings and reflect them back.
Communicate consistently with parents/guardians.
Interact with infants and toddlers and develop a relationship in the context of everyday routines (eg, diapering, feeding).

Opportunities should be provided for each infant and toddler to develop meaningful relationships with caregivers.

The facility’s touch policy should be direct in addressing that children may be touched when it is appropriate for, respectful to, and safe for the child. Caregivers/teachers should respect the wishes of children, regardless of their age, for physical contact and their comfort or discomfort with it. Caregivers/teachers should avoid even “friendly” contact (eg, touching the shoulder or arm) with a child if the child expresses that he or she is uncomfortable.

RATIONALE

When children trust caregivers and are comfortable in the environment that surrounds them, they are allowed to focus on educational discoveries in their physical, social, and emotional development.

Holding, and hugging, in a positive, respectful, and safe manner is an essential part of providing care for infants and toddlers.

Quality caregivers/teachers provide care and learning experiences that play a key role in a child’s development as an active, self-knowing, self-respecting, thinking, feeling, and loving person (8). Limiting the number of adults with whom an infant or a toddler interacts fosters reciprocal understanding of communication cues that are unique to each infant or toddler. This leads to a sense of trust of the adult by the infant or toddler that the infant’s or toddler’s needs will be understood and met promptly (5,6). Studies of infant behavior show that infants have difficulty forming trusting relationships in settings where many adults interact with infants (eg, in hospitalization of infants when shifts of adults provide care) (9).

Sexual abuse in the form of inappropriate touching is an act that induces or coerces children in a sexually suggestive manner or for the sexual gratification of the adult, such as sexual penetration and/or overall inappropriate touching or kissing (10).

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
3.4.4.2 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

Zero to Three. Primary caregiving and continuity of care. https://www.zerotothree.org/resources/85-primary-caregiving-and-continuity-of-care. Published February 8, 2010. Accessed January 11, 2018
National Scientific Council on the Developing Child. The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper 12. https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2012/05/The-Science-of-Neglect-The-Persistent-Absence-of-Responsive-Care-Disrupts-the-Developing-Brain.pdf. Published December 2012. Accessed January 11, 2018
Harvard University Center on the Developing Child. Three principles to improve outcomes for children and families. https://developingchild.harvard.edu/resources/three-early-childhood-development-principles-improve-child-family-outcomes. Accessed January 11, 2018
Recchia SL. Caregiver–child relationships as a context for continuity in child care. Early Years. 2012;32(2):143–157
US Department of Health and Human Services, Child Care State Capacity Building Center. Six essential program practices. Program for infant/toddler care. https://childcareta.acf.hhs.gov/sites/default/files/public/pitc_rationale_-_continuity_of_care_508_0.pdf. Published January 2017. Accessed January 11, 2018
Ruprecht K, Elicker J, Choi J. Continuity of care, caregiver–child interactions, toddler social competence and problem behaviors. Early Educ Dev. 2015;27:221–239
Kim Y. Relationship-based developmentally supportive approach to infant childcare practice. Early Child Dev Care. 2015:734-749
Understanding children’s behavior. In: Miller DF. Positive Child Guidance. 8th ed. Boston, MA: Cengage Learning; 2016
Sandstrom H, Huerta S. The negative effects of instability on child development: a research synthesis. Urban Institute Web site. https://www.urban.org/research/publication/negative-effects-instability-child-development-research-synthesis. Published September 18, 2013. Accessed January 11, 2018
Al Odhayani A, Watson WJ, Watson L. Behavioural consequences of child abuse. Can Fam Physician. 2013;59(8):831–836

NOTES

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

Standard 2.1.2.2: Interactions with Infants and Toddlers

Caregivers/teachers should provide consistent, continuous and inviting opportunities to talk, listen to, and otherwise interact with young infants throughout the day (indoors and outdoors) including feeding, changing, playing with, and cuddling them.

RATIONALE

Richness of language increases by nurturing it through verbal interactions between the child and adults and peers. Adults’ speech is one of the main channels through which children learn about themselves, others, and the world in which they live. While adults speaking to children teach the children facts, the social and emotional communications and the atmosphere of the exchange are equally important. Reciprocity of expression, response, the initiation and enrichment of dialogue are hallmarks of the social function and significance of the conversations (2-5). Infants and toddlers learn through meaningful relationships and interaction with consistent adults and peers.

The future development of the child depends on his/her command of language (1). Richness of language increases as it is nurtured by verbal interactions of the child with adults and peers. Basic communication with parents/guardians and children requires an ability to speak their language. A language-rich environment and warm, responsive interactions between staff and children are among the elements that produce positive impacts (6).

COMMENTS

Live, real-time interaction with caregivers/teachers is preferred. For example, caregivers/teachers naming objects in the indoor and outdoor learning/play environment or singing rhymes to all children supports language development. Children’s stories and poems presented on recordings with a fixed speed for sing-along can actually interfere with a child’s ability to participate in the singing or recitation. With fixed-speed activities, the pace may be too fast for some children, and the activity may have to be repeated for some children or the caregiver/teacher will need to try a different method for learning.

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.3 Screen Time/Digital Media Use

REFERENCES

Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. ERIC Digest (January).
Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: Why are they so important? Young Child 52:4-12.
National Forum on Early Childhood Program Evaluation, National Scientific Council on the Developing Child. 2007. A science-based framework for early childhood policy: Using evidence to improve outcomes in learning, behavior, and health for vulnerable children. Cambridge, MA: Center on the Developing Child, Harvard University. http://developingchild.harvard.edu/index.php/library/reports_and_working_papers/policy_framework/.
Szanton, E. S., ed. 1997. Creating child-centered programs for infants and toddlers, birth to 3 year olds, step by step: A Program for children and families. New York: Children’s Resources International.
Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, Ill: Learning Seed.
Moerk, E. L. 2000. The guided acquisition of first language skills. Advances Applied Dev Psychol 20:248.

Standard 2.1.2.3: Space and Activity to Support Learning of Infants and Toddlers

The facility should provide a safe and clean learning environment, both indoors and outdoors, colorful materials and equipment arranged to support learning. The indoor and outdoor learning/play environment should encourage and be comfortable with staff on the floor level when interacting with active infant crawlers and toddlers. The indoor and outdoor play and learning settings should provide opportunities for the child to act upon the environment by experiencing age-appropriate obstacles, frustrations, and risks in order to learn to negotiate environmental challenges. The facility should provide opportunities for play that:

Lessen the child’s anxiety and help the child adapt to reality and resolve conflicts;
Enable the child to explore and experience the natural world;
Help the child practice resolving conflicts;
Use symbols (words, numbers, etc.);
Manipulate objects;
Exercise physical skills;
Encourage language development;
Foster self-expression;
Strengthen the child’s identity as a member of a family and a cultural community;
Promote sensory exploration.

For infants and toddlers the curriculum should be based on the child’s development at the time and connected to a sound understanding as to where they are in their developmental course.

RATIONALE

Opportunities to be an active learner are vitally important for the development of motor competence and awareness of one’s own body and person, the development of sensory motor skills, the ability to demonstrate initiative through active outdoor and indoor play, and feelings of mastery and successful coping. Coping involves original, imaginative, and innovative behavior as well as previously learned strategies.

Learning to resolve conflicts constructively in childhood is essential in preventing violence later in life (1,2). A physical and social environment that offers opportunities for active mastery and coping enhances the child’s adaptive abilities (3,4,9). The importance of play for developing cognitive skills, for maintaining an affective and intellectual equilibrium, and for creating and testing new capacities is well recognized (8). Play involves a balance of action and symbolization, and of feeling and thinking (5-7). Children need access to age-appropriate toys and safe household objects.

COMMENTS

For more information regarding appropriate play materials for young children, see “Which Toy for Which Child: A Consumer’s Guide for Selecting Suitable Toys” from the U.S. Consumer Product Safety Commission (CPSC) and “The Right Stuff for Children Birth to 8: Selecting Play Materials to Support Development” from the National Association for the Education of Young Children (NAEYC). For information regarding appropriate materials for outdoor play, see POEMS: Preschool Outdoor Environment Measurement Scale (10).

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.2.1 Space Required per Child
5.2.9.14 Shoes in Infant Play Areas
5.3.1.1 Indoor and Outdoor Equipment, Materials, and Furnishing
3.1.3.1 Active Opportunities for Physical Activity
5.3.1.5 Placement of Equipment and Furnishings

REFERENCES

Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Education 7:229-39.
Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer cultures of preschool and preadolescent children: An interpretative approach. Childhood 5:377-402.
DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. 2005. Preschool outdoor environment measurement scale. Lewisville, NC: Kaplan Early Learning Co.
Torelli, L., C. Durrett. 1996. Landscape for learning: The impact of classroom design on infants and toddlers. Early Childhood News 8 (March-April): 12-17. http://www.spacesforchildren.com/landc1.pdf.
Tepperman, J., ed. 2007. Play in the early years: Key to school success, a policy brief. El Cerrito, CA: Early Childhood Funders. http://www.4children.org/images/pdf/play07.pdf.
Pica, R. 1997. Beyond physical development: Why young children need to move. Young Child 52:4-11.
Petersen, E. A. 1998. The amazing benefits of play. Child Family 17:7-8.
Cartwright, S. 1998. Group trips: An invitation to cooperative learning. Child Care Infor Exch 124:95-97.
Levin, D. E. 1994. Teaching young children in violent times: Building a peaceable classroom, A preschool-grade 3 violence prevention and conflict resolution guide. Cambridge, MA: Educators for Social Responsibility.
Massey, M. S. 1998. Early childhood violence prevention. ERIC Digest (October).

Standard 2.1.2.4: Separation of Infants and Toddlers from Older Children

Infants and toddlers younger than three years of age should be cared for in a closed room(s) that separates them from older children, except in small family child care homes with closed groups of mixed aged children.

In facilities caring for three or more children younger than three years of age, activities that bring children younger than three years of age in contact with older children should be prohibited, unless the younger children already have regular contact with the older children as part of a group.

Pooling, as a practice in larger settings where the infants/toddlers are not part of the group all day – as in home care – should be avoided for the following reasons:

Unfamiliarity with caregivers/teachers if not the primary one during the day;
Concerns of noise levels, space ratios, social-emotional well-being, etc.;
Occurs at times when children are least able to handle transitions;
Increases the number of transitions for children,
Increases the number of adults caring for infants and toddlers, a practice to be avoided if possible.

Caregivers/teachers of infants should not be responsible for the care of older children who are not a part of the infants’ closed child care group.

Groups of younger infants should receive care in closed room(s) that separates them from other groups of toddlers and older children.

When partitions are used, they must control interaction between groups, provide separated ventilation of the spaces and control sound transmission. The acoustic controls should limit significant transmission of sound from one group’s activity into other group environments.

RATIONALE

Infants need quiet, calm environments, away from the stimulation of older children. Younger infants should be cared for in rooms separate from the more boisterous toddlers. In addition to these developmental needs of infants, separation is important for reasons of disease prevention. Rates of hospitalization for all forms of acute infectious respiratory tract diseases are highest during the first year of life, indicating that respiratory tract illness becomes less severe as the child gets older (1). Therefore, infants should be a focus for interventions to reduce the incidence of respiratory tract diseases. Handwashing and sanitizing practices are key.

Depending on the temperament of the child, an increase in transitions can increase anxiety in young children by reducing the opportunity for routine and predictability (2), and it increases basic health and safety concerns of cross contamination with older children who have more contact with the environment.

COMMENTS

This separation of younger children from older children ideally should be implemented in all facilities, but may be less feasible in small or large family child care homes.

Separation of groups of children by low partitions that divide a single common space is not acceptable. Without sound attenuation, limitation of shared air pollutants including airborne infectious disease agents, or control of interactions among the caregivers/teachers who are working with different groups, the separate smaller groups are essentially one large group.

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.2 Handwashing Procedure
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

Poole, C. 1998. Routine matters. Scholastic Parent Child (August/September).
Izurieta, H. S., W. W. Thompson, P. Kramarz, et al. 2000. Influenza and the rates of hospitalization for respiratory disease among infants and young children. New England J Med 342:232-39.

Standard 2.1.2.5: Toilet Learning/Training

The facility should develop and implement a plan that teaches each child how and when to use the toilet. Toilet learning/training, when initiated, should follow a prescribed, sequential plan that is developed and coordinated with the parent’s/guardian’s plan for implementation in the home environment. Toilet learning/training should be based on the child’s developmental level rather than chronological age.

To help children achieve bowel and bladder control, caregivers/teachers should enable children to take an active role in using the toilet when they are physically able to do so and when parents/guardians support their children’s learning to use the toilet.

Diapering/toilet training should not be used as rationale for not spending time outdoors. Practices and policies should be offered to address diapering/toileting needs outdoors such as providing staff who can address children’s needs, or provide outdoor diapering and toileting that meets all sanitation requirements.

Caregivers/teachers should take into account the preferences and customs of the child’s family.

For children who have not yet learned to use the toilet, the facility should defer toilet learning/training until the child’s family is ready to support this learning and the child demonstrates:

An understanding of the concept of cause and effect;
An ability to communicate, including sign language;
The physical ability to remain dry for up to two hours;
An ability to sit on the toilet, to feel/understand the sense of elimination;
A demonstrated interest in autonomous behavior.

For preschool and school-age children, an emphasis should be placed on appropriate handwashing after using the toilet and they should be provided frequent and unrestricted opportunities to use the toilet.

Children with special health care needs may require specific instructions, training techniques, adapted toilets, and/or supports or precautions. Some children will need to be taught special techniques like catheterization or care of ostomies. This can be provided by trained staff or older children can sometimes learn self-care techniques. Any special techniques should be documented in a written care plan. The child care health consultant can provide training or coordinate resources necessary to accommodate special toileting techniques while in child care.

Cultural expectations of toilet learning/training need to be recognized and respected.

RATIONALE

A child’s achievements of motor and cognitive or developmental skills assist in determining when s/he is ready for toilet learning/training (1). Physical ability/neurological function also includes the ability to sit on the toilet and to feel/understand the sense of elimination.

Toilet learning/training is achieved more rapidly once expectations from adults across environments are consistent (3). The family may not be prepared, at the time, to extend this learning/training into the home environment (2).

School-age and preschool children may not respond when their bodies signal a need to use the toilet because they are involved in activities or embarrassed about needing to use the toilet. Holding back stool or urine can lead to constipation and urinary tract problems (4). Also, unless reminded, many children forget to correctly wash their hands after toileting.

COMMENTS

The area of toilet learning/training for children with special health care needs is difficult because there are no age-related, disability-specific rules to follow. As a result, support and counseling for parents/guardians and caregivers/teachers are required to help them deal with this issue. Some children with multiple disabilities do not demonstrate any requisite skills other than being dry for a few hours. Establishing a toilet routine may be the first step toward learning to use the toilet, and at the same time, improving hygiene and skin care. The child care health consultant should be considered a resource to assist is supporting special health care needs.

Sometimes children need to increase their fluid intake to help a medical condition and this can lead to increased urination. Other conditions can lead to loose stools. Children should be given unrestricted access to toileting facilities, especially in these situations. Children who are recovering from gastrointestinal illness might temporarily lose continence, especially if they are recently toilet trained, and may need to revert to diapers or training pants for a short period of time. Children who are experiencing stress (e.g., a new infant in the family) may regress and also return to using diapers for a period of time.

For more information on toilet learning/training, see “Toilet Training: Guidelines for Parents,” available from the American Academy of Pediatrics (AAP) at http://www.aap.org and the AAP Section on Developmental and Behavioral Pediatrics at http://www.aap.org/sections/dbpeds/.

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning and Training Equipment
3.2.1.5 Procedure for Changing Children’s Soiled Underwear, Disposable Training Pants and Clothing
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.5 Chemical Toilets
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)

REFERENCES

Schmitt, B. D. 2004. Toilet training problems: Underachievers, refusers, and stool holders. Contemporary Pediatrics 21:71-77.
Anthony-Pillai, R. 2007. What’s potty about early toilet training? British Med J 334:1166.
American Academy of Pediatrics. 2009. When is the right time to start toilet training? http://www.aap.org/publiced/BR_ToiletTrain.htm.
Mayo Clinic. 2009. Potty training: How to get the job done. http://www.mayoclinic.com/health/potty-training/CC00060/.

Standard 2.2.0.2: Limiting Infant/Toddler Time in Crib, High Chair, Car Seat, Etc.

Frequently Asked Questions/CFOC Clarifications

Reference: 2.2.0.2

Date: 10/13/2011

Topic & Location:
Chapter 2
Program Activities
Standard 2.2.0.2: Limiting In-fant/Toddler Time in Crib, High Chair, Care Seat, Etc.

Question:
Please provide more contexts surrounding the research that informed the recommendation that “children should not be left to sleep in equipment, such as car seats, swings, or infants seats that do not meet the ASTM International (ASTM) product safety standards for sleep equipment.”

Is part of the intent regarding this standard to educate parents about safe infant sleep practices or is it actually dangerous for infants to sleep sitting up, or both?

Answer:
Both. Extended periods of time in the crib, high chair, car seat, or other confined space limits infants’ physical growth (gross motor development) and also affects their social interactions. Injuries and Sudden Infant Death Syndrome (SIDS) have occurred when children have been left to sleep in car seats or infants seats.

Please see the Standard’s rationale and references for information on related injuries and SIDS.

A child should not sit in a high chair or other equipment that constrains his/her movement (1,2) indoors or outdoors for longer than fifteen minutes, other than at meals or snack time. Children should never be left out of the view and attention of adult caregivers/teachers while in these types of equipment/furniture. A least restrictive environment should be encouraged at all times. Children should not be left to sleep in equipment, such as car seats, swings, or infant seats that does not meet ASTM International (ASTM) product safety standards for sleep equipment.

RATIONALE

Children are continually developing their physical skills. They need opportunities to use and build on their physical abilities. This is especially true for infants and toddlers who are eagerly using their bodies to explore their environment. Extended periods of time in the crib, high chair, car seat, or other confined space limits their physical growth and also affects their social interactions. Injuries and Sudden Infant Death Syndrome (SIDS) have occurred when children have been left to sleep in car seats or infant seats when the straps have entrapped body parts, or the children have turned the seats over while in them. Sleeping in a seated position can restrict breathing and cause oxygen desaturation in young infants (3). Sleeping should occur in equipment manufactured for this activity. When children are awake, restricting them to a seat may limit social interactions. These social interactions are essential for children to gain language skills, develop self-esteem, and build relationships (4).

TYPE OF FACILITY

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

RELATED STANDARDS

5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
3.1.3.1 Active Opportunities for Physical Activity
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.3.1.10 Restrictive Infant Equipment Requirements

REFERENCES

New York State Office of Children and Family Services. Website. http://www.ocfs.state.ny.us/main/.
Bass, J. L., M. Bull. 2008. Oxygen desaturation in term infants in car safety seats. Pediatrics 110:401-2.
Benjamin, S.E., S.L. Rifas-Shiman, E.M. Taveras, J. Haines, J. Finkelstein, K. Kleinman, M.W. Gillman. 2009. Early child care and adiposity at ages 1 and 3 years. Pediatrics 124:555-62.
Kornhauser Cerar, L., C.V. Scirica, I. Stucin Gantar, D. Osredkar, D. Neubauer, T.B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in care safety seats and beds. Pediatrics 124:e396-e402.

Standard 2.2.0.3: Screen Time/Digital Media Use

Frequently Asked Questions/CFOC Clarifications

Reference: 2.2.0.3

Date: 03/08/2012

Topic & Location:
Chapter 2
Program Activities
Standard 2.2.0.3: Limiting Screen Time - Media, Computer Time

Question:
This standard states that children two years and older in early care and education settings should not be exposed to more than thirty minutes per week of screen time and that computer use should be limited to no more than fifteen minute increments.

Is the fifteen minute increment for computer use included in the total screen time of thirty minutes per week?

Answer:
Yes.

Content in the STANDARD was modified on 10/12/2017.

Please note: For the purposes of this standard “screen time/digital media” refers to media content viewed on cell/mobile phone, tablet, computer, television (TV), video, film, and DVD. It does not include video-chatting with family.

Screen time/digital media should not be used with children ages 2 and younger in early care and education settings. For children ages 2 to 5 years, total exposure (in early care and education and at home combined) to digital media should be limited to 1 hour per day of high-quality programming [1], and viewed with an adult who can help them apply what they are learning to the world around them (1).

Children ages 5 and older may need to use digital media in early care and education to complete homework. However, caregivers/teachers should ensure that entertainment media time does not displace healthy activities such as exercise, refreshing sleep, and family time, including meals.

For children of all ages, digital media and devices should not be used during meal or snack time, or during nap/rest times and in bed. Devices should be turned off at least one hour before bedtime. When offered, digital media should be free of advertising and brand placement, violence, and sounds that tempt children to overuse the product.

Caregivers/teachers should communicate with parents/guardians about their guidelines for home media use. Caregivers/teachers should take this information into consideration when planning the amount of media use at the child care program to help in meeting daily recommendations (1).

Programs should prioritize physical activity and increased personal social interactions and engagement during the program day. It is important for young children to have active social interactions with adults and children. Media use can distract children (and adults), limit conversations and play, and reduce healthy physical activity, increasing the risk for overweight and obesity. Media should be turned off when not in use since background media can be distracting, and reduce social engagement and learning. Overuse of media can also be associated with problems with behavior, limit-setting, and emotional and behavioral self-regulation; therefore, caregivers/teachers should avoid using media to calm a child down (1).

Note: The guidance above should not limit digital media use for children with special health care needs who require and consistently use assistive and adaptive computer technology (2). However, the same guidelines apply for entertainment media use. Consultation with an expert in assistive communication may be necessary.

[1] designed with child psychologists and educators to meet specific educational goals

RATIONALE

The first two years of life are critical periods of growth and development for children’s brains and bodies, and rapid brain development continues through the early childhood years. To best develop their cognitive, language, motor, and social-emotional skills, infants and toddlers need hands-on exploration and social interaction with trusted caregivers (1). Digital media viewing do not promote such skills development as well as “real life”.

Excessive media use has been associated with lags in achievement of knowledge and skills, as well as negative impacts on sleep, weight, and social/emotional health. (1). For example, among 2-year-olds, research has shown that body mass index (BMI) increases with greater weekly media consumption (3).

COMMENTS

Digital media is not without benefits, including learning from high-quality content, creative engagement, and social interactions. However, especially in young children, real-life social interactions promote greater learning and retention of knowledge and skills. When limited digital media are used, co-viewing and co-teaching with an engaged adult promotes more effective learning and development.

Because children may use digital media before and after attending early care and education settings, limiting digital media use in early care and education settings and substituting developmentally appropriate play and other hands-on activities can better promote learning and skills development. Such an activity is reading. Caregivers/teachers should begin reading to children at infancy (4) and facilities should make age-appropriate books available for each cognitive stage of development that can be co-read and discussed with an adult. See the American Academy of Pediatrics’ “Books Build Connections Toolkit” at https://littoolkit.aap.org/forprofessionals/Pages/home.aspx for more information.
The American Academy of Pediatrics has developed a Family Media Use Plan tool, available at https://www.healthychildren.org/English/media/Pages/default.aspx, which can help parents/guardians, caregivers, and families identify healthy activities for each child, and prioritize them ahead of limited digital media use (5).

Caregivers/teachers serve as role models for children in early care and education settings by not using or being distracted by digital media during care hours. In addition, if adults view media such as news in the presence of children, children may be exposed to inappropriate language or violent or frightening images that can cause emotional upset or increase aggressive thoughts and behavior. Caregivers/teachers should be discouraged from using digital media for personal use while actively engaging with and supervising the children in their care. Instead, opportunities for collaborative activities are preferred.

It is important to safeguard privacy for children on the internet and digital media. Pictures and videos of children should never be posted on social media without parent/guardian consent. Caregivers/teachers should know and follow their program’s policy for taking, sharing, or posting pictures and videos.

ADDITIONAL RESOURCES

American Academy of Pediatrics Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5): e20162593. http://pediatrics.aappublications.org/content/pediatrics/early/2016/10/19/peds.2016-2593.full.pdf.

American Academy of Pediatrics. Media and children communication toolkit. Aap.org Web site. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/pages/media-and-children.aspx. Accessed October 12, 2017.

Campaign for a Commercial-Free Childhood. Screenfree.org Web site. http://www.screenfree.org/. Accessed October 12, 2017.

Common Sense Education. Commonsense.org Web site. https://www.commonsense.org/education/toolkit/audience/device-free-dinner-educator-resources. Accessed October 12, 2017.

Fred Rogers Center for Early Learning and Children’s Media at Saint Vincent College. How am I doing? A checklist for identifying exemplary uses of technology and interactive media for early learning. Fredrogerscenter.org Web site. http://www.fredrogerscenter.org/2014/02/25/how-am-i-doing-checklist-exemplary-uses-of-technology-early-learning/. Updated February 25, 2014. Accessed October 12, 2017.

National Association for the Education of Young Children. Technology and interactive media as tools in early childhood programs serving children from birth through age 8. Position Statement. NAEYC.org Web site. http://www.naeyc.org/files/naeyc/PS_technology_WEB.pdf. January 2012. Accessed October 12, 2017.

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.1 Methods of Supervision of Children
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
3.1.3.1 Active Opportunities for Physical Activity
2.1.3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds
2.1.4.3 Developing Relationships for School-Age Children
Appendix S: Physical Activity: How Much Is Needed?

REFERENCES

American Academy of Pediatrics Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591. http://pediatrics.aappublications.org/content/pediatrics/138/5/e20162591.full.pdf
Reid CY, Radesky J, Christakis D, et al., American Academy of Pediatrics Council on Communications and Media. Children and adolescents and digital media. Pediatrics. 2016;138(5):e2016593.
http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2593.
Wen LM, Baur LA, Rissel C, Xu H, Simpson, JM. Correlates of body mass index and overweight and obesity of children aged 2 years: finding from the healthy beginnings trial. Obesity. 2014;22(7):1723-1730.
American Academy of Pediatrics. Council on Early Childhood. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134(2):1-6. http://pediatrics.aappublications.org/content/early/2014/06/19/peds.2014-1384.
American Academy of Pediatrics Council on Communications and Media. Media use in school-aged children and adolescents. Pediatrics. 2016;138(5):e20162592. http://pediatrics.aappublications.org/content/138/5/e20162592.

NOTES

Content in the STANDARD was modified on 10/12/2017.

Standard 2.2.0.5: Behavior Around a Pool

When children are in or around a pool, caregivers/teachers should teach age-appropriate behavior and safety skills including not pushing each other, holding each other under water, or running at the poolside. Children should be shown the depth of the water at different part of the pool. They should be taught that when going into a body of water, they should go in feet first the first time to check the depth. Children should be instructed what an emergency would be and to only call for help only in a real/genuine emergency. They should be taught to never dive in shallow water.

RATIONALE

Caregivers/teachers should take the opportunities to explain how certain behaviors could injure other children. Also such behavior can distract caregivers/teachers from supervising other children, thereby placing the other children at risk (1).

TYPE OF FACILITY

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

REFERENCES

U.S. Department of Health and Human Services, Maternal and Child Health Bureau. 1999. Basic emergency lifesaving skills (BELS): A framework for teaching emergency lifesaving skills to children and adolescents. Newton, MA: Children’s Safety Network, Education Development Center. http://bolivia.hrsa.gov/emsc/Downloads/BELS/BELS.htm.

Standard 2.3.1.1: Mutual Responsibility of Parents/Guardians and Staff

The quality of the relationship between parents/guardians and caregivers/teachers has an influence on the child. There should be a reciprocal responsibility of the family and caregivers/teachers to observe, participate, and be trained in the care that each child requires, and they should be encouraged to work together as partners in providing care.

During the enrollment process, caregivers/teachers should clarify who is/are the legal guardian(s) of the child. All relevant legal documents, court orders, etc., should also be collected and filed during the enrollment process (1). Caregivers/teachers should comply with court orders and written consent from the parent/guardian with legal authority, and not try to make the determination themselves regarding the best interests of the child.

All aspects of child care programs should be designed to facilitate parent/guardian input and involvement. Non-custodial parents should have access to the same developmental and behavioral information given to the custodial parent/guardian, if they have joint legal custody, permission by court order, or written consent from the custodial parent/guardian.

Caregivers/teachers should also clarify with whom the child spends significant time and with whom the child has primary relationships as they will be key informants for the caregivers/teachers about the child and his/her needs.

Parent/guardian involvement is needed at all levels of the program, including program planning for indoors and outdoors, provision of quality care, screening for children who are ill, and support for other parents/guardians. Communication between the administrator, caregiver/teacher and parent/guardian are essential to facilitate the involvement and commitment of parents/guardians. Parents/guardians should be invited to participate on the program board or planning meetings for the program. Parents/guardians should meet with their child’s caregiver/teacher or the director annually to discuss how their child is doing in the program. On a daily basis, parents/guardians and caregivers/teachers should share information about the child’s health, changes in drop-off or pick-up times, and changes in family routines or family events. Caregivers/teachers should communicate regularly with parents/guardians by providing injury report forms if their child sustains an injury, posting notices of exposures to infectious diseases, and greeting the parent/guardian at drop-off each day. Parents/guardians should receive a copy of the child care programs’ written policies, including health and safety policies.

Caregivers/teachers should informally share with parents/guardians daily information about their child’s needs and activities.

Transition reports on any symptoms that the child developed, differences in patterns of appetite or urinating, and activity level should be exchanged to keep parents/guardians informed.

RATIONALE

This plan will help achieve the important goal of carryover of facility components from the child care setting to the child’s home environment. The child’s learning of new skills is a continuous process occurring both at home and in child care.

Research, practice, and accumulated wisdom attest to the crucially important influence of children’s relationships with those closest to them. Children’s experience in child care will be most beneficial when parents/guardians and caregivers/teachers develop feelings of mutual respect and trust. In such a situation, children feel a continuity of affection and concern, which facilitates their adjustment to separation and use of the facility. Especially for infants and toddlers, attention to consistency across settings will help minimize stress that can result from notable differences in routines across caregivers/teachers and settings.

Another ongoing source of stress for an infant or a young child is the separation from those they love and depend upon. Of the various programmatic elements in the facility that can help to alleviate that stress, by far the most important is the comfort in knowing that parents/guardians and caregivers/teachers know the children and their needs and wishes, are in close contact with each other, and can respond in ways that enable children to deal with separation.

The encouragement and involvement of parents/guardians in the social and cognitive leaps of the child provides parents/guardians with the confidence vital to their sense of competence. Caregivers/teachers should be able to direct parents/guardians to sources of information and activities that support child’s development and learning and be able to assist them to obtain appropriate screening and assessment when there are concerns. Communication should be sensitive to ethnic and cultural practices. The parent/guardian/caregiver/teacher partnership models positive adult behavior for school-age children and demonstrates a mutual concern for the child’s well-being (2-16).

In families where the parents/guardians are separated, it is usually in the child’s best interest for both parents/guardians to be involved in the child’s care, and informed about the child’s progress and problems in care. However, it is up to the courts to decide who has legal custody of the child.

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.1.5 Helping Families Cope with Separation
2.1.1.7 Communication in Native Language Other Than English
2.1.1.9 Verbal Interaction
2.1.1.8 Diversity in Enrollment and Curriculum

REFERENCES

O’Connor, S., et al. 1996. ASQ: Assessing school age child care quality. Wellesly, MA: Center for Research on Women.
Seibel, N. L., L. G. Gillespie, and T. Temple. 2008. The role of child care providers in child abuse prevention. Zero to Three 28:33-40.
Fagan, J. 1994. Mother and father involvement in day care centers serving infants and young toddlers. Early Child Dev Care 103:95-101.
Endsley, R. C., et al. 1993. Parent involvement and quality day care in proprietary centers. J Res Child Educ 7:53-61.
Larner, M. 1995. Linking family support and early childhood programs: Issues, experiences, opportunities: Best practices project, 1-40. Chicago, IL: Family Resource Coalition.
Dombro, A. L. 1995. Sharing the care: What every provider and parent needs to know. Child Today 23:22-5.
Miller, S. H., et al. 1995. Family support in early education and child care settings: Making a case for both principles and practices. Child Today 23:26-29.
Powell, D. R. 1998. Reweaving parents back into the fabric of early childhood programs: Research in review. Young Child 53:60-67.
Jones, R. 1996. Producing a school newsletter parents will read. Child Care Infor Exch 107:91-3.
Tijus, C. A., et al. 1997. The impact of parental involvement on the quality of day care centers. Int J Early Years Educ 5:7-20.
Massachusetts State Office for Children. Establishing a successful family daycare home: A resource guide for providers. 1990. Boston: MA State Office for Children.
Shores, E. J. 1998. A call to action: Family involvement as a critical component of teacher education programs. Tallahassee, FL: Southeastern Regional Vision for Education.
Greenman, J. 1998. Parent partnerships: What they don’t teach you can hurt. Child Care Infor Exch 124:78-82.
Marshall, N. L. 1991. Empowering low-income parents: The role of child care. Boston, MA: EDRS.
Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An exploratory empirical study. Int J Early Years Educ 7:229-39.
Public Counsel Law Center in California. Guidelines for Releasing Children and Custody Issues. http://www.publiccounsel.org/publications/release.pdf.

Standard 3.1.4.4: Scheduled Rest Periods and Sleep Arrangements

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

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

5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.2.2.1 Levels of Illumination

REFERENCES

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
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
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
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
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
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
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.
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.

Standard 5.3.1.10: Restrictive Infant Equipment Requirements

Restrictive infant equipment such as swings, stationary activity centers (e.g., exersaucers), infant seats (e.g., bouncers), molded seats, etc., if used, should only be used for short periods of time (a maximum of fifteen minutes twice a day) (1). Infants should not be placed in equipment until they are developmentally ready. Infants should be supervised when using equipment. Safety straps should be used if provided by the manufacturer of the equipment. Equipment should not be placed on elevated surfaces, uneven surfaces, near the top of stairs, or within reach of safety hazards. Stationary activity centers should be used with the stabilizing legs down in a locked position. Infants should not be allowed to sleep in equipment that was not manufactured as infant rest/sleep equipment. The use of jumpers (attached to a door frame or ceiling) and infant walkers is prohibited.

RATIONALE

Keeping an infant confined in a piece of infant equipment prevents an infant from active movement. Infants need the opportunity to play on the floor in a safe open area to develop their gross motor skills. If infants are not given the opportunity for floor time, their development can be hindered or delayed (2). The shape of an infant’s head can be affected if pressure is applied often and for long periods of time. This molding of the skull is called plagiocephaly. Due to the recommendation for back sleeping, an infant’s skull already experiences a great amount of time with pressure on the back of the head. When an infant is kept in a piece of infant equipment such as an infant seat or a swing, the pressure again is applied to the back of an infant’s head; thus, increasing the likelihood of plagiocephaly. To prevent plagiocephaly and to promote normal development, infants should spend time on their tummies when awake and supervised (3).

Infants are not well-protected in restrictive infant equipment and can be injured by animals or other children. Other children or animals can hang, climb, or jump on or into the equipment; therefore, supervision is required during use. Safety straps must be used to prevent injuries and deaths of infants; infants have fallen out of equipment or have been strangled when safety straps have not been used (10).

Equipment must always be placed on the floor and away from the top of stairs to prevent falls; infants have been injured when equipment has been pushed or pulled off an elevated surface or the top of stairs. The surface or floor under the equipment needs to be level to prevent the risk of the equipment tipping over. It is imperative for equipment to be placed out of the reach of potential safety hazards such as furniture, dangling appliance cords, curtain pulls, blind cords, hot surfaces, etc., so infants cannot reach them. The guideline of twenty minutes twice a day was designated so that use could be clearly measured and monitored (1).

Infants should not be placed in equipment, such as stationary activity centers, that require them to support their heads on their own unless they have mastered this skill. Allowing infants to sleep in infant equipment is not recommended due to the documented decrease in an infant’s oxygen saturation caused by the downward flexion of an infant’s head and neck due to an infant’s underdeveloped head and neck muscles (8,9). If an infant falls asleep in a piece of equipment, the infant should be promptly removed and placed flat on the infant’s back in a safety approved crib.

If the stabilizing legs on stationary activity centers are not down and locked in place, this puts an infant at risk of tipping over in the equipment as well as creates an unstable piece of equipment for a mobile infant to use to pull himself up.

Infant walkers are dangerous because they move children around too fast and to hazardous areas, such as stairs. The upright position also can cause children in walkers to “tip over” or can bring children close to objects that they can pull down onto themselves. In addition, walkers can run over or run into others, causing pain or injury. Many injuries, some fatal, have been associated with infant walkers (4-7). There have been several reports of spring/clamp breaking on various models of jumpers (jump-up seats) according to the CPSC (7).

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity

REFERENCES

Warda, L., G. Griggs. 2006. Childhood Falls in Manitoba: CHIRPP Report: An assessment of injury severity and fall events by age group. Winnipeg: The Injury Prevention Centre of Children’s Hospital. http://www.mpeta.ca/documents/IOI/Falls.pdf.
Kornhauser, C. L., C. V. Scirica, I. S. Gantar, D. Osredkar, D. Neubauer, T. B. Kinane. 2009. A comparison of respiratory patterns in healthy term infants placed in car safety seats and beds. Pediatrics 124: e396-e402.
Kinane, T. B., J. Murphy, J. L. Bass, M. J. Corwin. 2006. Comparison of respiratory physiologic features when infants are placed in car safety seats or car beds. Pediatrics 118:522-27.
Chowdhury, R. T. 2009. Nursery product-related injuries and deaths among children under age five. Washington, DC: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/nursery07.pdf.
Shields, B. J., G. A. Smith. 2006. Success in the prevention of infant walker-related injuries: An analysis of national data, 1990-2001. Pediatrics 117: e452-59.
DiLillo, D., A. Damashek, L. Peterson. 2001. Maternal use of baby walkers with young children: Recent trends and possible alternatives. Injury Prevention 7:223-27.
American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2008. Policy statement: Injuries associated with infant walkers. Pediatrics 122:450.
American Academy of Pediatrics (AAP), Healthy Child Care America. 2008. Back to sleep, tummy to play. Elk Grove Village, IL: AAP. http://www.healthychildcare.org/pdf/SIDStummytime.pdf.
American Physical Therapy Association (APTA). 2008. Lack of time on tummy shown to hinder achievement of developmental milestones, say physical therapists. Press release.
National Association for Family Child Care, The Family Child Care Accreditation Project, Wheelock College. 2005. Quality standards for NAFCC accreditation, standard 4.5. 4th ed. Salt Lake City, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf.

Standard 9.2.1.1: Content of Policies

The facility should have policies to specify how the caregiver/teacher addresses the developmental functioning and individual or special health care needs of children of different ages and abilities who can be served by the facility, as well as other services and procedures. These policies should include, but not be limited to, the following:

Admissions criteria, enrollment procedures, and daily sign-in/sign-out policies, including authorized individuals for pick-up and allowing parent/guardian access whenever their child is in care;
Inclusion of children with special health care needs;
Nondiscrimination;
Payment of fees, deposits, and refunds;
Termination of enrollment and parent/guardian notification of termination;
Supervision;
Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
A written comprehensive and coordinated planned program based on a statement of principles;
Discipline;
Methods and schedules for conferences or other methods of communication between parents/guardians and staff;
Care of children and staff who are ill;
Temporary exclusion for children and staff who are ill and alternative care for children who are ill;
Health assessments and immunizations;
Handling urgent medical care or threatening incidents;
Medication administration;
Use of child care health consultants and education and mental health consultants;
Plan for health promotion and prevention (e.g., tracking routine child health care, health consultation, health education for children/staff/families, oral health, sun safety, safety surveillance, preventing obesity, etc.);
Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
Security;
Confidentiality of records;
Transportation and field trips;
Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
Sanitation and hygiene;
Presence and care of any animals on the premises;
Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
Evening and night care plan;
Smoking, tobacco use, alcohol, prohibited substances, and firearms;
Human resource management;
Staff health;
Maintenance of the facility and equipment;
Preventing and reporting child abuse and neglect;
Use of pesticides and other potentially toxic substances in or around the facility;
Review and revision of policies, plans, and procedures.

The facility should have specific strategies for implementing each policy. For centers, all of these items should be written. Facility policies should vary according to the ages and abilities of the children enrolled to accommodate individual or special health care needs. Program planning should precede, not follow the enrollment and care of children at different developmental levels and abilities and with different health care needs. Policies, plans, and procedures should generally be reviewed annually or when any changes are made. A child care health consultant can be very helpful in developing and implementing model policies.

RATIONALE

Neither plans nor policies affect quality unless the program has devised a way to implement the plan or policy. Children develop special health care needs and have developmental differences recognized while they are enrolled in child care (2). Effort should be made to facilitate accommodation as quickly as possible to minimize delay or interruption of care (1). For examples of policies see Model Child Care Health Policies at http://www.ecels-healthy
childcarepa.org/content/MHP4thEd Total.pdf and the California Childcare Health Program at http://www
.ucsfchildcarehealth.org. Nutrition and physical activity policies for child care developed by the NAP SACC Program, Center for Health Promotion and Disease Prevention, University of North Carolina are available at http://www
.center-trt.org.

COMMENTS

Reader’s note: Chapter 9 includes many standards containing additional information on specific policies noted above.

TYPE OF FACILITY

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

RELATED STANDARDS

1.8.2.1 Staff Familiarity with Facility Policies, Plans and Procedures

REFERENCES

Child Care Law Center. 2009. Questions and answers about the Americans with Disabilities Act: A quick reference for child care providers. Updated Version. http://www.childcarelaw.org/docs/
ADA Q and A 2009 Final 3 09.pdf.
Aronson, S. S., ed. 2002. Model child care health policies. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 9.2.2.1: Planning for Child’s Transition to New Services

If a parent/guardian requests assistance with the transition process from the facility to a public school or another program, the designated care or service coordinator at the facility should review the child’s records, including needs, learning style, supports, progress, and recommendations. The designated care or service coordinator should obtain written informed consent from the parent/guardian prior to sharing information at a transition meeting, in a written summary, or in some other verbal or written format.

The process for the child’s departure should also involve sharing and the exchange of progress reports with other care providers for the child and the parents/guardians of the child within the realm of confidentiality guidelines.

Any special health care need of the child and successful strategies that have been employed while at child care should be shared. For children who are receiving services under Part C of IDEA 2004, a transition plan is required, usually at least ninety days prior to the time that the child will leave the facility or program.

In the case of a child who may be eligible for preschool services, with approval of the family of the child, a conference should be convened among the lead agency, the family, and the local educational agency not less than ninety days (and at the discretion of all such parties, not more than nine months) before the child is eligible for the preschool services, to discuss any such services that the child may receive. In the case of a child who may not be eligible for such preschool services, with the approval of the family, reasonable efforts should be made to convene a conference among the lead agency, the family, and providers of other appropriate services, to discuss the appropriate services that the child may receive; to review the child’s program options; for the period from the child’s third birthday through the remainder of the school year; and to establish a transition plan, including as appropriate, steps to exit from the program. A plan also requires description of efforts to promote collaboration among Early Head Start programs under section 645A of the Head Start Act, early education and child care programs.

The facility should determine in what form and for how long archival records of transitioned children should be maintained by the facility.

RATIONALE

All children and their families will experience one or more program transitions during early childhood. One of the most common transitions is from preschool to kindergarten. Families in transition benefit when support and advocacy are available from a facility representative who is aware of their needs and of the community’s resources (1). This process is essential in planning the child’s departure or transition to another program. Information regarding successful behavior strategies, motivational strategies, and similar information may be helpful to staff in the setting to which the child is transitioning.

COMMENTS

Some families are capable of advocating effectively for themselves and their children; others require help negotiating the system outside of the facility. An interdisciplinary process is encouraged. Though coordinating and evaluating health and therapeutic services for children with special health care needs is primarily the responsibility of the school district or regional center, staff from the child care facility (one of many service providers) should participate, as staff members have had a unique opportunity to observe the child. In small and large family child care homes where an interdisciplinary team is not present, the caregivers/teachers should participate in the planning and preparation along with other care or treatment providers, with parent/guardian written consent.

It is important for all providers of care to coordinate their activities and referrals; otherwise the family may not be well informed. If records are shared electronically, providers should ensure that the records are encrypted for security and confidentiality.

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.2.2 Format for the Transition Plan
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

REFERENCES

Harbin, G., B. Rous, N. Peeler, J. Schuster, K. McCormick. 2007. Research brief: Desired family outcomes of the early childhood transition process. http://community.fpg.unc.edu/connect/

Positive Behavior Management

Standard 2.2.0.6: Discipline Measures

Reader’s Note: The word discipline means to teach and guide. Discipline is not punishment. The discipline standard therefore reflects an approach that focuses on preventing behavior problems by supporting children in learning appropriate social skills and emotional responses.

Caregivers/teachers should guide children to develop self-control and appropriate behaviors in the context of relationships with peers and adults. Caregivers/teachers should care for children without ever resorting to physical punishment or abusive language. When a child needs assistance to resolve a conflict, manage a transition, engage in a challenging situation, or express feelings, needs, and wants, the adult should help the child learn strategies for dealing with the situation. Discipline should be an ongoing process to help children learn to manage their own behavior in a socially acceptable manner, and should not just occur in response to a problem behavior. Rather, the adult’s guidance helps children respond to difficult situations using socially appropriate strategies. To develop self-control, children should receive adult support that is individual to the child and adapts as the child develops internal controls. This process should include:

Forming a positive relationship with the child. When children have a positive relationship with the adult, they are more likely to follow that person’s directions. This positive relationship occurs when the adult spends time talking to the child, listening to the child, following the child’s lead, playing with the child, and responding to the child’s needs;
Basing expectations on children’s developmental level;
Establishing simple rules children can understand (e.g., you can’t hurt others, our things, or yourself) and being proactive in teaching and supporting children in learning the rules;
Adapting the physical indoor and outdoor learning/play environment or family child care home to encourage positive behavior and self regulation by providing engaging materials based on children’s interests and ensuring that the learning environment promotes active participation of each child. Well-designed child care environments are ones that are supportive of appropriate behavior in children, and are designed to help children learn about what to expect in that environment and to promote positive interactions and engagement with others;
Modifying the learning/play environment (e.g., schedule, routine, activities, transitions) to support the child’s appropriate behavior;
Creating a predictable daily routine and schedule. When a routine is predictable, children are more likely to know what to do and what is expected of them. This may decrease anxiety in the child. When there is less anxiety, there may be less acting out. Reminders need to be given to the children so they can anticipate and prepare themselves for transitions within the schedule. Reminders should be individualized such that each child understands and anticipates the transition;
Using encouragement and descriptive praise. When clear encouragement and descriptive praise are used to give attention to appropriate behaviors, those behaviors are likely to be repeated. Encouragement and praise should be stated positively and descriptively. Encouragement and praise should provide information that the behavior the child engaged in was appropriate. Examples: “I can tell you are ready for circle time because you are sitting on your name and looking at me.” “Your friend looked so happy when you helped him clean up his toys.” “You must be so proud of yourself for putting on your coat all by yourself.” Encouragement and praise should label the behaviors, not the child (e.g., good listening, good eating, instead of good boy);
Using clear, direct, and simple commands. When clear commands are used with children, they are more likely to follow them. The caregiver/teacher should tell the child what to do rather than what NOT to do. The caregiver/teacher should limit the number of commands. The caregiver/teacher should use if/then and when/then statements with logical and natural consequences. These practices help children understand they can make choices and that choices have consequences;
Showing children positive alternatives rather than just telling children “no”;
Modeling desired behavior;
Using planned ignoring and redirection. Certain behaviors can be ignored while at the same time the adult is able to redirect the children to another activity. If the behavior cannot be ignored, the adult should prompt the child to use a more appropriate behavior and provide positive feedback when the child engages in the behavior;
Individualizing discipline based on the individual needs of children. For example, if a child has a hard time transitioning, the caregiver/teacher can identify strategies to help the child with the transition (individualized warning, job during transition, individual schedule, peer buddy to help, etc.) If a child has a difficult time during a large group activity, the child might be taught to ask for a break;
Using time-out for behaviors that are persistent and unacceptable. Time-out should only be used in combination with instructional approaches that teach children what to do in place of the behavior problem. (See guidance for time-outs below.)

Expectations for children’s behavior and the facility’s policies regarding their response to behaviors should be written and shared with families and children of appropriate age. Further, the policies should address proactive as well as reactive strategies. Programs should work with families to support their children’s appropriate behaviors before it becomes a problem.

RATIONALE

Common usage of the word “discipline” has corrupted the word so that many consider discipline as synonymous with punishment, most particularly corporal punishment (2,3). Discipline is most effective when it is consistent, reinforces desired behaviors, and offers natural and logical consequences for negative behaviors. Research studies find that corporal punishment has limited effectiveness and potentially harmful side effects (4-9). Children have to be taught expectations for their behavior if they are to develop internal control of their actions. The goal is to help children learn to control their own behavior.

COMMENTS

Children respond well when they receive descriptive praise/attention for behaviors that the caregiver/teacher wants to see again. It is best if caregivers/teachers are sincere and enthusiastic when using descriptive praise. On the contrary, children should not receive praise for undesirable behaviors, but instead be praised for honest efforts towards the behaviors the caregivers/teachers want to see repeated (1). Discipline is best received when it includes positive guidance, redirection, and setting clear-cut limits that foster the child’s ability to become self-disciplined. In order to respond effectively when children display challenging behavior, it is beneficial for caregivers/teachers to understand typical social and emotional development and behaviors. Discipline is an ongoing process to help children develop inner control so they can manage their own behavior in a socially approved manner. A comprehensive behavior plan is often based first on a positive, affectionate relationship between the child and the caregiver/teacher. Measures that prevent behavior problems often include developmentally appropriate environments, supervision, routines, and transitions. Children can benefit from receiving guidance and repeated instructions for navigating the various social interactions that take place in the child care setting such as friendship development, problem-solving, and conflict-resolution.

Time-out (also known as temporary separation) is one strategy to help children change their behavior and should be used in the context of a positive behavioral support approach which works to understand undesired behaviors and teach new skills to replace the behavior. Listed below are guidelines when using time-out (8):

Time-outs should be used for behaviors that are persistent and unacceptable, used infrequently and used only for children who are at least two years of age. Time-outs can be considered an extended ignore or a time-out from positive enforcement;
The caregiver/teacher should explain how time-out works to the child BEFORE s/he uses it the first time. The adult should be clear about the behavior that will lead to time-out;
When placing the child in time-out, the caregiver/teacher should stay calm;
While the child is in time-out, the caregiver/teacher should not talk to or look at the child (as an extended ignore). However, the adult should keep the child in sight. The child could 1) remain sitting quietly in a chair or on a pillow within the room or 2) participate in some activity that requires solitary pursuit (painting, coloring, puzzle, etc.) If the child cannot remain in the room, s/he will spend time in an alternate space, with supervision;
Time-outs do not need to be long. The caregiver/teacher should use the one minute of time-out for each year of the child’s age (e.g., three-years-old = three minutes of time-out);
The caregiver/teacher should end the time-out on a positive note and allow the child to feel good again. Discussions with the child to “explain WHY you were in time-out” are not usually effective;
If the child is unable to be distracted or consoled, parents/guardians should be contacted.

How to respond to failure to cooperate during time-out:

Caregivers/teachers should expect resistance from children who are new to the time-out procedure. If a child has never experienced time-out, s/he may respond by becoming very emotional. Time-out should not turn into a power struggle with the child. If the child is refusing to stay on time-out, the caregiver/teacher should give the child an if/then statement. For example, “if you cannot take your time-out, then you cannot join story time.” If the child continues to refuse the time-out, then the child cannot join story time. Note that children should not be restrained to keep them in time-out.

More resources for caregivers/teachers on discipline can be found at the following organizations’ Websites: a) Center on the Social and Emotional Foundations for Early Learning (CSEFEL) at http://csefel.vanderbilt.edu and b) Technical Assistance Center on Social Emotional Intervention (TACSEI) at http://challengingbehavior.fmhi.usf.edu/.

ADDITIONAL RESOURCES

Gross, D., C. Garvey, W. Julion, L. Fogg, S. Tucker, H. Mokos. 2009. Efficacy of the Chicago Parent Program with low-income multi-ethnic parents of young children. Preventions Science 10:54-65.

Breitenstein, S., D. Gross, I. Ordaz, W. Julion, C. Garvey, A. Ridge. 2007. Promoting mental health in early childhood programs serving families from low income neighborhoods. J Am Psychiatric Nurses Assoc 13:313-20.

Gross, D., C. Garvey, W. Julion, L. Fogg. 2007. Preventive parent training with low-income ethnic minority parents of preschoolers. In Handbook of parent training: Helping parents prevent and solve problem behaviors. Ed. J. M. Briesmeister, C. E. Schaefer. 3rd ed. Hoboken, NJ: Wiley.

Gartrell, D. 2007. He did it on purpose! Young Children 62:62-64.

Gartrell, D. 2004. The power of guidance: Teaching social-emotional skills in early childhood classrooms. Clifton Park, NY: Thomson Delmar Learning; Washington, DC: NAEYC.

Gartrell, D., K. Sonsteng. 2008. Promoting physical activity: It’s pro-active guidance. Young Children 63:51-53.

Shiller, V. M., J. C. O’Flynn. 2008. Using rewards in the early childhood classroom: A reexamination of the issues. Young Children 63:88, 90-93.

Reineke, J., K. Sonsteng, D. Gartrell. 2008. Nurturing mastery motivation: No need for rewards. Young Children 63:89, 93-97.

Ryan, R. M., E. L. Deci. 2000. When rewards compete with nature: The undermining of intrinsic motivation and self-regulation. In Intrinsic and extrinsic motivation: The search for optimal motivation and performance, ed. C. Sanstone, J. M. Harackiewicz, 13-54. San Diego, CA: Academic Press

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
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
9.2.1.6 Written Discipline Policies
9.4.1.6 Availability of Documents to Parents/Guardians
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services

REFERENCES

Henderlong, J., M. Lepper. 2002 The effects of praise on children’s intrinsic motivation: A review and synthesis. Psychological Bulletin 128:774-95.
Hodgkin, R. 1997. Why the “gentle smack” should go: Policy review. Child Soc 11:201-4.
Fraiberg, S. H. 1959. The Magic Years. New York: Charles Scribner’s Sons.
Straus, M. A., et al. 1997. Spanking by parents and subsequent antisocial behavior of children. Arch Pediatric Adolescent Medicine 151:761-67.
Deater-Deckard, K., et al. 1996. Physical discipline among African American and European American mothers: Links to children’s externalizing behaviors. Dev Psychol 32:1065-72.
Weiss, B., et al. 1992. Some consequences of early harsh discipline: Child aggression and a maladaptive social information processing style. Child Dev 63:1321-35.
American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in schools. Pediatrics 118:1266.
Dunlap, S., L. Fox, M. L. Hemmeter, P. Strain. 2004. The role of time-out in a comprehensive approach for addressing challenging behaviors of preschool children. CSEFEL What Works Series. http://csefel.vanderbilt.edu/briefs/wwb14.pdf.
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.

Standard 2.2.0.7: Handling Physical Aggression, Biting, and Hitting

Caregivers/teachers should intervene immediately when a child’s behavior is aggressive and endangers the safety of others. It is important that the child be clearly told verbally, “no hitting” or “no biting.” The caregiver/teacher should use age–appropriate interventions. For example, a toddler can be picked up and moved to another location in the room if s/he bites other children or adults. A preschool child can be invited to walk with you first but, if not compliant, taken by the hand and walked to another location in the room. The caregiver/teacher should remain calm and make eye contact with the child telling him/her the behavior is unacceptable. If the behavior persists, parents/guardians, caregivers/teachers, the child care health consultant and the early childhood mental health consultant should be involved to create a plan targeting this behavior. For example, a plan may be developed to recognize non-aggressive behavior. Children who might not have the social skills or language to communicate appropriately may use physical aggression to express themselves and the reason for and antecedents of the behavior must be considered when developing a plan for addressing the behavior.

RATIONALE

Caregiver/teacher intervention protects children and encourages children to exhibit more acceptable behavior (1).

COMMENTS

Biting is a phase. Here are some specific steps to deal with biting:

Step 1: If a child bites another child, the caregiver/teacher should comfort the child who was bitten and remind the biter that biting hurts and we do not bite. Children should be given some space from each other for an appropriate amount of time.

Step 2: The caregiver/teacher should follow first aid instructions (available from the American Academy of Pediatrics [AAP] and the American Red Cross) and use the Center for Disease Control and Prevention’s (CDC’s) Standard Precautions to handle potential exposure to blood.

Step 3: The caregiver/teacher should allow for “dignity of risk,” and let the children back in the same space with increased supervision. Interactions should be structured between children such that the child learns to use more appropriate social skills or language rather than biting. If there is another incident, caregivers/teachers should repeat step one. The biter can play with children they have not bitten.

Step 4: The adult needs to shadow the biter to ensure safety of the other children. This can be challenging but imperative for the biter.

Step 5: For all transitions when the biter would be in close contact, the caregiver/teacher should hold him/her on her/his hip or if possible hold hands, keep a close watch, and keep the biter from close proximity with peers.

Step 6: The child (biter) should play with one or two other children whom they have not bitten with a favored adult in a section separate from the other children. Sometimes, until a phase (biting is a phase) passes, the caregiver/teacher needs to extinguish the behavior by not allowing it to happen and thereby reducing the attention given to the behavior.

Step 7: Parents/guardians of both children of the incident should be informed.

Step 8: The caregiver/teacher should determine whether the incident necessitates documentation (see Standard 9.4.1.9). If so, s/he should complete a report form.

Caregivers/teachers need to consider why the child is biting and teach the child a more appropriate way to communicate the same need. Possible reasons why a child would bite include:

Lack of words (desire to stop the behavior of another child);
Teething;
Tired (is nap time too late?);
Hungry (is lunch time too late?);
Lack of toys – consider buying duplicates of popular items;
Lack of supervision – more staff should be added, staff are near children during transitions, and room is set up to ensure visibility;
Child is bored – too much sitting, activities are too frustrating;
Child has oral motor needs – teethers are offered;
Child is avoiding something, and biting gets him/her out of it;
Lack of attention – child receives attention when biting.

Other important strategies to consider:

The caregiver/teacher should point out the effect of the child’s biting on the victim: “Emma is crying. Biting hurts. Look at her face. See how sad she is?” Label feelings and give victims the words to respond. “Emma, you can say ‘No biting!’ to Josh”;
The child should help the victim feel better. He can get a wet paper towel, a blankie or favorite toy for the victim and sit near them until the other child is feeling better. This encourages children to take responsibility for their actions, briefly removes the child from other activities and also lets the child experience success as a helper.

Discussing aggressive behavior in group time with the children can be an effective way to gain and share understanding among the children about how it feels when aggressive behavior occurs. Although bullying has not been studied in the preschool population, it is a form of aggression (2). Here are some helpful Websites: http://stopbullying.gov and http://www.eyesonbullying.org/preschool.html.

For more helpful strategies for handling aggression, see Center on the Social and Emotional Foundations for Early Learning Website at http://csefel.vanderbilt.edu. In addition, a child care health consultant or child care mental health consultant can help when the biting behavior continues.

TYPE OF FACILITY

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

RELATED STANDARDS

2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff
2.2.0.6 Discipline Measures
3.2.3.3 Cuts and Scrapes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
9.4.1.9 Records of Injury
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services

REFERENCES

Ross, Scott W., Horner, Robert H. 2009. Bully prevention in positive behavior support. J Applied Behavior Analysis 42:747-59.
Rush, K. L. 1999. Caregiver-child interactions and early literacy development of preschool children from low-income environments. Topics Early Child Special Education 19:3-14.

Standard 2.2.0.8: Preventing Expulsions, Suspensions, and Other Limitations in Services

Child care programs should not expel, suspend, or otherwise limit the amount of services (including denying outdoor time, withholding food, or using food as a reward/punishment) provided to a child or family on the basis of challenging behaviors or a health/safety condition or situation unless the condition or situation meets one of the two exceptions listed in this standard.

Expulsion refers to terminating the enrollment of a child or family in the regular group setting because of a challenging behavior or a health condition. Suspension and other limitations in services include all other reductions in the amount of time a child may be in attendance of the regular group setting, either by requiring the child to cease attendance for a particular period of time or reducing the number of days or amount of time that a child may attend. Requiring a child to attend the program in a special place away from the other children in the regular group setting is included in this definition.

Child care programs should have a comprehensive discipline policy that includes an explicit description of alternatives to expulsion for children exhibiting extreme levels of challenging behaviors, and should include the program’s protocol for preventing challenging behaviors. These policies should be in writing and clearly articulated and communicated to parents/guardians, staff and others. These policies should also explicitly state how the program plans to use any available internal mental health and other support staff during behavioral crises to eliminate to the degree possible any need for external supports (e.g., local police departments) during crises.

Staff should have access to in-service training on both a proactive and as-needed basis on how to reduce the likelihood of problem behaviors escalating to the level of risk for expulsion and how to more effectively manage behaviors throughout the entire class/group. Staff should also have access to in-service training, resources, and child care health consultation to manage children’s health conditions in collaboration with parents/guardians and the child’s primary care provider. Programs should attempt to obtain access to behavioral or mental health consultation to help establish and maintain environments that will support children’s mental well-being and social-emotional health, and have access to such a consultant when more targeted child-specific interventions are needed. Mental health consultation may be obtained from a variety of sources, as described in Standard 1.6.0.3.

When children exhibit or engage in challenging behaviors that cannot be resolved easily, as above, staff should:

Assess the health of the child and the adequacy of the curriculum in meeting the developmental and educational needs of the child;
Immediately engage the parents/guardians/family in a spirit of collaboration regarding how the child’s behaviors may be best handled, including appropriate solutions that have worked at home or in other settings;
Access an early childhood mental health consultant to assist in developing an effective plan to address the child’s challenging behaviors and to assist the child in developing age-appropriate, pro-social skills;
Facilitate, with the family’s assistance, a referral for an evaluation for either Part C (early intervention) or Part B (preschool special education), as well as any other appropriate community-based services (e.g., child mental health clinic);
Facilitate with the family communication with the child’s primary care provider (e.g., pediatrician, family medicine provider, etc.), so that the primary care provider can assess for any related health concerns and help facilitate appropriate referrals.

The only possible reasons for considering expelling, suspending or otherwise l

Special Collection

Caring for Infants and Toddlers in Early Care and Education (I/T)

Table of Contents

I. Enrollment and Admission

Staffing, Consultants, and Supervision

Staff Qualifications and Training

Consultants

Supervision

Environment and Equipment

Building and Environment: Inside and Outside

Equipment, Materials, and Toys

Facility

Food Preparation and Feeding Area

Play Areas

Program Activities for Healthy Development

Developmentally Appropriate Practice

Positive Behavior Management

Healthy Weight Promotion

Physical Activity

B. Nutrition

Safe and Healthy Practices and Procedures

Safe Food Practices

Health Promotion and Protection

C. Cleaning/Sanitizing/Disinfecting Practices

Infection Control/Disease Prevention and Management

Medication Administration

Abuse/Neglect

Appendices

I. Enrollment and Admission

Standard 1.1.2.1: Minimum Age to Enter Child Care

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 9.2.1.3: Enrollment Information to Parents/Guardians and Caregivers/Teachers

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

Standard 9.4.2.3: Contents of Admission Agreement Between Child Care Program and Parent/Guardian

RATIONALE

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Staffing, Consultants, and Supervision

Standard 1.6.0.1: Child Care Health Consultants

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

NOTES

Standard 1.6.0.2: Frequency of Child Care Health Consultation Visits

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

NOTES

Standard 1.6.0.3: Infant and Early Childhood Mental Health Consultants

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

NOTES

Standard 1.6.0.4: Early Childhood Education Consultants

RATIONALE

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.1.1.2: Ratios for Large Family Child Care Homes and Centers

RATIONALE