Special Collection

Oral Health in Child Care and Early Education

A Joint Collaborative Project of:

American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1019

American Public Health Association
800 I Street, NW
Washington, DC 20001-3710

National Resource Center for Health and Safety in Child Care and Early Education
University of Colorado, College of Nursing
13120 E 19th Avenue
Aurora, CO 80045

Support for this project was provided by the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services (Cooperative Agreement #U46MC09810)

Copyright © 2013
American Academy of Pediatrics
American Public Health Association
National Resource Center for Health and Safety in Child Care and Early Education

 

 

Table of Contents

Oral Health Practices

3.1.4.3 Pacifier Use
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
3.6.1.5 Sharing of Personal Articles Prohibited
5.5.0.1 Storage and Labeling of Personal Articles
2.1.1.1 Written Daily Activity Program and Statement of Principles

Education and Training

2.4.1.1 Health and Safety Education Topics for Children
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
2.4.2.1 Health and Safety Education Topics for Staff
2.4.3.2 Parent/Guardian Education Plan
3.1.5.3 Oral Health Education
1.4.3.2 Topics Covered in Pediatric First Aid Training
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
1.6.0.1 Child Care Health Consultants
1.3.2.7 Qualifications and Responsibilities for Health Advocates

Feeding and Nutrition

4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.3.1.8 Techniques for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

Oral Health-Related Infectious Disease

7.5.12.1 Thrush (Candidiasis)
7.6.1.1 Disease Recognition and Control of Hepatitis B Virus (HBV) Infection
7.6.1.3 Staff Education on Prevention of Bloodborne Diseases

Oral Health-Related Emergencies

9.4.1.9 Records of Injury

Oral Health Policies and Information

9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.3.6 Identification of Child’s Medical Home and Parental Consent for Information Exchange
9.2.3.13 Plans for Evening and Nighttime Child Care
9.2.3.14 Oral Health Policy
9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History

Licensing and State Responsibilities

10.3.2.1 Child Care Licensing Advisory Board
10.3.4.1 Sources of Technical Assistance to Support Quality of Child Care
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
10.6.1.1 Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services

Related Issues

1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

Appendices

Appendix E: Child Care Staff Health Assessment
Appendix AA: Medication Administration Packet
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America’s Playgrounds Safety Report Card
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix FF: Child Health Assessment
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix CC: Incident Report Form

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Oral Health Practices

Standard 3.1.4.3: Pacifier Use

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

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

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

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 3.1.5.1: Routine Oral Hygiene Activities

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

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

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

RATIONALE

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

COMMENTS

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.5.2 Toothbrushes and Toothpaste
3.1.5.3 Oral Health Education
9.4.2.1 Contents of Child’s Records
9.4.2.2 Pre-Admission Enrollment Information for Each Child
9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
9.4.2.5 Health History
9.4.2.6 Contents of Medication Record
9.4.2.7 Contents of Facility Health Log for Each Child
9.4.2.8 Release of Child’s Records

REFERENCES

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

NOTES

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

Standard 3.1.5.2: Toothbrushes and Toothpaste

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

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


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

                             Photo Credit: National Center on Early Childhood Health and Wellness

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

RATIONALE

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

COMMENTS

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
3.6.1.5 Sharing of Personal Articles Prohibited
5.5.0.1 Storage and Labeling of Personal Articles

REFERENCES

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

NOTES

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

Standard 3.6.1.5: Sharing of Personal Articles Prohibited

Combs, hairbrushes, toothbrushes, personal clothing, bedding, and towels should not be shared and should be labeled with the name of the child who uses these objects.

RATIONALE

Respiratory and gastrointestinal infections are common infectious diseases in child care. These diseases are transmitted by direct person-to-person contact or by sharing personal articles such as combs, brushes, towels, clothing, and bedding. Prohibiting the sharing of personal articles and providing space so that personal items may be stored separately helps prevent these diseases from spreading.

TYPE OF FACILITY

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

RELATED STANDARDS

5.5.0.1 Storage and Labeling of Personal Articles

Standard 5.5.0.1: Storage and Labeling of Personal Articles

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

The facility should provide separate storage areas for each child’s and staff member’s personal articles and clothing. Personal effects and clothing should be labeled with the child’s name. Bedding should be labeled with the child’s full name, stored separately for each child, and not touching other children’s personal items (1,2).

If children use the following items at the child care facility, those items should be stored in separate, clean containers and should be labeled with the child’s full name:

1. Individual cloth towels for bathing purposes;
2. Toothbrushes;
3. Washcloths; and
4. Combs and brushes (1).

Toothbrushes, towels, and washcloths should be allowed to dry when they are stored and not touching (1).

COVID-19 modification as of September 20, 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 care and education programs:  Label and store masks separately when removed for eating and sleeping. Have more than one mask on hand so that you can easily replace a dirty mask with a clean one. Store wet or dirty masks in a sealed plastic bag or container. Store dry masks in a paper bag Place contaminated clothes or other personal items in a plastic bag and send home.   For more information, refer to Standards 3.1.5.1 Routine Oral Hygiene Activities and 3.1.5.2 Toothbrushes and Toothpaste.   Additional Resources:   Centers for Disease Control and Prevention - Mask Guidance

 

RATIONALE

This standard prevents the spread of organisms that cause disease and promotes organization of a child’s personal possessions. Lice infestation, scabies, and ringworm are common infectious diseases in child care. Providing space so personal items may be stored separately helps to prevent the spread of these diseases.

TYPE OF FACILITY

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

RELATED STANDARDS

3.6.1.5 Sharing of Personal Articles Prohibited
3.6.3.2 Labeling, Storage, and Disposal of Medications
5.4.5.1 Sleeping Equipment and Supplies

REFERENCES

1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
   

2. American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL:  American Academy of Pediatrics; 2018: 138-146

   
   

NOTES

COVID-19 modification as of September 20, 2021

Standard 2.1.1.1: Written Daily Activity Program and Statement of Principles

Facilities should have a written comprehensive and coordinated planned program of daily activities appropriate for groups of children at each stage of early childhood. This plan should be based on a statement of principles for the facility and each child’s individual development.The objective of the program of daily activities should be to foster incremental developmental progress in a healthy and safe environment, and the program should be flexible to capture the interests and individual abilities of the children.

Infants and toddlers learn through healthy and ongoing relationships with primary caregivers/teachers, and a relationship-based plan should be shared with parents/guardians that includes opportunities for parents/guardians to be an integral partner and member of this relationship system.

Centers and all family child care homes should develop a written statement of principles that set out the basic elements from which the daily indoor/outdoor program is to be built.

These principles should address the following elements:

1. Overall child health and safety
2. Physical development, which facilitates small and large motor skills
3. Family partnership, which acknowledges the essential role of the family, and reflects their culture and language
4. Social development, which leads to cooperative play with other children and the ability to make relationships with other children, including those  of diverse backgrounds and ability levels and adults 
5. Emotional development, which facilitates self-awareness and self-confidence
6. Cognitive development, which includes an understanding of the world and environment in which children live and leads to understanding science, math, and literacy concepts, as well as increasing the use and understanding of language to express feelings and ideas

 

All the principles should be developed with play being the foundation of the planned curriculum. Material such as blocks, clay, paints, books, puzzles, and/or other manipulatives should be available indoors and outdoors to children to further the planned curriculum.

 

The program plan should provide for the incorporation of specific health education topics on a daily basis throughout the year. Topics of health education should include health promotion and disease prevention topics (e.g., handwashing, oral health, nutrition, physical activity, healthy sleep habits) (1-3).

Health and safety behaviors should be modeled by staff to foster healthy habits for children during their time in child care.

Staff should ensure that children and parents/guardians understand the need for a safe indoor and outdoor learning/play environment and feel comfortable when playing indoors and outdoors.

Continuity and consistency by a caring staff are vital so that children and parents/guardians know what to expect.

RATIONALE

Children attending early care and education programs with well-developed curricula are more likely to achieve appropriate levels of development (4).

Early childhood specialists agree on the

1. Inseparability and interdependence of cognitive, physical, emotional, communication, and social development. Social-emotional capacities do not develop or function separately.
2. Influence of the child’s health and safety on cognitive, physical, emotional, communication, and social development.
3. Central importance of continuity and consistent relationships with affectionate care that is the formation of strong, nurturing relationships between caregivers/teachers and children.
4. Relevance of the development phase or stage of the child.
5. Importance of action (including play) as a mode of learning and to express self (5).

Those who provide early care and education must be able to articulate the components of the curriculum they are implementing and the related values/principles on which the curriculum is based. In centers and large family child care homes, because more than 2 caregivers/teachers are involved in operating the facility, a written statement of principles helps achieve consensus about the basic elements from which all staff will plan the daily program (4).

A written description of the planned program of daily activities allows staff and parents/guardians to have a common understanding and gives them the ability to compare the program’s actual performance to the stated intent. Early care and education is a “delivery of service” involving a contractual relationship between the caregiver/teacher and the consumer. A written plan helps to define the service and contributes to specific and responsible operations that are conducive to sound child development and safety practices and to positive consumer relations (4).

Professional development is often required to enable staff to develop proficiency in the development and implementation of a curriculum that they use to carry out daily activities appropriately (1).

Planning ensures that some thought goes into indoor and outdoor programming for children. The plan is a tool for monitoring and accountability. Also, a written plan is a tool for staff and parent/guardian orientation.

COMMENTS

The National Association for the Education of Young Children (NAEYC) accreditation criteria and procedures, the National Association for Family Child Care accreditation standards, and the National Child Care Association standards can serve as resources for planning program activities.

Parents/guardians and staff can experience mutual learning in an open, supportive early care and education setting. Suggestions for topics and methods of presentation are widely available. For example, the publication catalogs of the NAEYC and the American Academy of Pediatrics contain many materials for child, parent/guardian, and staff education on child development and physical and mental health development, covering topics such as the importance of attachment and temperament. A certified health education specialist, a child care health consultant, or an early childhood mental health consultant can also be a source of assistance.

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.3 Coordinated Child Care Health Program Model
2.1.1.8 Diversity in Enrollment and Curriculum
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
2.4.1.1 Health and Safety Education Topics for Children
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

REFERENCES

1. Rosenthal MS, Crowley AA, Curry L. Family child care providers’ self-perceived role in obesity prevention: working with children, parents, and external influences. J Nutr Educ Behav. 2013;45(6):595–601

2. Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24

3. Policy on oral health in child care centers. Pediatr Dent. 2016;38(6):34–36

4. Modigliani K. Quality Standards for NAFCC Accreditation. 4th ed. The National Foundation for Family Child Care Foundation, Family Child Care Project - Wheelock College. Salt Lake City, UT: The National Association for Family Child Care Foundation; 2013
5. Pinkham AM, Kaefer T, Neuman SB, eds. Knowledge Development in Early Childhood: Sources of Learning and Classroom Implications. New York, NY: The Guilford Press; 2012

NOTES

Content in the STANDARD was modified on 5/30/2018

Education and Training

Standard 2.4.1.1: Health and Safety Education Topics for Children

Health and safety education topics for children should include physical, oral, mental, nutritional, and social and emotional health, and physical activity. These topics should be integrated daily into the program of age-appropriate activities, to include:

     a.Body awareness and use of appropriate terms for body parts

     b.Families, including that families have varying compositions, beliefs, and cultures

     c. Personal social skills, such as sharing, being kind, helping others, and communicating appropriately

     d. Expression and identification of feelings

     e.Self-esteem and self-awareness

     f.Nutrition and healthy eating, drinking water, including healthy habits and preventing obesity

     g. Healthy sleep habits

     h. Outdoor learning/play

     i. Fitness and age-appropriate physical activity

     j. Personal and dental hygiene, including wiping, flushing, handwashing, cough and sneezing etiquette, and tooth brushing

     k. Safety, such as home, vehicular car seats and safety belts, playground, bicycle, fire, firearms, water, and hat to do in an emergency, getting help, and/or dialing 911 for
         emergencies

     l. Conflict management, violence prevention, and bullying prevention

     m. Age-appropriate first aid concepts

     n.Healthy and safe behaviors

     o. Poisoning prevention and poison safety

     p. Awareness of routine preventive care

     q. Care of children with special health care needs

     r. Health risks of secondhand and third-hand smoke

     s. Appropriate use of medications

     t. Handling food safely

     u. Preventing choking and falls

RATIONALE

For young children, health education and safety education are inseparable from one another. Children learn about health and safety by experiencing risk-taking and risk control, fostered and modeled by adults who are involved with them. Whenever opportunities for learning arise, caregivers/teachers should integrate education to promote healthy and safe behaviors.1 Health and safety education does not have to be seen as a structured curriculum but as a daily component of the planned program that is part of a child’s development and habit. Health and safety education supports and reinforces a healthy and safe lifestyle (1,2).

COMMENTS

Teaching children the appropriate names for their body parts is a good way to increase body awareness and personal safety. Learning about routine health maintenance practices, such as vaccination, vision screening, blood pressure screening, oral health examinations, and blood tests, helps children understand these activities and appreciate their value rather than fearing them. Similarly, learning about the importance of nutrition, drinking water, fitness, and healthy sleeping habits helps children make responsible healthful decisions. Good sleep hygiene (3) (e.g., early and routine bedtimes) and obtaining a sufficient amount of sleep in early childhood4 are associated with improved social and emotional (5,6) cognitive, and weight outcomes (7-10).

Child care health consultants and certified health education specialists are good resources for this instruction. The National Commission for Health Education Credentialing provides information on certified health education specialists.

ADDITIONAL RESOURCES

American Academy of Pediatrics. Healthy sleep habits: how many hours does your child need? HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/sleep/Pages/Healthy-Sleep-Habits-How-Many-Hours-Does-Your-Child-Need.aspx. Updated March 23, 2017. Accessed November 14, 2017

Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24

Kobayashi K, Yorifuji T, Yamakawa M, et al. Poor toddler-age sleep schedules predict school-age behavioral disorders in a longitudinal survey. Brain Dev. 2015;37(6):572–578

Owens JA, Witmans M. Sleep problems. Curr Probl Pediatr Adolesc Health Care. 2004;34(4):154–179

TYPE OF FACILITY

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

RELATED STANDARDS

2.1.1.1 Written Daily Activity Program and Statement of Principles
1.6.0.1 Child Care Health Consultants
1.6.0.3 Infant and Early Childhood Mental Health Consultants
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.1.5.3 Oral Health Education
3.2.2.2 Handwashing Procedure
3.2.3.2 Cough and Sneeze Etiquette
4.5.0.10 Foods that Are Choking Hazards
4.7.0.1 Nutrition Learning Experiences for Children
4.7.0.2 Nutrition Education for Parents/Guardians
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.4.1.3 Gender and Body Awareness

REFERENCES

1. Sharma M. Health education and health promotion. In: Theoretical Foundations of Health Education and Health Promotion. Burlington, MA: Jones & Bartlett Learning; 2017:4–7

2. Lyn R, Evers S, Davis J, Maalouf J, Griffin M. Barriers and supports to implementing a nutrition and physical activity intervention in child care: directors’ perspectives. J Nutr Educ Behav. 2014;46(3);171–180

3. Anderson SE, Andridge R, Whitaker RC. Bedtime in preschool-aged children and risk for adolescent obesity. J Pediatr. 2016;176:17–22

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Bonuck K, Chervin RD, Howe LD. Sleep-disordered breathing, sleep duration, and childhood overweight: a longitudinal cohort study. J Pediatr. 2015;166(3):632–639

NOTES

Content in the STANDARD was modified on 1/10/2017 and 5/30/2018

Standard 2.4.1.2: Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities

The program should strongly encourage all staff members to model healthy and safe behaviors and attitudes in their contact with children in the indoor and outdoor learning/play environment, including, eating nutritious foods, drinking water or nutritious beverages when with the children, sitting with children during mealtime, and eating some of the same foods as the children. Caregivers/teachers should engage in daily movement and physical activity; limit sedentary behaviors when in the outdoor learning/play environment (e.g., not sitting in structured chairs); not watch TV; and comply with handwashing protocols, and tobacco, electronic cigarettes (e-cigarettes), and drug use policies.

Caregivers/teachers should talk about and model healthy and safe behaviors while they carry out routine daily activities. Activities should be accompanied by words of encouragement and praise for achievement.

Facilities should encourage and support staff who wish to breastfeed their own infants and those who engage in gardening to enhance interest in healthy food, science, inquiries and learning. Staff are consistently a model for children and should be cognizant of the environmental information and print messages they bring into the indoor and outdoor learning/play environment. The labels and print messages that are present in the indoor and outdoor learning/play environment or family child care home should be in line with the healthy and safe behaviors and attitudes they wish to impart to the children.

Facilities should use developmentally appropriate health and safety education materials in the children’s activities and should also share these with the families whenever possible.

All health and safety education activities should be geared to the child’s developmental age and should take into account individual personalities and interests.

RATIONALE

Modeling is an effective way of confirming that a behavior is one to be imitated. Young children are particularly dependent on adults for their nutritional needs in both the home (1) and child care environment (2). Thus, modeling healthy and safe behaviors is an important way to demonstrate and reinforce healthy and safe behaviors of caregivers/teachers and children. Young children learn better through experiencing an activity and observing behavior than through didactic training (3,4). Learning and play have a reciprocal relationship; play experiences are closely related to learning (4).

Caregivers/teachers impact the nutrition habits of the children under their care, not only by making choices regarding the types of foods that are available but by influencing children’s attitudes and beliefs about that food as well as social interactions at mealtime. This provides a unique opportunity for programs to guide children’s choices by assigning parents/guardians and caregivers/teachers to the role of nutritional gatekeepers for the young children in their care. Such intervention is consistent with the U.S. Department of Agriculture's (USDA's) and U.S. Department of Health and Human Services' (DHHS') 2015-2020 Dietary Guidelines for Americans, 8th Edition. The Dietary Guidelines focus on increased healthy eating and physical activity to reduce the current rate of overweight or obesity in American children (one in three in the nation) (5).

The effectiveness of health and safety education is enhanced when shared between the caregiver/teacher and the parents/guardians (6,7).

COMMENTS

Caregivers/teachers are important in the lives of the young children in their care. They should be educated and supported to be able to interact optimally with the children in their care. Compliance should be documented by observation. Consultation can be sought from a child care health consultant or certified health education specialist. The American Association for Health Education (AAHE) and the National Commission for Health Education Credentialing (NCHEC) provide information on certified health education specialists.

An extensive education program to make such experiential learning possible indoors and outdoors should be supported by strong community resources in the form of both consultation and materials from sources such as the health department, nutrition councils, and so forth. Suggestions for topics and methods of presentation are widely available (7). Examples include, but are not limited to, routine preventive care by health professionals; nutrition education and physical activity to prevent obesity; crossing streets safely; how to develop and use outdoor learning/play environments; car seat safety; poison safety; latch key programs; health risks from secondhand smoke (exhaled smoke from smokers into the air), thirdhand smoke (residual smoke and chemicals on the smoker's clothes and hair or on surfaces where smoking occurs) (8,9), and secondhand emission from e-cigarettes (exhaled vapors into the air) (9); personal hygiene; and oral health; including limiting sweets; rinsing the mouth with water after sweets; and regular tooth brushing. It can be helpful to place visual cues in the indoor and outdoor learning/play environments to serve as reminders (e.g., posters). “Risk Watch” is a prepared curriculum from the National Fire Protection Association (NFPA) offering comprehensive injury prevention strategies for children in preschool through eighth grade (10).

TYPE OF FACILITY

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

RELATED STANDARDS

2.4.1.1 Health and Safety Education Topics for Children
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
4.2.0.1 Written Nutrition Plan
4.2.0.6 Availability of Drinking Water
4.3.1.1 General Plan for Feeding Infants
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.2.2 Serving Size for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children
4.5.0.4 Socialization During Meals
4.5.0.7 Participation of Older Children and Staff in Mealtime Activities
4.6.0.2 Nutritional Quality of Food Brought From Home
4.7.0.1 Nutrition Learning Experiences for Children
2.2.0.3 Screen Time/Digital Media Use
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities

REFERENCES

1. Kendrick, D., L. Groom, J. Stewart, M. Watson, C. Mulvaney, R. Casterton. 2007. Risk Watch: Cluster randomized controlled trial evaluating an injury prevention program. Injury Prevention 13:93-99.
   
2. American Lung Association. E-cigarettes and Lung Health. 2016. http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html?referrer=https://www.google.com/.
   
3. Hemmeter, M. L., L. Fox, S. Jack, L. Broyles. 2007. A program-wide model of positive behavior support in early childhood settings. J Early Intervention 29:337-55.
   
4. Dale, L. 2014. What is thirdhand smoke, and why is it a concern? http://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/third-hand-smoke/faq-20057791.
   
5. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-505. http://pediatrics.aappublications.org/content/116/4/e499. 
   
6. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. http://health.gov/dietaryguidelines/2015/guidelines/.
   
7. White. R.E. The power of play. A research summary on play and learning. 2012. http://www.childrensmuseums.org/images/MCMResearchSummary.pdf. 
   
8. Ward, S., et al. 2015. Systematic review of the relationship between childcare educators' practices and preschoolers' physical activity and eating behaviors. Obesity Reviews 16: 1055-1070.
   
9. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The role of parents in preventing childhood obesity. Future Child 16:169-86.
   
10. Centers for Disease Control and Prevention. Education and community support for health literacy. 2016. http://www.cdc.gov/healthliteracy/education-support/index.html. 
    

NOTES

Content in the STANDARD was modified on 1/10/2017.

Standard 2.4.2.1: Health and Safety Education Topics for Staff

The program activities on health and safety education should prepare early care and education staff in physical health; infection control; oral health; mental, and social and emotional health; nutrition; physical activity; environmental health; and safe environments for children and staff. Staff should be able to demonstrate knowledge or implement best practices of the following health education topics:

Physical Health

• Hearing, vision, and language problems
• Children with special health care needs
• Safe medication administration
• Shaken baby syndrome and abusive head trauma
• Gaining access to community resources
• Tobacco use/smoking and electronic cigarette (e-cigarette) use/vaping
• Marijuana use

Infection Control

• Hand hygiene
• Cleaning/sanitizing/disinfecting
• Illness exclusion policies
• Immunizations

Oral Health

• Proper infant feeding techniques
• Age-appropriate oral care

Mental, and Social and Emotional Health

• Promoting healthy mind and brain development through child care
• Behavior/discipline
• Monitoring developmental abilities, including indicators of potential delays
• Family/guardian mental health
• Staff mental health

Nutrition

• Age-appropriate nutrition
• Lactation (breast/chest feeding) support
  

Physical Activity

• Age-appropriate physical activity
• Outdoor play and learning

 Environmental Health and Safe Environments

• Food safety
• Clean, healthy drinking water
• Safe sleep environments and SIDS prevention
• Healthy indoor and outdoor learning/play environments
• Safety/injury prevention
• Managing emergency situations
• Safe use, storage, and cleanup of chemicals
• Safe medication administration and storage
• Safe storage of toxic substances
• Safe storage of marijuana in all forms (e.g., edibles)
• Safe use and storage of firearms
• Reducing exposure to environmental toxins (e.g., pesticides, cleaning products)
• Healthy air and good ventilation

RATIONALE

Early care and education staff members who are up to date on health and safety practices are more likely to provide a safe and healthy environment for children.¹ The most significant predictor of compliance with state child care health and safety regulations is staff continuing education in the areas of health, safety, child development, and abuse identification.²

More health and safety topics that staff needs to be knowledgeable about to teach children are listed in Standard 2.4.1.1.

COMMENTS

Child care staff often learn about health and safety from a child care health consultant (CCHC).³ Data support the relationship between child care health consultation and the increased quality of the health of the children and safety of the child care center environment.^3,4 Community resources can provide written materials about health and safety. Examples of materials can be found at https://eclkc.ohs.acf.hhs.gov/ and http://www.childhealthonline.org/.

State and local public health departments and child care state licensing agencies often conduct trainings or offer resources on the health and safety education topics listed above. Early care and education programs should consider offering “credit” for health education classes or encourage staff members to attend accredited education programs that can give education credits. The American Association for Health Education (AAHE) and the National Commission for Health Education Credentialing (NCHEC) provide information on certified health education specialists.

For more information on e-cigarettes and marijuana use, please visit:

American Lung Association. E-Cigarettes. 2020. https://www.lung.org/quit-smoking/e-cigarettes-vaping/lung-health  

American Lung Association. Marijuana and Lung Health. 2020. https://www.lung.org/quit-smoking/smoking-facts/health-effects/marijuana-and-lung-health

National Institute on Drug Abuse. Marijuana DrugFacts. 2019. https://www.drugabuse.gov/publications/drugfacts/marijuana   

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
4.3.1.1 General Plan for Feeding Infants
5.2.9.1 Use and Storage of Toxic Substances
5.5.0.8 Firearms
9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.4.1.19 Community Resource Information
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.2.0.4 Supervision Near Bodies of Water
2.2.0.6 Discipline Measures

REFERENCES

1. Chödrön G, Barger B, Pizur-Barnekow K, Viehweg S, Puk-Ament A. “Watch Me!” Training increases knowledge and impacts attitudes related to developmental monitoring and referral among childcare providers. Matern Child Health J. 2021;25(6):980-990. doi:10.1007/s10995-020-03097-w

2. Crowley AA, Rosenthal MS. Ensuring the Health and Safety of Connecticut’s Early Care and Education Programs. Farmington, CT: The Child Health and Development Institute of Connecticut; 2009.

3. Alkon A, Crowley AA, Benjamin Neelon SE, et al. Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children’s body mass index. BMC Public Health. 2014;14(1):215. doi:10.1186/1471-2458-14-215

4. Alkon A, Nouredini S, Swartz A, et al. Integrated pest management intervention in child care centers improves knowledge, pest control, and practices. J Pediatr Health Car. 2016;20(6):e27-e41. doi:10.1016/j.pedhc.2016/07/004

NOTES

Content in the STANDARD was modified on 1/10/2017 and 02/25/2022.

Standard 2.4.3.2: Parent/Guardian Education Plan

The content of a parent/guardian education plan should be individualized to meet each family’s needs and should be sensitive to cultural values and beliefs. Written material, at a minimum, should address the most important health and safety issues for all age groups served, should be in a language understood by families, and may include the topics listed in Standard 2.4.1.1, with special emphasis on the following:

1. Safety (such as home, community, playground, firearm, age- and size-appropriate car seat use, safe medication administration procedures, poison awareness, vehicular, or bicycle, and awareness of environmental toxins and healthy choices to reduce exposure);
2. Value of developing healthy and safe lifestyle choices early in life and parental/guardian health (such as exercise and routine physical activity, nutrition, weight control, breastfeeding, avoidance of substance abuse and tobacco use, stress management, maternal depression, HIV/AIDS prevention);
3. Importance of outdoor play and learning;
4. Importance of role modeling;
5. Importance of well-child care (such as immunizations, hearing/vision screening, monitoring growth and development);
6. Child development and behavior including bonding and attachment;
7. Domestic and relational violence;
8. Conflict management and violence prevention;
9. Oral health promotion and disease prevention;
10. Effective toothbrushing, handwashing, diapering, and sanitation;
11. Positive discipline, effective communication, and behavior management;
12. Handling emergencies/first aid;
13. Child advocacy skills;
14. Special health care needs;
15. Information on how to access services such as the supplemental food and nutrition program (i.e., The Women, Infants and Children [WIC] Supplemental Food Program), Food Stamps (SNAP), food pantries, as well as access to medical/health care and services for developmental disabilities for children;
16. Handling loss, deployment, and divorce;
17. The importance of routines and traditions (including reading and early literacy) with a child.

Health and safety education for parents/guardians should utilize principles of adult learning to maximize the potential for parents/guardians to learn about key concepts. Facilities should utilize opportunities for learning, such as the case of an illness present in the facility, to inform parents/guardians about illness and prevention strategies.

The staff should introduce seasonal topics when they are relevant to the health and safety of parents/guardians and children.

RATIONALE

Adults learn best when they are motivated, comfortable, and respected; when they can immediately apply what they have learned; and when multiple learning strategies are used. Individualized content and approaches are needed for successful intervention. Parent/guardian attitudes, beliefs, fears, and educational and socioeconomic levels all should be given consideration in planning and conducting parent/guardian education (1,2). Parental/guardian behavior can be modified by education. Parents/guardians should be involved closely with the facility and be actively involved in planning parent/guardian education activities. If done well, adult learning activities can be effective for educating parents/guardians. If not done well, there is a danger of demeaning parents/guardians and making them feel less, rather than more, capable (1,2).

The concept of parent/guardian control and empowerment is key to successful parent/guardian education in the child care setting. Support and education for parents/guardians lead to better parenting skills and abilities.

Knowing the family will help the staff such as the health and safety advocate determine content of the parent/guardian education plan and method for delivery. Specific attention should be paid to the parents’/guardians’ need for support and consultation and help locating resources for their problems. If the facility suggests a referral or resource, this should be documented in the child’s record. Specifics of what the parent/guardian shared need not be recorded.

COMMENTS

Community resources can provide written health- and safety-related materials. 

TYPE OF FACILITY

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

RELATED STANDARDS

2.4.1.1 Health and Safety Education Topics for Children
1.3.2.7 Qualifications and Responsibilities for Health Advocates
1.6.0.1 Child Care Health Consultants
9.4.1.19 Community Resource Information
2.1.1.5 Helping Families Cope with Separation
2.3.1.1 Mutual Responsibility of Parents/Guardians and Staff

REFERENCES

1. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505. http://pediatrics.aappublications.org/content/116/4/e499.      
2. National Association for the Education of Young Children. 2012. Supporting cultural competence: Accreditation of programs for young children cross-cutting theme in program standards. https://www.naeyc.org/academy/files/academy/file/TrendBriefsSupportingCulturalCompetence.pdf. 
   
3. ADDITIONAL REFERENCES:
   
   Centers for Disease Control and Prevention. Education and community support for health literacy. 2016. http://www.cdc.gov/healthliteracy/education-support/index.html.
    
   Centers for Disease Control and Prevention. Tips for parents – Ideas to help children maintain a healthy weight. 2016. http://www.cdc.gov/healthyweight/children/.
    
   Office of Head Start. Head start cultural and linguistic responsiveness resource catalogue. Volume three : Cultural responsiveness  (first edition). 2012. https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/cultural-linguistic/fcp/docs/resource-catalogue-cultural-linguistic-responsiveness.pdf.

NOTES

Content in the STANDARD was modified on 1/17/17.

Standard 3.1.5.3: Oral Health Education

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

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

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

School-age children should receive additional information including:

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

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

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

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

RATIONALE

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

COMMENTS

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

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

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

For more resources on oral health education, see:

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.4.3 Pacifier Use
3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
4.2.0.7 100% Fruit Juice
9.2.3.14 Oral Health Policy

REFERENCES

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

Standard 1.4.3.2: Topics Covered in Pediatric First Aid Training

To ensure the health and safety of children in an early care and education setting, staff should be able to respond to common injuries and life-threatening emergencies. Staff trained in pediatric first aid should be in attendance at all times. Pediatric first aid training is necessary to gain skills that allow caregivers/teachers to respond to emergencies and nonemergencies.¹ First aid training should present a variety of topics, including accessing emergency medical services (EMS), accessing poison control centers, safety at the scene of an incident, and isolation of bodily substances (standard precautions). Procedures for parental notification and records of communications with EMS should be established.

Pediatric first aid training in the early care and education setting should include instruction on recognizing and responding to:

• Abrasions and lacerations
• Airway management, both blocked airway and rescue breathing for infants and children, with return demonstration by the learner (pediatric cardiopulmonary resuscitation [CPR])
• Allergic reactions, including information about when epinephrine may be required
• Asthmatic reactions, including information about when rescue inhalers should be used
• Bites, including insect, animal, and human
• Bleeding, including nosebleeds
• Burns
• Cold-related injuries, including frostbite
• Dental and mouth injuries/trauma
• Drowning
• Electric shock
• Eye injuries
• Fainting
• Head injuries, including shaken baby syndrome/abusive head trauma
• Heat-related injuries, including heat exhaustion/heatstroke
• Illness-related emergencies (eg, stiff neck; inexplicable confusion; sudden onset of blood-red or purple rash; severe pain; temperature above 101°F [38.3°C] taken orally, above 102°F [38.9°C] taken rectally, or 100°F [37.8°C] or higher taken axillary [armpit] or measured by an equivalent method; looking/acting severely ill)
• Loss of consciousness
• Musculoskeletal injuries (eg, sprains, fractures)
• Poisoning, including swallowed, skin or eye contact, and inhaled
• Puncture wounds, including splinters
• Seizure care
• Shock

In addition, first aid training should include

• Managing first aid interventions for children with special health care needs
• Addressing the needs of all children in the group when managing emergencies in a child care setting
• Moving/positioning injured/ill persons

RATIONALE

First aid training provides instruction for simple, commonsense procedures that are intended to keep a child’s medical condition from becoming worse. Training in first aid is not intended to replace proper medical treatment; instead, it is for providing initial aid until EMS, medical professionals, or parents/guardians assume responsibility of the child’s medical care.^1(p3)

First aid for children in the early care and education setting requires a more child-specific approach than standard adult-oriented first aid offers. A staff member trained in pediatric first aid, including pediatric CPR, coupled with a facility that has been designed or modified to ensure the safety of children can reduce the potential for death and disability. Knowledge of pediatric first aid, including the ability to demonstrate pediatric CPR skills, and the confidence to use these skills are critically important to the outcome of an emergency.²

Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of children in care. Caregivers/teachers in these settings, who participate in pediatric first aid trainings, are better equipped on how to properly manage the supervision of other children during a medical emergency.

COMMENTS

Additional Resources:

First aid information can be obtained from:

• American Academy of Pediatrics (https://www.pedfactsonline.com)
• American Heart Association (https://www.heart.org)
• American Red Cross (https://www.redcross.org/take-a-class/first-aid)

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
3.4.3.1 Medical Emergency Procedures
3.6.1.3 Guidelines for Taking Children’s Temperatures
5.6.0.1 First Aid and Emergency Supplies
9.4.3.3 Training Record

REFERENCES

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

2. Scott JP, Baptist LL, Berens RJ. Pediatric resuscitation: outcome effects of location, intervention, and duration. Adv Anesth. 2015;2015:1–9 https://doi.org/10.1155/2015/517863

NOTES

Content in the STANDARD was modified on 5/17/2019.

Standard 1.4.4.1: Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes

All directors and caregivers/teachers of centers and large family child care homes should successfully complete at least thirty clock-hours per year of continuing education/professional development in the first year of employment, sixteen clock-hours of which should be in child development programming and fourteen of which should be in child health, safety, and staff health. In the second and each of the following years of employment at a facility, all directors and caregivers/teachers should successfully complete at least twenty-four clock-hours of continuing education based on individual competency needs and any special needs of the children in their care, sixteen hours of which should be in child development programming and eight hours of which should be in child health, safety, and staff health.

Programs should conduct a needs assessment to identify areas of focus, trainer qualifications, adult learning strategies, and create an annual professional development plan for staff based on the needs assessment. The effectiveness of training should be evident by the change in performance as measured by accreditation standards or other quality assurance systems.

RATIONALE

Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the staff member(s) involved. Too often, staff members make training choices based on what they like to learn about (their “wants”) and not the areas in which their performance should be improved (their “needs”). Participation in training does not ensure that the participant will master the information and skills offered in the training experience. Therefore, caregiver/teacher change in behavior or the continuation of appropriate practice resulting from the training, not just participation in training, should be assessed by supervisors and directors (4).

In addition to low child:staff ratio, group size, age mix of children, and stability of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (2). Most skilled roles require training related to the functions and responsibilities the role requires. Staff members who are better trained are better able to prevent, recognize, and correct health and safety problems. The number of training hours recommended in this standard reflects the central focus of caregivers/teachers on child development, health, and safety.

Children may come to child care with identified special health care needs or special needs may be identified while attending child care, so staff should be trained in recognizing health problems as well as in implementing care plans for previously identified needs. Medications are often required either on an emergent or scheduled basis for a child to safely attend child care. Caregivers/teachers should be well trained on medication administration and appropriate policies should be in place.

The National Association for the Education of Young Children (NAEYC), a leading organization in child care and early childhood education, recommends annual training/professional development based on the needs of the program and the pre-service qualifications of staff (1). Training should address the following areas:

1. Promoting child growth and development correlated with developmentally appropriate activities;
2. Infant care;
3. Recognizing and managing minor illness and injury;
4. Managing the care of children who require the special procedures listed in Standard 3.5.0.2;
5. Medication administration;
6. Business aspects of the small family child care home;
7. Planning developmentally appropriate activities in mixed age groupings;
8. Nutrition for children in the context of preparing nutritious meals for the family;
9. Age-appropriate size servings of food and child feeding practices;
10. Acceptable methods of discipline/setting limits;
11. Organizing the home for child care;
12. Preventing unintentional injuries in the home (e.g., falls, poisoning, burns, drowning);
13. Available community services;
14. Detecting, preventing, and reporting child abuse and neglect;
15. Advocacy skills;
16. Pediatric first aid, including pediatric CPR;
17. Methods of effective communication with children and parents/guardians;
18. Socio-emotional and mental health (positive approaches with consistent and nurturing relationships);
19. Evacuation and shelter-in-place drill procedures;
20. Occupational health hazards;
21. Infant safe sleep environments and practices;
22. Standard Precautions;
23. Shaken baby syndrome/abusive head trauma;
24. Dental issues;
25. Age-appropriate nutrition and physical activity.

There are few illnesses for which children should be excluded from child care. Decisions about management of ill children are facilitated by skill in assessing the extent to which the behavior suggesting illness requires special management (3). Continuing education on managing infectious diseases helps prepare caregivers/teachers to make these decisions devoid of personal biases (5). Recommendations regarding responses to illnesses may change (e.g., H1N1), so caregivers/teachers need to know where they can find the most current information. All caregivers/teachers should be trained to prevent, assess, and treat injuries common in child care settings and to comfort an injured child and children witnessing an injury.

COMMENTS

Tools for assessment of training needs are part of the accreditation self-study tools available from the NAEYC, the National Association for Family Child Care (NAFCC), National Early Childhood Professional Accreditation (NECPA), Association for Christian Education International (ACEI), National AfterSchool Association (NAA), and the National Child Care Association (NCCA). Successful completion of training can be measured by a performance test at the end of training and by ongoing evaluation of performance on the job.

Resources for training on health and safety issues include:

1. State and local health departments (health education, environmental health and sanitation, nutrition, public health nursing departments, fire and EMS, etc.);
2. Networks of child care health consultants;
3. Graduates of the National Training Institute for Child Care Health Consultants (NTI);
4. Child care resource and referral agencies;
5. University Centers for Excellence on Disabilities;
6. Local children’s hospitals;
7. State and local chapters of:
   1. American Academy of Pediatrics (AAP), including AAP Chapter Child Care Contacts;
   2. American Academy of Family Physicians (AAFP);
   3. American Nurses’ Association (ANA);
   4. American Public Health Association (APHA);
   5. Visiting Nurse Association (VNA);
   6. National Association of Pediatric Nurse Practitioners (NAPNAP);
   7. National Association for the Education of Young Children (NAEYC);
   8. National Association for Family Child Care (NAFCC);
   9. National Association of School Nurses (NASN);
   10. Emergency Medical Services for Children (EMSC) National Resource Center;
   11. National Association for Sport and Physical Education (NASPE);
   12. American Dietetic Association (ADA);
   13. American Association of Poison Control Centers (AAPCC).

For nutrition training, facilities should check that the nutritionist/registered dietician (RD), who provides advice, has experience with, and knowledge of, child development, infant and early childhood nutrition, school-age child nutrition, prescribed nutrition therapies, food service and food safety issues in the child care setting. Most state Maternal and Child Health (MCH) programs, Child and Adult Care Food Programs (CACFP), and Special Supplemental Nutrition Programs for Women, Infants, and Children (WIC) have a nutrition specialist on staff or access to a local consultant. If this nutrition specialist has knowledge and experience in early childhood and child care, facilities might negotiate for this individual to serve or identify someone to serve as a consultant and trainer for the facility.

Many resources are available for nutritionists/RDs who provide training in food service and nutrition. Some resources to contact include:

1. Local, county, and state health departments to locate MCH, CACFP, or WIC programs;
2. State university and college nutrition departments;
3. Home economists at utility companies;
4. State affiliates of the American Dietetic Association;
5. State and regional affiliates of the American Public Health Association;
6. The American Association of Family and Consumer Services;
7. National Resource Center for Health and Safety in Child Care and Early Education;
8. Nutritionist/RD at a hospital;
9. High school home economics teachers;
10. The Dairy Council;
11. The local American Heart Association affiliate;
12. The local Cancer Society;
13. The Society for Nutrition Education;
14. The local Cooperative Extension office;
15. Local community colleges and trade schools.

Nutrition education resources may be obtained from the Food and Nutrition Information Center at http://fnic.nal.usda.gov. The staff’s continuing education in nutrition may be supplemented by periodic newsletters and/or literature (frequently bilingual) or audiovisual materials prepared or recommended by the Nutrition Specialist.

Caregivers/teachers should have a basic knowledge of special health care needs, supplemented by specialized training for children with special health care needs. The type of special health care needs of the children in care should influence the selection of the training topics. The number of hours offered in any in-service training program should be determined by the experience and professional background of the staff, which is best achieved through a regular staff conference mechanism.

Financial support and accessibility to training programs requires attention to facilitate compliance with this standard. Many states are using federal funds from the Child Care and Development Block Grant to improve access, quality, and affordability of training for early care and education professionals. College courses, either online or face to face, and training workshops can be used to meet the training hours requirement. These training opportunities can also be conducted on site at the child care facility. Completion of training should be documented by a college transcript or a training certificate that includes title/content of training, contact hours, name and credentials of trainer or course instructor and date of training. Whenever possible the submission of documentation that shows how the learner implemented the concepts taught in the training in the child care program should be documented. Although on-site training can be costly, it may be a more effective approach than participation in training at a remote location.

Projects and Outreach: Early Childhood Research and Evaluation Projects, Midwest Child Care Research Consortium at http://ccfl.unl.edu/projects_outreach/projects/current/ecp/mwcrc.php, identifies the number of hours for education of staff and fourteen indicators of quality from a study conducted in four Midwestern states.

TYPE OF FACILITY

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

RELATED STANDARDS

1.8.2.2 Annual Staff Competency Evaluation
10.3.3.4 Licensing Agency Provision of Child Abuse Prevention Materials
10.3.4.6 Compensation for Participation in Multidisciplinary Assessments for Children with Special Health Care or Education Needs
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
3.5.0.2 Caring for Children Who Require Medical Procedures
3.6.3.1 Medication Administration
9.4.3.3 Training Record
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES

1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
2. Crowley, A. A. 1990. Health services in child care day care centers: A survey. J Pediatr Health Care 4:252-59.
3. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
4. 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.
5. 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; 2020:15.

Standard 1.4.4.2: Continuing Education for Small Family Child Care Home Caregivers/Teachers

Small family child care home caregivers/teachers should have at least thirty clock-hours per year (2) of continuing education in areas determined by self-assessment and, where possible, by a performance review of a skilled mentor or peer reviewer.

RATIONALE

In addition to low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (1). Most skilled roles require training related to the functions and responsibilities the role requires. Caregivers/teachers who engage in on-going training are more likely to decrease morbidity and mortality in their setting (3) and are better able to prevent, recognize, and correct health and safety problems.

Children may come to child care with identified special health care needs or may develop them while attending child care, so staff must be trained in recognizing health problems as well as in implementing care plans for previously identified needs.

Because of the nature of their caregiving/teaching tasks, caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to any education/training curriculum and program management plan. Planning and evaluation of training should be based on performance of the caregiver/teacher. Provision of workshops and courses on all facets of a small family child care business may be difficult to access and may lead to caregivers/teachers enrolling in training opportunities in curriculum related areas only. Too often, caregivers/teachers make training choices based on what they like to learn about (their “wants”) and not the areas in which their performance should be improved (their “needs”).

Small family child care home caregivers/teachers often work alone and are solely responsible for the health and safety of small numbers of children in care. Peer review is part of the process for accreditation of family child care and can be valuable in assisting the caregiver/teacher in the identification of areas of need for training. Self-evaluation may not identify training needs or focus on areas in which the caregiver/teacher is particularly interested and may be skilled already.

COMMENTS

The content of continuing education for small family child care home caregivers/teachers should include the following topics:

1. Promoting child growth and development correlated with developmentally appropriate activities;
2. Infant care;
3. Recognizing and managing minor illness and injury;
4. Managing the care of children who require the special procedures listed in Standard 3.5.0.2;
5. Medication administration;
6. Business aspects of the small family child care home;
7. Planning developmentally appropriate activities in mixed age groupings;
8. Nutrition for children in the context of preparing nutritious meals for the family;
9. Age-appropriate size servings of food and child feeding practices;
10. Acceptable methods of discipline/setting limits;
11. Organizing the home for child care;
12. Preventing unintentional injuries in the home (falls, poisoning, burns, drowning);
13. Available community services;
14. Detecting, preventing, and reporting child abuse and neglect;
15. Advocacy skills;
16. Pediatric first aid, including pediatric CPR;
17. Methods of effective communication with children and parents/guardians;
18. Socio-emotional and mental health (positive approaches with consistent and nurturing relationships);
19. Evacuation and shelter-in-place drill procedures;
20. Occupational health hazards;
21. Infant-safe sleep environments and practices;
22. Standard Precautions;
23. Shaken baby syndrome/abusive head trauma;
24. Dental issues;
25. Age-appropriate nutrition and physical activity.

Small family child care home caregivers/teachers should maintain current contact lists of community pediatric primary care providers, specialists for health issues of individual children in their care and child care health consultants who could provide training when needed.

In-home training alternatives to group training for small family child care home caregivers/teachers are available, such as distance courses on the Internet, listening to audiotapes or viewing media (e.g., DVDs) with self-checklists. These training alternatives provide more flexibility for caregivers/teachers who are remote from central training locations or have difficulty arranging coverage for their child care duties to attend training. Nevertheless, gathering family child care home caregivers/teachers for training when possible provides a break from the isolation of their work and promotes networking and support. Satellite training via down links at local extension service sites, high schools, and community colleges scheduled at convenient evening or weekend times is another way to mix quality training with local availability and some networking.

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.4.1 Continuing Education for Directors and Caregivers/Teachers in Centers and Large Family Child Care Homes
1.7.0.4 On-Site Occupational Hazards
3.5.0.2 Caring for Children Who Require Medical Procedures
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
9.4.3.3 Training Record

REFERENCES

1. The National Association of Family Child Care (NAFCC). 2005. Quality standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. http://www.nafcc.org/documents/QualStd.pdf.
2. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The national child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.
3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 1.6.0.1: Child Care Health Consultants

*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:

1. Consultation skills both as a child care health consultant as well as a member of an interdisciplinary team of consultants;
2. National health and safety standards for out-of-home child care;
3. Indicators of quality early care and education;
4. Day-to-day operations of child care facilities;
5. State child care licensing and public health requirements;
6. 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);
7. Infancy and early childhood development, social and emotional health, and developmentally appropriate practice;
8. Recognition and reporting requirements for infectious diseases;
9. American Academy of Pediatrics (AAP) and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) screening recommendations and immunizations schedules for children;
10. 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);
11. Injury prevention for children;
12. Oral health for children;
13. Nutrition and age-appropriate physical activity recommendations for children including feeding of infants and children, the importance of breastfeeding and the prevention of obesity;
14. Inclusion of children with special health care needs, and developmental disabilities in child care;
15. Safe medication administration practices;
16. Health education of children;
17. Recognition and reporting requirements for child abuse and neglect/child maltreatment;
18. Safe sleep practices and policies (including reducing the risk of SIDS);
19. Development and implementation of health and safety policies and practices including poison awareness and poison prevention;
20. Staff health, including adult health screening, occupational health risks, and immunizations;
21. Disaster planning resources and collaborations within child care community;
22. Community health and mental health resources for child, parent/guardian and staff health;
23. 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:

1. Assessing caregivers’/teachers’ knowledge of health, development, and safety and offering training as indicated;
2. Assessing parents’/guardians’ health, development, and safety knowledge, and offering training as indicated;
3. Assessing children’s knowledge about health and safety and offering training as indicated;
4. Conducting a comprehensive indoor and outdoor health and safety assessment and on-going observations of the child care facility;
5. Consulting collaboratively on-site and/or by telephone or electronic media;
6. 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;
7. Developing or updating policies and procedures for child care facilities (see comment section below);
8. Reviewing health records of children;
9. Reviewing health records of caregivers/teachers;
10. Assisting caregivers/teachers and parents/guardians in the management of children with behavioral, social and emotional problems and those with special health care needs;
11. 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);
12. Consulting with a child’s primary care provider about medications as needed, in collaboration with parents/guardians;
13. Teaching staff safe medication administration practices;
14. Monitoring safe medication administration practices;
15. 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;
16. 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;
17. Understanding and observing confidentiality requirements;
18. Assisting in the development of disaster/emergency medical plans (especially for those children with special health care needs) in collaboration with community resources;
19. Developing an obesity prevention program in consultation with a nutritionist/registered dietitian (RD) and physical education specialist;
20. 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:

1. Admission and readmission after illness, including inclusion/exclusion criteria;
2. 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;
3. Plans for care and management of children with communicable diseases;
4. Plans for prevention, surveillance and management of illnesses, injuries, and behavioral and emotional problems that arise in the care of children;
5. Plans for caregiver/teacher training and for communication with parents/guardians and primary care providers;
6. Policies regarding nutrition, nutrition education, age-appropriate infant and child feeding, oral health, and physical activity requirements;
7. Plans for the inclusion of children with special health or mental health care needs as well as oversight of their care and needs;
8. Emergency/disaster plans;
9. Safety assessment of facility playground and indoor play equipment;
10. Policies regarding staff health and safety;
11. Policy for safe sleep practices and reducing the risk of SIDS;
12. Policies for preventing shaken baby syndrome/abusive head trauma;
13. Policies for administration of medication;
14. Policies for safely transporting children;
15. 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

1. Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81.
2. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.
3. 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.
4. Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health consultation: A conceptual model. J for Specialists in Pediatric Nurs 13:74-88.
5. Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
6. 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.
7. Farrer, J., A. Alkon, K. To. 2007. Child care health consultation programs: Barriers and opportunities. Maternal Child Health J 11:111-18.
8. 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.
9. Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
10. Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21.
11. 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 1.3.2.7: 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:

1. Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, and reporting requirements;
2. Childhood immunization requirements, record-keeping, and at least quarterly review and follow-up for children who need to have updated immunizations;
3. Child health assessment form review and follow-up of children who need further medical assessment or updating of their information;
4. How to plan for, recognize, and handle an emergency;
5. Poison awareness and poison safety;
6. Recognition of safety, hazards, and injury prevention interventions;
7. Safe sleep practices and the reduction of the risk of Sudden Infant Death Syndrome (SIDS);
8. How to help parents/guardians, caregivers/teachers, and children cope with death, severe injury, and natural or man-made catastrophes;
9. 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;
10. Facilitate collaboration with families, primary care providers, and other health service providers to create a health, developmental, or behavioral care plan;
11. Implementing care plans;
12. 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;
13. Medication administration;
14. Recognizing and understanding the needs of children with serious behavior and mental health problems;
15. Maintaining confidentiality;
16. Healthy nutritional choices;
17. The promotion of developmentally appropriate types and amounts of physical activity;
18. How to work collaboratively with parents/guardians and family members;
19. 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;
20. 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

1.4.3.2 Topics Covered in Pediatric First Aid Training
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
1.6.0.1 Child Care Health Consultants
1.3.1.1 General Qualifications of Directors
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
1.4.3.3 Cardiopulmonary Resuscitation Training for Swimming and Water Play
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

1. 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.
2. Centers for Disease Control and Prevention (CDC). 2011. Immunization schedules. http://www.cdc.gov/vaccines/recs/schedules/.
3. 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.
4. 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.
5. 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.
6. Ulione, M. S. 1997. Health promotion and injury prevention in a child development center. J Pediatr Nurs 12:148-54.

Feeding and Nutrition

Standard 4.2.0.6: Availability of Drinking Water

Clean, sanitary drinking water should be readily available and offered throughout the day in indoor and outdoor areas.^1,2 Water should not be a substitute for milk at meals or snacks at which milk is a required food component unless recommended by the child’s primary health care provider. 

On hot days, infants receiving human milk in a bottle can be given additional human milk in a bottle but should not be given water, especially in the first 6 months after birth.¹ Infants receiving formula and water can be given additional formula in a bottle. Toddlers and older children will need additional water as physical activity and/or hot temperatures cause their needs to increase. Toddlers should learn to drink water from a cup or drinking fountain without mouthing the fixture. They should not be allowed to have water continuously in hand in a sippy cup or bottle. Permitting toddlers to suck continuously on a bottle or sippy cup filled with water, to soothe themselves, may cause nutritional or, in rare instances, electrolyte imbalances. When toothbrushing is not done after a feeding, children should be offered water to drink to rinse food from their teeth.

Drinking fountains should be kept clean and sanitary and maintained to provide adequate drainage.

RATIONALE

When children are thirsty between meals and snacks, water is the best choice. Young children may not be able to request water on their own prompting the need for caregivers/teachers to offer water throughout the day.² Additionally, having clean, small pitchers of water and single-use paper cups available in classrooms and on playgrounds allows children to serve themselves water when they are thirsty. Drinking water during the day can keep children hydrated while reducing calorie intake if the water replaces high-caloric beverages, such as fruit drinks/nectars and sodas, which are associated with overweight and obesity.³ Personal and environmental factors, such as age, weight, gender, physical activity level, outside air temperature, heat, and humidity, can affect an individual child’s water needs.⁴ Fluoride has been added to the tap (faucet) water in many communities. Drinking fluoridated water and keeping teeth “bathed” in low levels of fluoride protect a child’s teeth by decreasing the likelihood of early childhood caries (cavities) when consumed throughout the day, especially between meals and snacks.^5–7

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
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water

REFERENCES

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

2. US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program: meal pattern revisions related to the Healthy, Hunger-Free Kids Act of 2010. Final rule. Fed Regist. 2016;81(79):24347–24383

3. Muckelbauer R, Sarganas G, Grüneis A, Müller-Nordhorn J. Association between water consumption and body weight outcomes: a systematic review. Am J Clin Nutr. 2013;98(2):282–299

4. Wolfram T. Water: how much do kids need? Academy of Nutrition and Dietetics Eat Right website. http://www.eatright.org/resource/fitness/sports-and-performance/hydrate-right/water-go-with-the-flow. Published August 10, 2018. Accessed December 20, 2018

5. American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition. Kleinman RE, Greer FR, eds. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014

6. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017 
   

7. Early Childhood Learning and Knowledge Center, US Department of Health and Human Services Administration for Children and Families, Head Start. Encouraging your child to drink water. https://eclkc.ohs.acf.hhs.gov/publication/encouraging-your-child-drink-water. Updated September 11, 2018. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 11/9/2017, 03/22/2019 and 05/21/2019.

Standard 4.2.0.7: 100% Fruit Juice

Fruit or vegetable juice may be served once per day during a scheduled meal or snack to children 12 months or older (1). All juices should be pasteurized and 100% juice without added sugars or sweeteners.

Age	Maximum Allowed (1)
0–12 mo	Do not offer juices to infants younger than 12 months.
1–3 y	Limit consumption to 4 oz/day (½ cup).
4–6 y	Limit consumption to 4–6 oz/day (½–¾ cup).
7–18 y	Limit consumption to 8 oz/day (1 cup).

RATIONALE

While 100% fruit juice can be included in a healthy eating pattern, whole fruit is more nutritious and provides many nutrients, including dietary fiber, not found in juices (4).

Limiting overall juice consumption and encouraging children to drink water in-between meals will reduce acids produced by bacteria in the mouth that cause tooth decay. The frequency of exposure and liquids being pooled in the mouth are important in determining the cause of tooth decay in children (5). Beverages labeled as “fruit punch,” “fruit nectar”, or “fruit cocktail” contain less than 100% fruit juice and may be higher in overall sugar content. Routine consumption of fruit juices does not provide adequate amounts of vitamin E, iron, calcium, and dietary fiber—all essential in the growth and development of young children (6). Continuous consumption of fruit juice may be associated with decreased appetite during mealtimes, which may lead to inadequate nutrition, feeding issues, and increases in a child’s body mass index—all of which are considered risk factors that may contribute to childhood obesity (7).

Serving pasteurized juice protects against the possible outbreak of foodborne illness because the process destroys any harmful bacteria that may have been present (8).

 Drinks high in sugar and caffeine should be avoided because they can contribute to childhood obesity, tooth decay, and poor nutrition (9).

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.5.1 Routine Oral Hygiene Activities
3.1.5.3 Oral Health Education
4.2.0.6 Availability of Drinking Water
4.2.0.4 Categories of Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants

REFERENCES

1. US Department of Health and Human Services, US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. Accessed September 19, 2017
   
2. American Academy of Pediatrics. Starting solid foods. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx. Updated April 7, 2017. Accessed September 19, 2017
   
3. American Academy of Pediatrics. Fruit juice and your child's diet. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Fruit-Juice-and-Your-Childs-Diet.aspx. Updated May 22, 2017. Accessed September 19, 2017
   
4. Heyman MB, Abrams SA; American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition and Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967
   
5. Centers for Disease Control and Prevention. Healthy schools. The buzz on energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Updated March 22, 2016. Accessed September 19, 2017.
   
6. US Food and Drug Administration. Talking about juice safety: what you need to know. https://www.fda.gov/food/resourcesforyou/consumers/ucm110526.htm. Updated September 19, 2017. Accessed September 19, 2017
   
7. Shefferly A, Scharf RJ, DeBoer MD. Longitudinal evaluation of 100% fruit juice consumption on BMI status in 2–5?year?old children. Pediatr Obes. 2016;11(3):221–227
   
8. Crowe-White K, O’Neil CE, Parrott JS, et al. Impact of 100% fruit juice consumption on diet and weight status of children: an evidence-based review. Crit Rev Food Sci Nutr. 2016;56(5):871–884
   
9. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. Accessed September 19, 2017
   

NOTES

Content in the STANDARD was modified on 11/9/2017. 

Standard 4.3.1.8: Techniques for Bottle Feeding

Infants should always be held for bottle feeding. Caregivers/teachers should hold infants in the caregiver’s/teacher’s arms or sitting up on the caregiver’s/teacher’s lap. Bottles should never be propped. The facility should not permit infants to have bottles in the crib. The facility should not permit an infant to carry a bottle while standing, walking, or running around.

Bottle feeding techniques should mimic approaches to breastfeeding:
a.    Initiate feeding when infant provides cues (rooting, sucking, etc.);
b.    Hold the infant during feedings and respond to vocalizations with eye contact and vocalizations;
c.     Alternate sides of caregiver’s/teacher’s lap;
d.    Allow breaks during the feeding for burping;
e.    Allow infant to stop the feeding.

A caregiver/teacher should not bottle feed more than one infant at a time.

Bottles should be checked to ensure they are given to the appropriate child, have human milk or infant formula in them. When using a bottle for a breastfed infant, a nipple with a cylindrical teat and a wider base is usually preferable. A shorter or softer nipple may be helpful for infants with a hypersensitive gag reflex, or those who cannot get their lips well back on the wide base of the teat (1).

The use of a bottle or cup to modify or pacify a child’s behavior should not be allowed (2).

RATIONALE

The manner in which food is given to infants is conducive to the development of sound eating habits for life. Caregivers/teachers and parents/guardians need to understand the relationship between bottle feeding and emotional security. Caregivers/teachers should hold infants who are bottle feeding whenever possible, even if the children are old enough to hold their own bottle. Caregivers/teachers should promote proper feeding practices and oral hygiene including proper use of the bottle for all infants and toddlers. Bottle propping can cause choking and aspiration and may contribute to long-term health issues, including ear infections (otitis media), orthodontic problems, speech disorders, and psychological problems (3). When infants and children are fed on cue, they are in control of frequency and amount of feedings. This has been found to reduce the risk of childhood obesity. Any liquid except plain water can cause early childhood caries (4). Early childhood caries in primary teeth may hold significant short-term and long-term implications for the child’s health (5). Frequently sipping any liquid besides plain water between feeds encourages tooth decay.

Children are at an increased risk for injury when they walk around with bottle nipples in their mouths. Bottles should not be allowed in the crib or bed for safety and sanitary reasons and for preventing dental caries. It is difficult for a caregiver/teacher to be aware of and respond to infant feeding cues when the child is in a crib or bed and when feeding more than one infant at a time. Infants should be burped after every feeding and preferably during the feeding as well.

Caregivers/teachers should offer children fluids from a cup as soon as they are developmentally ready. Some children may be able to drink from a cup around six months of age, while for others it is later (6). Weaning a child to drink from a cup is an individual process, which occurs over a wide range of time. The American Academy of Pediatric Dentistry (AAPD) recommends weaning from a bottle by the child’s first birthday (7). Instead of sippy cups, caregivers/teachers should use smaller cups and fill halfway or less to prevent spills as children learn to use a cup (8). If sippy cups are used, it should only be for a very short transition period.

Some children around six months to a year of age may be developmentally ready to feed themselves and may want to drink from a cup. The transition from bottle to cup can come at a time when a child’s fine motor skills allow use of a cup. The caregiver/teacher should use a clean small cup without cracks or chips and should help the child to lift and tilt the cup to avoid spillage and leftover fluid. The caregiver/teacher and parent/guardian should work together on cup feeding of human milk to ensure the child’s receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of feeding. Two to three ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (about an ounce) can be discarded.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.1.9 Warming Bottles and Infant Foods

REFERENCES

1. Holt K, Wooldridge N, Story M, Sofka D. Breast Milk/ microwaving, storage of, advantages of. In: Bright Futures: Nutrition. Chicago, IL: American Academy of Pediatrics; 2011: 27, 118, 120
   
2. Rupal, C. 2016. Stopping the Bottle. Nemours, KidsHealth. http://kidshealth.org/en/parents/no-bottles.html#.
   
3. Hirsch, L. 2017. Feeding your 4- to 7-month old. Nemours, KidsHealth. http://kidshealth.org/en/parents/feed47m.html#
   
4. Çolak, H., Dülgergil, Ç. T., Dalli, M., & Hamidi, M. M. 2013. Early childhood caries update: A review of causes, diagnoses, and treatments. Journal of natural science, biology, and medicine, 4(1), 29.
   
5. American Academy of Pediatrics, Healthy Children. 2015. How to prevent tooth decay in your baby. https://www.healthychildren.org/English/ages-stages/baby/teething-tooth-care/Pages/How-to-Prevent-Tooth-Decay-in-Your-Baby.aspx.
   
6. American Academy of Pediatrics, Healthy Children. 2015. Practical bottle feeding tips. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Practical-Bottle-Feeding-Tips.aspx.
   
7. Lerner, C., & Parlakian, R. 2016. Colic and crying. Zero to three. https://www.zerotothree.org/resources/197-colic-and-crying.
   
8. Ben-Joseph, E. 2015. Formula feeding FAQs: Getting started. Nemours: KidsHealth. http://kidshealth.org/en/parents/formulafeed-starting.html#
   

Standard 4.3.1.11: Introduction of Age-Appropriate Solid Foods to Infants

A plan to introduce complementary, age-appropriate solid foods to infants should be made in consultation with the child’s parent/guardian and primary health care provider. Complementary foods are nutritious foods and beverages other than human breast milk or infant formula.⁶ Age-appropriate solid foods may be introduced by 6 months, or sooner or later based on the child’s developmental level.^1,5-6 Caregivers/teachers should watch for signs to decide when the infant is ready for solid foods. These signs include sitting up with only a little support, proper head control, the ability to chew well, or grabbing food from the plate. Also, infants will lose the tongue-thrusting reflex and begin acting hungry after formula feeding or breastfeeding.^4,6 Recommendations on the introduction of complementary should take into account:⁶

• The infant’s developmental level
• Nutritional needs
• Coexisting medical conditions
• Social factors
• Cultural, ethnic, and religious food preferences of the family
• Financial considerations
• Other related factors found through the nutrition assessment

For infants who are exclusively breastfed, the amount of certain nutrients in the body ¾ such as iron and zinc ¾ begins to get lower after the age of 6 months. So, gradually introduce puréed meats or meat substitutes and iron-fortified cereals.^5-6 Iron-fortified cereals, puréed meats, and puréed fruits and vegetables are all appropriate foods to introduce. The first food introduced should have just one ingredient that is served in a small portion for 3 to 5 days before introducing another food.⁶ Watch the infant closely for potential reactions to the foods being introduced. Gradually increase the variety and portion, one at a time, depending on how the infant reacts .⁸ 

Caregivers/teachers should use or develop a take-home sheet for parents/guardians in which the caregiver/teacher records the food consumed, how much, and other important notes on the infant, each day. Caregivers/teachers should also continue to talk with each infant’s parents/guardians about which foods they have introduced and are feeding. When appropriate, changes to basic food patterns should be given in writing by the infant’s primary health care provider.

If caregivers/teachers will give nutritional supplements/medications, written orders from the prescribing health care provider should specify the medical need; medication or supplement; dosage; and how long to give the medication or supplement.

RATIONALE

The ideal time to introduce complementary foods to infants may vary because infants develop at different rates. Early introduction of age-appropriate solid food and fruit juice interferes with the intake of human milk or iron-fortified formula that the infant needs for growth. Solid foods given before an infant is developmentally ready may be related to extra weight gain, a higher risk of choking, and consuming less than the right amount of breast milk or formula.^1,4,6 Age-appropriate solid foods, such as meat and fortified cereals, are needed beginning at 6 months to make up for any losses in zinc and iron from breastfeeding exclusively.^5-6 Typically, low levels of vitamin D are transferred to infants via breast milk, so it is recommended that breastfed or partially breastfed infants receive at least 400 IU of vitamin D supplements every day beginning soon after birth.^2,3,6 Parents/guardians give these supplements at home, unless the primary health care provider has different instructions.

Many caregivers/teachers and parents/guardians believe that infants sleep better when they start to eat age-appropriate solid foods, but research shows that longer sleeping periods are developmental -not nutritionally- determined in mid-infancy, and so this shouldn’t be the only reason for deciding when to introduce solid foods.^4,6 Also, for infants who are exclusively formula fed or fed a combination of formula and human milk, evidence for introducing complementary foods in a specific order has not been proven.

Good communication between the caregiver/teacher and the parents/guardians cannot be overemphasized and is needed for successful feeding in general, including when and how to introduce age-appropriate solid foods.

COMMENTS

ADDITIONAL RESOURCES:

American Academy of Pediatrics

Starting Solid Foods - https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Starting-Solid-Foods.aspx

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.7 100% Fruit Juice
3.6.3.1 Medication Administration
4.2.0.9 Written Menus and Introduction of New Foods
4.2.0.10 Care for Children with Food Allergies
4.2.0.12 Vegetarian/Vegan Diets
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.5.0.8 Experience with Familiar and New Foods

REFERENCES

1. American Academy of Pediatrics. Infant food and feeding. AAP.org Web site. https://www.aap.org/en/patient-care/healthy-active-living-for-families/infant-food-and-feeding/. Published July 6, 2021. Accessed November 20, 2022

2. American Academy of Pediatrics. Where we stand: vitamin D & iron supplements for babies. Updated May 24, 2022. Healthy Children.org Web site. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Vitamin-Iron-Supplements.aspx. Accessed November 20, 2022

3. Centers for Disease Control and Prevention. Vitamin D supplementation CDC (Centers for Disease Control and Prevention). CDC.gov Web site. http://www.cdc.gov/breastfeeding/recommendations/vitamin_D.htm. Last Reviewed July 2, 2021. Accessed November 20, 2022

4. U.S Department of Agriculture. Food and Nutrition Service. Feeding infants in the Child and Adult Care Food Program. USDA.gov Web site. https://www.fns.usda.gov/tn/infant-and-toddler-nutrition. Published July 2021. Accessed November 20, 2022

5. U.S Department of Agriculture. Food and Nutrition Service. Q&As: Feeding infants and meal pattern requirements in the Child and Adult Care Food Program. https://fns-prod.azureedge.us/sites/default/files/cacfp/CACFP06-2017os.pdf. Published January 17, 2017. Accessed November 20, 2022

6. U.S Department of Agriculture. WIC Works Resource System. WIC infant nutrition and feeding guide. Chapter 5: Complementary foods. USDA.gov Web site. https://wicworks.fns.usda.gov/resources/infant-nutrition-and-feeding-guide. Published April 2019. Accessed November 20, 2022

7. Vadiveloo M, Tovar A, Østbye T, Benjamin-Neelon SE. Associations between timing and quality of solid food introduction with infant weight-for-length z-scores at 12 months: findings from the Nurture cohort. Appetite, 141, p.104299. https://www.sciencedirect.com/science/article/pii/S0195666318317860?casa_token=AI_mEyEGr4IAAAAA:sWFkOzAZjvFMH_TAGxxymoYTKr0XlLodeP4MT_unvd3fyUB0CqGmqP6K7G5QCdmQwSk2iwjQvis. Published October 1, 2019. Accessed November 20, 2022

8. World Health Organization. Infant and young child feeding: key facts. WHO.int Web site. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding. Published June 9, 2021. Accessed November 20, 2022

NOTES

Content in the STANDARD was modified on 5/31/2018 and 2/9/2023.

Oral Health-Related Infectious Disease

Standard 7.5.12.1: Thrush (Candidiasis)

Children with thrush do not need to be excluded from group settings (1). Careful hand hygiene and sanitization of surfaces and objects potentially exposed to oral secretions including pacifiers and toothbrushes is the best way to prevent spread (1). Toothbrushes and pacifiers should be labeled individually so that children do not share toothbrushes or pacifiers, as specified in Standard 3.1.5.2. The presence of children with thrush should be noted by caregivers/teachers, and parents/guardians of the children should be notified to seek care, if indicated.

Treatment of thrush may consist of a topical or an oral medication. Most people are able to control thrush without treatment. Evaluation by a primary care provider of people with severe or prolonged symptoms may be indicated.

RATIONALE

Thrush is a common infection, especially among infants (1). Thrush is caused by yeast, a type of fungus called Candida. This fungus thrives in warm, moist areas (skin, skin under a diaper, and on mucous membranes). Thrush appears as white patches on the mucous membranes, commonly on the inner cheeks, gums, and tongue, and may cause diaper rash. The yeast that causes thrush lives on skin and mucous membranes of healthy people and is present on surfaces throughout the environment. An imbalance in the normal bacteria and fungi on the skin may cause the yeast to begin growing on the mucous membranes, appearing as white plaques that are adherent. Intermittent thrush may be normal in infants and young children. People with exposure to moisture, those receiving antibiotics, or those with an illness may develop thrush (2).

COMMENTS

Occasionally, thrush might occur in several individuals at the same time or within a couple of days of each other. Consultation with a health care professional and the local health department may be sought when several individuals have these symptoms.

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.5.2 Toothbrushes and Toothpaste
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children

REFERENCES

1. American Academy of Pediatrics. Thrush (Candidiasis) 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: 264

2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Standard 7.6.1.1: Disease Recognition and Control of Hepatitis B Virus (HBV) Infection

Facilities should have written policies for inclusion and exclusion of children known to be infected with hepatitis B virus (HBV) and for immunization of all children with hepatitis B vaccine per the “Recommended Immunization Schedules” for children and adolescents. All infants should complete a three dose series of hepatitis B vaccine beginning at birth as recommended by the American Academy of Pediatrics (AAP) and Centers for Disease Control and Prevention (CDC) (1). When a child who is an HBV carrier is admitted to a facility, the facility director and primary caregivers/teachers should be informed.

Children who carry HBV chronically and who have no behavioral or medical risk factors, such as aggressive behavior (such as biting or frequent scratching), generalized dermatitis (weeping skin lesions), or bleeding problems, may be admitted to the facility without restrictions.

Testing of children for HBV should not be a prerequisite for admission to facilities.

With regard to infection control measures and handling of blood or blood-containing body fluids, every person should be assumed to be an HBV carrier with regard to blood exposure. All blood should be considered as potentially containing HBV. Child care personnel should adopt Standard Precautions, as outlined in Prevention of Exposure to Blood and Body Fluids, Standard 3.2.3.4.

Toys and objects that young children (infants and toddlers) mouth should be cleaned and sanitized, as stated in Standards 3.3.0.2-3.3.0.3.

Toothbrushes and pacifiers should be individually labeled so that the children do not share toothbrushes or pacifiers, as specified in Standard 3.1.5.2.

RATIONALE

Prior to routine hepatitis B immunization of infants, transmission in child care facilities was reported (2,3). Currently the risk of transmitting the disease in child care is theoretically small because of the low risk of transmission, implementation of infection control measures, and high immunization rates. Immunization not only will reduce the potential for transmission but also will allay anxiety about transmission from children and staff in the child care setting who may be carriers of hepatitis B (1). However, children who are HBV carriers (particularly children born in countries highly endemic for HBV) could be enrolled in child care. Thus, transmission of HBV in the child care setting is of concern to public health authorities.

The risk of disease transmission from an HBV-carrier child or staff member with no behavioral risk factors and without generalized dermatitis or bleeding problems is considered rare. This extremely low risk does not justify exclusion of an HBV-carrier child from out-of-home care, nor does it justify the routine screening of children as possible HBV carriers prior to admission to child care.

HBV transmission in a child care setting is most likely to occur through direct exposure via bites or scratches that break the skin and introduce blood or body secretions from the HBV carrier into a susceptible person. Indirect transmission via blood or saliva through environmental contamination may be possible but has not been documented. Saliva contains much less virus (1/1000) than blood; therefore, the potential infection from saliva is much lower than that of blood.

No data are available to indicate the risk of transmission if a susceptible person bites an HBV carrier. When the HBV statuses of both the biting child and the victim are unknown, the risk of HBV transmission would be extremely low because of the expected low incidence of HBV carriage by children of preschool-age and the low efficiency of disease transmission by bite exposure. Because a bite in this situation is extremely unlikely to involve an HBV-carrier child, screening is not warranted, particularly in children who are immunized appropriately against HBV (1), but each situation should be evaluated individually. In the rare circumstance that an unimmunized child bites a known HBV carrier, the hepatitis B vaccine series should be initiated (4).

COMMENTS

Parents/guardians are not required to share information about their child’s HBV status, but they should be encouraged to do so. For additional information regarding HBV consult the current edition of the Red Book from the AAP.

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.5.2 Toothbrushes and Toothpaste
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children

REFERENCES

1. Shane, A. L., L. K. Pickering. 2008. Infections associated with group child care. In Principles and practice of pediatric infectious diseases, eds. S. S. Long, L. K. Pickering, C. G. Prober. 3rd ed. Philadelphia: Churchill Livingstone.
2. Shapiro, C. N., L. F. McCaig, K. F. Genesheimer, et al. 1989. Hepatitis B virus transmission between children in day care. Pediatr Infect Dis J 8:870-75.
3. Deseda, D. D., C. N. Shapiro, K. Carroll. 1994. Hepatitis B virus transmission between a child and staff member at a day-care center. Pediatr Infect Dis J 13:828-30.
4. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.

Standard 7.6.1.3: Staff Education on Prevention of Bloodborne Diseases

All caregivers/teachers should receive training at employment and annually thereafter as required by the Occupational Safety and Health Administration (OSHA) on how to prevent transmission of bloodborne diseases, including hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV (1).

RATIONALE

Efforts to reduce risk of transmitting diseases in child care through hygiene and environmental standards in general should focus primarily on blood precautions, limiting saliva contamination (no sharing of utensils, pacifiers, tooth brushes), and ensuring that children are appropriately immunized against HBV. People, including caregivers/teachers, who may be expected to come into contact with blood as a part of their employment, are required to be trained how to protect themselves from bloodborne diseases by their employers and be offered hepatitis B vaccine at no charge to them, within ten working days of initial assignment (1,2).

COMMENTS

If the employee initially declines hepatitis B vaccination but at a later date, while still covered under the acceptable timeline (ten working days), decides to accept the vaccination, the employer should make hepatitis B vaccination available at that time. The employer should require that employees who decline to accept the offer of hepatitis B vaccination sign the Occupational Safety and Health Administration’s (OSHA) “Hepatitis B Vaccine Declination” statement (1). The “Hepatitis B Vaccine Declination” statement can be found at http://www.ecels-healthychildcarepa
.org/content/Keeping Safe 07-27-10.pdf.

For additional information regarding HBV and HCV infections, consult the associated chapters 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

3.2.3.4 Prevention of Exposure to Blood and Body Fluids

REFERENCES

1. Centers for Disease Control and Prevention. 2005. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States. MMWR 54 (RR16). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm.
2. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha
   .gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051.

Oral Health-Related Emergencies

Standard 9.4.1.9: Records of Injury

When an injury occurs in the facility that results in first aid or medical attention for a child or adult, the facility should complete a report form that provides the following information:

1. Name, sex, and age of the injured person;
2. Date and time of injury;
3. Location where injury took place;
4. Description of how the injury occurred, including who (name, address, and phone number) saw the incident and what they reported, as well as what was reported by the child;
5. Body part(s) involved;
6. Description of any consumer product involved;
7. Name and location of the staff member responsible for supervising the child at the time of the injury;
8. Actions taken by staff members on behalf of the injured following the injury as well as specifically whether emergency medical services and/or professional dental/medical care was required;
9. Recommendations of preventive strategies that could be taken to avoid future occurrences of this type of injury;
10. Name of person who completed the report;
11. Name, address, and phone number of the facility;
12. Signature of the parent/guardian of the child injured or signature of the adult injured and the date signature obtained (recommended that the signature be obtained the same day as the injury);
13. If parent/guardian of child was notified at time of injury;
14. Documentation that written report was sent home the day of the injury, regardless of parental signature.

Examples of injuries that should be documented include:

1. Child maltreatment (physical, sexual, emotional, and neglect abuse);
2. Bites that are continuous in nature, break the skin, left a mark, and cause significant pain;
3. Falls, burns, broken limbs, tooth loss, other injury;
4. Motor vehicle injury;
5. Aggressive/unusual behavior;
6. Ingestion of non-food substances;
7. Medication error;
8. Blows to the head;
9. Death.

Three copies of the injury report form should be completed. One copy should be given to the child’s parent/guardian (or to the injured adult). The second copy should be kept in the child’s (or adult’s) folder at the facility. A third copy should be kept in a chronologically filed injury log that is analyzed periodically to determine any patterns regarding time of day, equipment, location or supervision issues. This last copy should be kept in the facility for the period required by the state’s statute of limitations. If required by state regulations, a copy of an injury report for each injury that required medical attention should be sent to the state licensing agency.

Based on the logs, the facility should plan to take corrective action. Examples of corrective action include: adjusting schedules, removing or limiting the use of equipment, relocating equipment or furnishings, and/or increasing supervision.

RATIONALE

Injury patterns and child abuse and neglect can be discerned from such records and can be used to prevent future problems (1,2). Known data on typical injuries (scanning for hazards, providing direct supervision, etc.) can also how to prevent them. A report form is also necessary for providing information to the child’s parents/guardians and primary care provider and other appropriate health or state agencies.

COMMENTS

Caregivers/teachers should report specific products that may have played a role in the injury to the U.S. Consumer Product Safety Commission (CPSC) via their toll-free consumer hotline: 800-638-2772 (TTY 800-638-8270) or online at http://www.cpsc.gov/talk.html. This data helps CPSC respond with needed recalls. Multi-copy forms can be used to make copies of an injury report simultaneously for the child’s record, for the parent/guardian, for the folder that logs all injuries at the facility, and for the regulatory agency.

Facilities should secure the parent’s/guardian’s signature on the form at the time it is presented to the parent/guardian.

TYPE OF FACILITY

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

RELATED STANDARDS

9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.4.1.10 Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program
9.4.1.11 Review and Accessibility of Injury and Illness Reports
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America’s Playgrounds Safety Report Card
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix CC: Incident Report Form

REFERENCES

1. ChildCare.net. Incident reports. http://www.childcare.net/library/incidentreports.shtml.
2. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.

Oral Health Policies and Information

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:

1. 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;
2. 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);
3. Hours and days of operation;
4. 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;
5. Payment of fees, deposits, and refunds;
6. Methods and schedules for conferences or other methods of communication between parents/guardians and staff.

Policies on:

1. Staffing, including caregivers/teachers, the use of volunteers, helpers, or substitute caregivers/teachers, and deployment of staff for different activities;
2. Inclusion of children with special health care needs;
3. Nondiscrimination;
4. Termination and parent/guardian notification of termination;
5. Supervision;
6. Discipline;
7. Care of children and caregivers/teachers who are ill;
8. Temporary exclusion and alternative care for children who are ill;
9. Health assessments and immunizations;
10. Handling urgent medical care or threatening incidents;
11. Medication administration;
12. Use of child care health consultants, education and mental health consultants;
13. 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.);
14. Disasters, emergency plan and drills, evacuation plan, and alternative shelter arrangements;
15. Security;
16. Confidentiality of records;
17. Transportation and field trips;
18. Physical activity (both outdoors and when children are kept indoors), play areas, screen time, and outdoor play policy;
19. Sleeping, safe sleep policy, areas used for sleeping/napping, sleep equipment, and bed linen;
20. Sanitation and hygiene;
21. Presence and care of any animals on the premises;
22. Food and nutrition including food handling, human milk, feeding and food brought from home, as well as a daily schedule of meals and snacks;
23. Evening and night care plan;
24. Smoking, tobacco use, alcohol, prohibited substances, and firearms;
25. Preventing and reporting child abuse and neglect;
26. 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

3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
2.1.1.1 Written Daily Activity Program and Statement of Principles
2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities
2.4.2.1 Health and Safety Education Topics for Staff
2.4.3.2 Parent/Guardian Education Plan
3.1.5.3 Oral Health Education
1.6.0.1 Child Care Health Consultants
4.2.0.6 Availability of Drinking Water
4.2.0.7 100% Fruit Juice
4.3.1.8 Techniques for Bottle Feeding
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
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
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
3.2.1.1 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
4.2.0.8 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
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
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
2.4.1.3 Gender and Body Awareness
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians
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 9.2.3.6: Identification of Child’s Medical Home and Parental Consent for Information Exchange

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

1. Sources of regular medical and dental care (such as the child’s primary care provider, dentist, and medical facility);
2. Special clinics the child may attend, including sessions with medical specialists and registered dietitians;
3. Special therapists for the child (e.g., occupational, physical, speech, and nutritional), along with written documentation of the services rendered provided by the special therapist;
4. Counselors, therapists, or mental health service providers for parents/guardians (e.g., social workers, psychologists, or psychiatrists);
5. Pharmacists for children who take prescription medication on a regular basis or have emergency medications for specific conditions.

RATIONALE

Primary care providers are involved not only in the medical care of the child but also involved in supporting the child’s emotional and developmental needs (1-3). A major barrier to productive working relationships between child care and health care professionals is inadequate communication (1,2).

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.5.0.1 Care Plan for Children with Special Health Care Needs
9.4.1.3 Written Policy on Confidentiality of Records
9.4.1.4 Access to Facility Records
9.4.1.5 Availability of Records to Licensing Agency
9.4.1.6 Availability of Documents to Parents/Guardians
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior
Appendix AA: Medication Administration Packet
Appendix FF: Child Health Assessment
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

1. 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.
2. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
3. Nowak, A. J., P. S. Casamassimo. 2002. The dental home: A primary care concept. JADA 133:93-98.
4. Inkelas, M., M. Regolado, N. Halfon. 2005. Stategies for integrating developmental services and promoting medical homes. Los Angeles: National Center for Infant and Early Childhood Health Policy.
5. Homer, C. J., K. Klatka, D. Romm, K. Kuhlthau, S. Bloom, P. Newacheck, J. Van Cleave, J. M. Perrin. 2008. A review of the evidence for the medical home for children with special health care needs. Pediatrics 122:e922–37.
6. Starfield, B., L. Shi. 2004. The medical home, access to care, and insurance: A review of evidence. Pediatrics 113:1493-98.
7. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

Standard 9.2.3.13: Plans for Evening and Nighttime Child Care

Facilities that provide evening and nighttime care should have plans for such care that include the supervision of sleeping children and the management and maintenance of sleep equipment including their sanitation and disinfection. Evacuation drills should occur during hours children are in care. Centers should have these plans in writing.

RATIONALE

Evening child care routines are similar to those required for daytime child care with the exception of sleep routines. Evening and nighttime child care requires special attention to sleep routines, safe sleep environment, supervision of sleeping children, and personal care routines, including bathing and tooth brushing. Nighttime child care must meet the nutritional needs of the children and address morning personal care routines such as toileting/diapering, hygiene, and dressing for the day. Children and staff must be familiar with evacuation procedures in case a natural or human generated disaster occurs during evening child care and nighttime child care hours.

COMMENTS

Sleeping time is a very sensitive time for infants and young children. Attention should be paid to individual needs, transitional objects, lighting preferences, and bedtime routines.

TYPE OF FACILITY

Center, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.4 Futons
5.4.5.5 Bunk Beds
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza
9.2.4.5 Emergency and Evacuation Drills Policy
2.2.0.1 Methods of Supervision of Children

Standard 9.2.3.14: Oral Health Policy

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

1. Information about fluoride content of water at the facility;
2. Contact information for each child’s dentist;
3. Resource list for children without a dentist;
4. Implementation of daily tooth brushing or rinsing the mouth with water after eating;
5. Use of sippy cups and bottles only at mealtimes during the day, not at naptimes;
6. Prohibition of serving sweetened food products;
7. Promotion of healthy foods per the USDA’s Child and Adult Care Food Program (CACFP);
8. Early identification of tooth decay;
9. Age-appropriate oral health educational activities;
10. Plan for handling dental emergencies.

RATIONALE

Good oral hygiene is as important for a six-month-old child with one tooth as it is for a six-year-old with many teeth (1). Tooth brushing and activities at home may not suffice to develop the skill of proper tooth brushing or accomplish the necessary plaque removal, especially when children eat most of their meals and snacks during a full day in child care.

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.5.1 Routine Oral Hygiene Activities
3.1.5.2 Toothbrushes and Toothpaste
5.5.0.1 Storage and Labeling of Personal Articles
3.1.5.3 Oral Health Education

REFERENCES

1. American Academy of Pediatric Dentistry. 2009. Clinical guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children. Pediatric Dentistry 30:112-18.

Standard 9.2.4.1: Written Plan and Training for Handling Urgent Medical or Threatening Incidents

Early care and education programs should have a written plan for urgent incidents that threaten the health or safety of children, staff, or volunteers. The plan should include policies and procedures for training staff to manage, document, and report these incidents.  

Developing a Written Plan

A written plan will cover these types of incidents:¹

• Lost or missing child
• Suspected sexual, physical or emotional abuse or neglect of a child
• Staff members not reporting their suspicion, although they are mandated reporters
• Suspected sexual, physical, or emotional abuse of staff, volunteers, or family members that takes place on site
• Illness or injury needing urgent or emergency medical care or dental care
• Mental health emergencies
• Health and safety emergencies involving parents/guardians and visitors
• Death of a child or staff member-including death from a serious illness or injury that happened on site, even if the person died outside of regular program hours
• An unauthorized, threatening, or violent person who tries to enter-or who does enter-the program
• Violence in the community

The written plan should include a policy for debriefing staff after an incident has occurred.

A written plan for illness or injuries that need urgent or emergency care should clearly state:

• Where the closest urgent care is
  • Hospital emergency department
  • Medical or dental clinic that is open during the program’s operating hours and is acceptable to families
• Which supplies and equipment to have on site. For example:
  • First aid kit
  • Car and car seat to accompany a child to a health care facility
• Standard safety precautions if exposed to body fluids
• How staff must stay with the child until the family arrives and takes responsibility for them
• Emergency information for medical personnel including:
  • A signed emergency medical care authorization form
  • A signed informed consent form that allows the program to share medical information with medical staff
  • Additional information for children with special health care needs or disabilities
• How backup staff members will step in to help maintain child-to-staff ratios
• How to alert others in the building about a medical urgency
• Communication procedures for promptly notifying parent/guardian, or family emergency contact
• A procedure to regularly update and verify emergency contact and health information²
• How to complete an incident/injury report and the program’s response to the emergency
• Using and restocking first aid kits, which includes checking their content, condition, and expiration dates every month.
• The policy for regular reviews of staff’s ability to perform first aid

A written plan for threatening incidents should include:

• How to control access to buildings and outdoor play areas
• How to report a lost child or child abuse
• How to alert others in the building that a threatening person is on site
• How to alert police/emergency services³
• How to alert a parent, guardian, or family emergency contact if an unauthorized or threatening person tries to make contact with or remove a child, staff member, or volunteer
• What to document (e.g., all possible descriptions of a person; a car’s color or license plate number)²
• How to complete an incident/injury report and the program’s response to the emergency

Staff Training on Drills

Policies and procedures for staff training on emergency drills should include:

• Frequency, timing, and documentation of drills²
• A system for notifying families, staff, and children about planned drills
• Preparing children to participate in drills by letting them know:
  • When the drill will happen
  • What to wear
  • What they will practice
• When to exclude children from drills
  • They should not practice some drills until they are developmentally ready.
  • They should only practice drills that will help, not harm, them.
• A policy for debriefing staff and children after a drill

RATIONALE

Medical urgencies are common in early care and education settings. Also, threatening intrusions can happen and sometimes involve violence, injury, and death. Having written plans, staff training, and regular drills help programs prepare for emergencies. They are a guide for making responsible decisions while under stress. Drills can help ease tension and build confidence in the staff’s ability to respond calmly during a real incident.

Careful planning means having written plans, policies, and procedures, and keeping accurate records. All this is needed to keep the program safe and to handle medical emergencies or threatening incidents consistently, even if the staff is different. For example, checking first aid kits regularly will make sure supplies are always available. Careful planning also helps families understand what the staff will do to keep their children safe.

Having children practice drills that are very intense (e.g., drills that use fake gunfire to simulate an attack by a shooter) is inappropriate. The intensity may distress and psychologically harm children who are not developmentally ready.⁴  

However, programs can still prepare for violent or threatening incidences, with advice from health care providers, mental health consultants, child care health consultants, and first responders.⁵ These experts can:

• Help programs prepare for and reduce potential harm
• Help programs prepare children, staff and families
• Make sure that emergency response and recovery plans consider children’s developmental needs.⁵  

ADDITIONAL RESOURCES

The National Center on Early Childhood Health and Wellness, U.S. Department of Health and Human Services Administration for Children and Families Office of Head Start’s Emergency Preparedness Manual for Early Childhood Programs has detailed explanations and examples of procedures for emergency situations.

https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/emergency-preparedness-manual-early-childhood-programs.pdf

The Emergency Medical Services for Children Innovation & Improvement Center has educational materials and disaster planning resources.

https://emscimprovement.center/domains/planning

 

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
9.4.1.9 Records of Injury
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.5.3 Training on Occupational Risk Related to Handling Body Fluids
1.5.0.1 Employment of Substitutes
1.5.0.2 Orientation of Substitutes
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.6.4.5 Death
5.6.0.1 First Aid and Emergency Supplies
9.2.4.2 Review of Written Plan for Urgent Care and Threatening Incidents
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.5 Emergency and Evacuation Drills Policy
9.2.4.8 Authorized Persons to Pick Up Child
9.4.1.10 Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program
9.4.1.11 Review and Accessibility of Injury and Illness Reports
9.4.2.1 Contents of Child’s Records

REFERENCES

1. Illinois Department of Public Health, Illinois Emergency Medical Services for Children. Emergency Preparedness Planning Guide for Child Care Centers & Child Care Homes. Published January 2016. LurieChildrens.org Web site. https://www.luriechildrens.org/en/emergency-medical-services-for-children/disaster/child-care-centers/. Accessed February 15, 2021.

2. Pennsylvania chapter of the American Academy of Pediatrics. Model Child Care Health Polices. Aronson SS, ed. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014.

3. Schonfeld DJ, Rossen E, Woodard D. Deception in schools — when crisis preparedness efforts go too far. JAMA Pediatr. 2017;171(11):1033–1034.
   

4. Schonfeld DJ, Hashikawa AN, Melzer-Lange M, Gorski PA; AAP Council on Children and Disasters; Council on Injury, Violence, and Poison Prevention; Council on School Health. Participation of children and adolescents in live crisis drills and exercises. Pediatrics. 2020;146(3):e2020015503
   

5. Needle S, Wright J, Disaster Preparedness Advisory Council, Committee on Pediatric Emergency Medicine. Ensuring the health of children in disasters. Pediatrics. 2015;136(5). https://publications.aap.org/pediatrics/article/136/5/e1407/33847/Ensuring-the-Health-of-Children-in-Disasters

NOTES

Content in the standard was modified on 03/22/22.

Standard 9.4.2.4: Contents of Child’s Primary Care Provider’s Assessment

The file for each child should include an initial health assessment completed and signed by the child’s primary care provider. This should be on file preferably at enrollment and no later than within six weeks of admission. (Requirements may be waived to comply with the federal McKinney-Vento Homeless Assistance Act regarding health and health records.) It should include:

1. Immunization Records;
2. Growth Assessment – may include percentiles of weight, height, and head circumference (under age of two); recording body mass index (BMI) and percentile for age is especially helpful in those children age two years and older who are over or underweight;
3. Health Assessment – includes descriptions of any current acute and/or chronic health issues and should also include any findings from an exam or screening that may need follow-up, e.g., vision, hearing, dental, obesity, or nutritional screens or tests for lead, anemia, or tuberculosis (these health concerns may require a care plan and possibly a medication plan [see h) below]);
4. Developmental Issues – includes descriptions of concerns and the child’s special needs in a child care setting, (for example, a vision or hearing deficit, a developmental variation, prematurity, or an emotional or behavioral disturbance);
5. Significant physical findings so that caregivers/teachers can note if there are changes from baseline and report those findings;
6. Dates of Significant Illnesses and/or Injuries;
7. Allergies;
8. Medication(s) List – includes dosage, time and frequency of administration of any ongoing prescription or non-prescription (over-the-counter [OTC]) medication that the person with prescriptive authority recommends for the child. This list would also include information on recognizing side-effects and responding to them appropriately and it may also contain the same information for intermittent use of a fever reducer medication;
9. Dietary modifications;
10. Emergency plans;
11. Other special instructions for the caregiver/teacher;
12. Care Plan – (if the child has a special health need as indicated by c) or d) above) includes routine and emergency management plans that might be required by the child while in child care. This plan also includes specific instructions for caregiver/teacher observations, activities or services that differ from those required by typically developing children and should include specific instructions to caregivers/teachers on how to provide medications, procedures, or implement modifications required by children with asthma, severe allergic reactions, diabetes, medically-indicated special feedings, seizures, hearing impairments, vision problems, or any other condition that requires accommodation in child care;
13. Parent’s/Guardian’s assessment and concerns (4).

For children up the age of three years, health care professional assessments should be at the recommended intervals indicated by the American Academy of Pediatrics (AAP) (3). For all other children, the Health Care Professional Assessment updates should be obtained annually. It should include any significant health status changes, any new medications, any hospitalizations, and any new immunizations given since the previous health assessment. This health report will be supplemented by the health history obtained from the parents/guardians by the child care provider at enrollment.

RATIONALE

The requirement of a health report for each child reflecting completion of health assessments and immunizations is a valid way to ensure timely preventive care for children who might not otherwise receive it and can be used in decision-making at the time of admission and during ongoing care (2). This requirement encourages families to have a primary care provider (medical home) for each child where timely and periodic well-child evaluations are done. The objective of timely and periodic evaluations is to permit detection and treatment for improved oral, physical, mental, and emotional/social health (1,3). The reports of such evaluations provide a conduit for communication of information that helps the primary care provider and the caregiver/teacher determine appropriate services for the child. When the parent/guardian carries the request for the report to the primary care provider, concerns of the caregiver/teacher can be delivered by the parent/guardian to the child’s primary care provider and consent for communication is thereby given. The parent/guardian can give written consent for direct communication between the primary care provider and the caregiver/teacher so that the forms can be faxed or mailed.

Quality child care requires information about the child’s health status and need for accommodations in child care (2).

COMMENTS

The purpose of a health care professional assessment is to:

1. Give information about a child’s health history, special health care needs, and current health status to allow the caregiver/teacher to provide a safe setting and healthy experience for each child;
2. Promote individual and collective health by fostering compliance with approved standards for health care assessments and immunizations;
3. Document compliance with licensing standards;
4. Serve as a means to ensure early detection of health problems and a guide to steps for remediation;
5. Serve as a means to facilitate and encourage communication and learning about the child’s needs among caregivers/teachers, primary care providers, and parents/guardians.

This approach is usually the most efficient, effective and least costly since the primary care provider has the child, the family member, and the record in hand, to provide the information that the child care facility should have. When the data are requested separate from the visit to the primary care provider for the health assessment, the record must be pulled from the file and the information retrieved from the notes in the file. Some health care facilities charge families for the cost of the additional work to complete forms either at the time of a health care visit or later. Collaborating in reducing the burden of form completion by writing in as much information as is known before giving the forms to the primary care provider helps foster effective communication. Many primary care providers appreciate having identifying information filled in on the form about the child care facility, the child, the family and a note about any concerns to be addressed.

Caregivers/teachers may offer a four-week grace period during which the parent/guardian can arrange to get this assessment. The health history can serve as an interim health assessment during this grace period.

Health data should be presented in a form usable for caregivers/teachers to help identify any special needs for care. Local Early Periodic Screening and Diagnostic Treatment (EPSDT) program contractor, if available, should be called upon to help with liaison and education activities. In some situations, screenings may be performed at the facilities, but it is always preferable that the child have a medical home and primary care provider who screens the child and provides the information. When clinicians do not fill out forms completely enough to assist the caregiver/teacher in understanding the significance of health assessment findings or the unique characteristics of a child, the caregiver/teacher should obtain parental consent to contact the child’s primary care provider to explain why the information is needed and to request clarification.

Health assessments should be in a format easily usable by caregivers/teachers to identify any special needs for care.

A child’s primary care provider is a key resource to families when racial, ethnic, socioeconomic, or educational disparities create barriers to the child receiving regular dental care. He or she can perform an oral examination and conduct an oral health risk assessment and triage for infants and young children. Children with suspected oral problems should see a dentist immediately, regardless of age or interval.

The American Academy of Pediatrics (AAP) and Bright Futures recommend vision/hearing and dental screenings are:

1. Vision/hearing at every well care visit (with objective measures of visual acuity by four years and audiometry measures of hearing by five years of age); and
2. Dental exam at one year (or sooner if there are suspected oral problems) (3).

TYPE OF FACILITY

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

RELATED STANDARDS

9.4.2.1 Contents of Child’s Records
9.4.2.5 Health History
Appendix FF: Child Health Assessment
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

1. 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.
2. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
3. Crowley A. A., G. C. Whitney. 2005. Connecticut’s new comprehensive and universal early childhood health assessment form. J School Health 75:281-85.
4. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Bright Futures Steering Committee. 2007. Policy statement: Recommendations for preventive pediatric health care. Pediatrics 120:1376.

Standard 9.4.2.5: Health History

The file for each child should include a health history completed by the parent/guardian at admission, preferably with staff involvement. This history should include the following:

1. Identification of the child’s medical home/primary care provider and dental home;
2. Permission to contact these professionals in case of emergency;
3. Chronic diseases/health issues currently under treatment;
4. Developmental variations, sensory impairment, serious behavior problems or disabilities that may need consideration in the child care setting;
5. Description of current physical, social, and language developmental levels;
6. Current medications, medical treatments and other therapeutic interventions;
7. Special concerns (such as allergies, chronic illness, pediatric first aid information needs);
8. Specific diet restrictions, if the child is on a special diet;
9. Individual characteristics or personality factors relevant to child care;
10. Special family considerations;
11. Dates of infectious diseases;
12. Plans for medical emergencies;
13. Any special equipment that might be needed;
14. Special transportation adaptations.

RATIONALE

A health history is the basis for meeting the child’s medical and psychosocial needs in the child care setting. This information must be obtained and reviewed at admission by the significant caregiver/teacher. This information may be the only health information on file for up to the first four weeks following enrollment.

COMMENTS

This history will complement the child’s health history which is completed by the primary care provider.

TYPE OF FACILITY

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

RELATED STANDARDS

9.4.2.1 Contents of Child’s Records

Licensing and State Responsibilities

Standard 10.3.2.1: Child Care Licensing Advisory Board

States should have an official child care licensing advisory body for regulatory and related policy issues. A child care advisory board should:

1. Review proposed rules and regulations prior to adoption;
2. Recommend administrative policy;
3. Recommend changes in legislation; and
4. Guide enforcement, if granted this authority via the legislative process.

The advisory group should include representatives from the following agencies and groups:

1. State agencies with regulatory responsibility or an interest in child care (human services, public health, fire marshal, emergency medical services, education, human resources, attorney general, safety council);
2. Organizations with a child care emphasis;
3. Operators, directors, owners, and caregivers/teachers reflecting various types of child care programs including for-profit and non-profit;
4. Professionals with expertise related to the rules; may include pediatrics, physical activity, nutrition, mental health, oral health, injury prevention, resource and referral, early childhood education, and early childhood professional development;
5. Parents/guardians who reflect the diversity of the families that are consumers of licensed child care programs.

This advisory board should be linked to the State Early Childhood Advisory Council (see Standard 10.3.2.2) as required by the Head Start Act of 2007 (1). 

RATIONALE

The advisory group should actively seek citizen participation in the development of child care policy, including parents/guardians, child care administrators, and caregivers/teachers. The licensing advisory board should report directly to the agency having administrative authority over licensing.

RELATED STANDARDS

10.3.2.2 State Early Childhood Advisory Council

REFERENCES

1. U.S. Congress. 2007. Head Start Act. 42 USC 9801. http://eclkc.ohs.acf.hhs.gov/hslc/Head Start Program/Program Design and Management/Head Start Requirements/Head Start Act/.

Standard 10.3.4.1: Sources of Technical Assistance to Support Quality of Child Care

Public authorities (such as licensing agencies) and private agencies (such as resource and referral agencies), should develop systems for technical assistance to states, localities, child care agencies, and caregivers/teachers that address the following:

1. Meeting licensing requirements;
2. Establishing programs that meet the developmental needs of children;
3. Educating parents/guardians on specific health and safety issues through the production and distribution of related material.

 

RATIONALE

The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:

1. Licensing agencies (on ways to meet the regulations);
2. Health departments (on health related matters);
3. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
4. Child care health, education, mental health consultant networks; American Academy of Pediatrics (AAP) state chapters and child care contacts; and state Early Childhood Comprehensive Systems (ECCS) grants are examples of partners providing technical assistance on health and related child care matters.

The state agency has a continuing responsibility to assist an applicant in qualifying for a license and to help licensees improve and maintain the quality of their facility. Regulations should be available to parents/guardians and interested citizens upon request and should be translated if needed. Licensing inspectors throughout the state should be required to offer assistance and consultation as a regular part of their duties and to coordinate consultation with other technical assistance providers as this is an integral part of the licensing process.

The Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) and the Office of Child Care (OCC) of the Administration for Children and Families (ACF) continue to develop initiatives that provide funding to support technical assistance to early care and education. States should check with their State Child Care Administrators, Maternal and Child Health Directors, and Head Start State Collaboration Directors, for more information.

Providing centers and networks of small or large family child care homes with guidelines and information on establishing a program of care is intended to promote appropriate programs of activities. Child care staff is rarely trained health professionals. Since staff and time are often limited, caregivers/teachers should have access to consultation on available resources in a variety of fields (such as physical and mental health care; nutrition; safety, including fire safety; oral health care; developmental disabilities; and cultural sensitivity) (1,2).

The public agencies can facilitate access to children and their families by providing useful materials to child care providers.

RELATED STANDARDS

2.4.3.2 Parent/Guardian Education Plan
10.3.3.1 Credentialing of Individual Child Care Providers
10.4.1.3 Licensing Agency Procedures Prior to Issuing a License
2.4.3.1 Opportunities for Communication and Modeling of Health and Safety Education for Parents/Guardians

REFERENCES

1. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.
2. American Academy of Pediatrics. 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

Standard 10.3.4.3: Support for Consultants to Provide Technical Assistance to Facilities

State agencies should encourage the arrangement and coordination of and the fiscal support for consultants from the local community to provide technical assistance for program development and maintenance. Consultants should have training and experience in early childhood education, early childhood growth and development, issues of health and safety in child care settings, business practices, ability to establish collegial relationships with child care providers, adult learning techniques, and ability to help establish links between facilities and community resources. There should be collaboration among all parts of the early care and education community to provide technical assistance and consultation to improve the quality of care. The licensing agency should be an integral part of the quality rating and improvement system (QRIS) in the state; all parts of the system must collaborate to assure the most effective and efficient use of resources to encourage quality improvement. See Glossary for definition of QRIS.

The state regulatory agency with the Title V or State Child Care Resource and Referral Agency should provide or arrange for other public agencies, private organizations or technical assistance agencies (such as a resource and referral agency) to make the following consultants available to the community of child care providers of all types:

1. Program consultant, to provide technical assistance for program development and maintenance and business practices. Consultants should be chosen on the basis of training and experience in early childhood education and ability to help establish links between the facility and community resources;
2. Child care health consultant (CCHC), who has knowledge and expertise in child health and child development, is knowledgeable about the special needs of children in out-of-home care settings, and knows the child care licensing requirements and available health resources. A regional plan to make consultants accessible to facilities for ongoing relationships should be developed;
3. Nutritionist/registered dietitian, who also has the knowledge of infant and child development, food service, nutrition and nutrition education methods, to be responsible for the development of policies and procedures and for the implementation of nutrition standards to provide high quality meals, nutrition education programs and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors;
4. Early childhood education consultant, to assist centers, large family child care homes, and networks of small family child care homes in partnering with families in meeting the individual development and learning needs of children, including any special developmental and educational needs that a child may have. Early Childhood Education Consultants can assist providers n early detection and referral for identifying and addressing special learning needs, especially infants and toddlers;
5. Early childhood mental health consultant (ECMHC), to assist centers, large family child care homes, and networks of small family child care homes in meeting the emotional needs of children and families. The state mental health agency should promote funding through community mental health agencies and child guidance clinics for these services. At the least, such consultants should be available when caregivers/teachers identify children whose behaviors are more difficult to manage than typically developing children;
6. Dental health consultant, to assist centers, large family child care homes and networks small family child care homes in meeting the oral health needs of children. The dental health consultant should have knowledge of pediatric oral health and be able to help with policy and procedure development in this area;
7. Physical activity consultant, who has knowledge in infant and child motor development (developmental biomechanics), locomotion, ballistic, and manipulative skills, sensory-perceptual development, social, psychosocial, and cultural constraints in motor development, and development of cardio-respiratory endurance, strength and flexibility, and body composition, to be responsible for the development of policies and procedures for the implementation of age and developmentally appropriate physical activity standards to provide children with the movement experiences needed for optimal growth and development, physical education/movement programs, and appropriately trained personnel, and to provide consultation to agency personnel, including collaborating with licensing inspectors.

A plan should be in place that supports the interdisciplinary collaboration of consultant support to programs to ensure coordinated support, avoid duplication and stress on programs and families, and promote efficient use of consultant resources.

Additionally, a plan should be in place that outlines how the state identifies, trains, and supports consultants who, in turn, support programs. Minimum qualifications required of consultants may be specified in state regulations. There are resources for training consultants that can be integrated into state plans for supporting health and other early childhood consultants. States will ideally take advantage of opportunities to partner with Head Start, child welfare, Part C and Part B, and others to maintain an ongoing system of supporting consultants and fostering partnerships that support children, families and programs and help improve the overall quality of services provided in the community.

RATIONALE

Securing expertise is acceptable by whatever method is most workable at the state or local level (for example, consultation could be provided from a resource and referral agency). Providers, not the regulatory agency, are responsible for securing the type of consultation that is required by their individual facilities. Ongoing relationships with CCHCs, nutritionists/registered dietitians, and ECMHCs are effective in promoting healthy and safe environments (3-5).

COMMENTS

Several states now have mental health consultants specifically serving the child care community. There are different models of mental health consultation. Some models are programmatic and only include the staff, others work with individual children with behavioral and emotional problems and the third model integrates both approaches. MHCs are usually social workers or professionals with a child development or psychology background who are trained to work in child care settings (2). There is no formal or standardized training for ECMHCs nationally. Developmental and behavioral pediatricians, child and adolescent psychiatrists, and child psychologists are resources for the behavioral and mental health needs of young children (1). Some, but not all, adolescent and child psychiatrists and psychologists, social workers and child counselors have the necessary skills to work with behavior problems of this youngest age group. To find such specialists, contact the Department of Pediatrics at academic centers or the State Department of Mental Health. The faculty at such centers can usually refer child care facilities to individuals with the necessary skills in their area.

The administrative practice of developing systems for technical assistance is designed to enhance the overall quality of child care that meets the social and developmental needs of children. The chief sources of technical assistance are:

1. AAP Chapter Child Care Contact (contact information can be found at http://www.healthychildcare.org);
2. Licensing agencies (on ways to meet the regulations and make quality improvements);
3. Health departments (on health related matters);
4. Resource and referral agencies (on ways to achieve quality, how to start a new facility, supply and demand data, how to get licensed, and what parents/guardians want);
5. Community action programs or non-profit organizations (on health related matters including physical education, for health education and/or quality improvement issues);
6. Local university kinesiology departments (on early childhood motor development and physical activity issues);
7. Small business administration (on financial issues related to program operations);
8. Subsidy agencies may fund a variety of consultants to programs through the Child Care and Development Fund (CCDF) quality dollars;
9. Education departments often administer the food program dollars and may have technical assistance related to the Individuals with Disabilities Education Act (IDEA).

REFERENCES

1. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Acad Pediatr 9:366-70.
2. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37.
3. Crowley, A. A., J. M. Kulikowich. Impact of training on child care health consultant knowledge and practice. Ped Nurs 35:93-100.
4. Healthy Child Care America. 2006. The influence of child care health consultants in promoting children’s health and well-being: A status report. Rockville, MD: Maternal and Child Health Bureau.
5. American Academy of Pediatrics (AAP). 2001. The pediatrician’s role in promoting health and safety in child care. Elk Grove Village, IL: AAP.

Standard 10.3.4.4: Development of List of Providers of Services to Facilities

The local regulatory agency or resource and referral agency should assist centers and small and large family child care homes to formulate and maintain a list of community professionals and agencies available to provide needed health, dental, and social services to families.

RATIONALE

Families depend on their child care facilities to provide information about obtaining health and dental care and other community services. A number of communities have Family Resource Centers, which are central points for information. It is important that regulatory agencies and resource and referral agencies have knowledge of family resource centers or can provide a directory of community services to child care facilities.

Partnerships among health care professionals and community agencies are necessary to provide a medical home for all children. The American Academy of Pediatrics (AAP) defines the medical home as care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent. The medical home is not a building, house, or hospital, but an approach to providing health care services in a high-quality and cost-effective manner (1,2). Health care professionals and other community service agencies are beginning to recognize that child care facilities are a logical opportunity to provide information or referral of children to a medical home. Child care programs also provide opportunities for education in health promotion and disease prevention for children and families (3).

REFERENCES

1. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116: e499-e505.
2. American Academy of Pediatrics. 2008. Policy statement: The medical home. Pediatrics 122:450.
3. Kempe, A., B. Beaty, B. P. Englund, R. J. Roark, N. Hester, J. F. Steiner. 2000. Quality of care and use of the medical home in a state-funded capitated primary care plan for low-income children. Pediatrics 105:1020-28.

Standard 10.6.1.1: Regulatory Agency Provision of Caregiver/Teacher and Consumer Training and Support Services

The licensing agency should promote participation in a variety of caregiver/teacher and consumer training and support services as an integral component of its mission to reduce risks to children in out-of-home child care. Such training should emphasize the importance of conducting regular safety checks and providing direct supervision of children at all times. Training plans should include mechanisms for training of prospective child care staff prior to their assuming responsibility for the care of children and for ongoing/continuing education. The higher education institutions providing early education degree programs should be coordinated with training provided at the community level to encourage continuing education and availability of appropriate content in the coursework provide by these institutions of higher education.

Persons wanting to enter the child care field should be able to learn from the regulatory agency about training opportunities offered by public and private agencies. Discussions of these trainings can emphasize critical child care health and safety messages. Some training can be provided online to reinforce classroom education.

Training programs should address the following:

1. Child growth and development including social-emotional, cognitive, language, and physical development;
2. Child care programming and activities;
3. Discipline and behavior management;
4. Mandated child abuse and neglect reporting;
5. Health and safety practices including injury prevention, basic first aid and CPR, reporting, preventing and controlling infectious diseases, children’s environmental health and health promotion, and reducing the risk of SIDS and use of safe sleep practices;
6. Cultural diversity;
7. Nutrition and eating habits including the importance of breastfeeding and the prevention of obesity and related chronic diseases;
8. Parent/guardian education;
9. Design, use and safe cleaning of physical space;
10. Care and education of children with special health care needs;
11. Oral health care;
12. Reporting requirements for infectious disease outbreaks;
13. Caregiver/teacher health;
14. Age-appropriate physical activity.

RATIONALE

Training enhances staff competence (1,2,4). In addition to low child:staff ratio, group size, age mix of children, and continuity of caregiver/teacher, the training/education of caregivers/teachers is a specific indicator of child care quality (1,2). Most states require limited training for child care staff depending on their functions and responsibilities. Some states do not require completion of a high school degree or GED for various levels of teacher positions (5). Staff members who are better trained are more able to prevent, recognize, and correct health and safety problems. Decisions about management of illness are facilitated by the caregiver’s/teacher’s increased skill in assessing a child’s behavior that suggests illness (2,3). Training should promote increased opportunity in the field and openings to advance through further degree-credentialed education.

RELATED STANDARDS

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
10.6.2.1 Development of Child Care Provider Organizations and Networks

REFERENCES

1. National Child Care Information and Technical Assistance Center, National Association for Regulatory Administration (NARA). 2010. The 2008 child care licensing study: Final report. Lexington, KY: NARA. http://www.naralicensing.org/associations/4734/files/1005_2008_Child Care Licensing Study_Full_Report.pdf.
2. Moon, R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
3. Kendrick, A. S. 1994. Training to ensure healthy child day-care programs. Pediatrics 94:1108-10.
4. Aronson, S. S., L. S. Aiken. 1980. Compliance of child care programs with health and safety standards: Impact of program evaluation and advocate training. Pediatrics 65:318-25.
5. Galinsky, E., C. Howes, S. Kontos, M. Shinn. 1994. The study of children in family child care and relative care. New York: Families and Work Institute.
6. U.S. General Accounting Office (USGAO); Health, Education, and Human Services Division. 1994. Child care: Promoting quality in family child care. Report to the chairman, subcommittee on regulation, business opportunities, and technology, committee on small business, House of Representatives. Publication no. GAO-HEHS-95-36. Washington, DC: USGAO.

Related Issues

Standard 1.7.0.1: Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

All paid and volunteer staff members should have a health appraisal before their first involvement in child care work. The appraisal should identify any accommodations required of the facility for the staff person to function in his or her assigned position.

Health appraisals for paid and volunteer staff members should include:

1. Physical exam;
2. Dental exam;
3. Vision and hearing screening;
4. The results and appropriate follow up of a tuberculosis (TB) screening, using the Tuberculin Skin Test (TST) or IGRA (interferon gamma release assay), once upon entering into the child care field with subsequent TB screening as determined by history of high risk for TB thereafter;
5. A review and certification of up-to-date immune status per the current Recommended Adult Immunization Schedule found in Appendix H, including annual influenza vaccination and up to date Tdap;
6. A review of occupational health concerns based on the performance of the essential functions of the job.

All adults who reside in a family child care home who are considered to be at high risk for TB, should have completed TB screening (1) as specified in Standard 7.3.10.1. Adults who are considered at high risk for TB include those who are foreign-born, have a history of homelessness, are HIV-infected, have contact with a prison population, or have contact with someone who has active TB.

Testing for TB of staff members with previously negative skin tests should not be repeated on a regular basis unless required by the local or state health department. A record of test results and appropriate follow-up evaluation should be on file in the facility.

RATIONALE

Caregivers/teachers need to be physically and emotionally healthy to perform the tasks of providing care to children. Performing their work while ill can spread infectious disease and illness to other staff and the children in their care (2). Under the Americans with Disabilities Act (ADA), employers are expected to make reasonable accommodations for persons with disabilities. Under ADA, accommodations are based on an individual case by case situation. Undue hardship is defined also on a case by case basis. Accommodation requires knowledge of conditions that must be accommodated to ensure competent function of staff and the well-being of children in care (3).

Since detection of tuberculosis using screening of healthy individuals has a low yield compared with screening of contacts of known cases of tuberculosis, public health authorities have determined that routine repeated screening of healthy individuals with previously negative skin tests is not a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be subject to modification by local or state health authorities.

COMMENTS

Child care facilities should provide the job description or list of activities that the staff person is expected to perform. Unless the job description defines the duties of the role specifically, under federal law the facility may be required to adjust the activities of that person. For example, child care facilities typically require the following activities of caregivers:

1. Moving quickly to supervise and assist young children;
2. Lifting children, equipment, and supplies;
3. Sitting on the floor and on child-sized furniture;
4. Washing hands frequently;
5. Responding quickly in case of an emergency;
6. Eating the same food as is served to the children (unless the staff member has dietary restrictions);
7. Hearing and seeing at a distance required for playground supervision or driving;
8. Being absent from work for illness no more often than the typical adult, to provide continuity of caregiving relationships for children in child care.

Healthy Young Children: A Manual for Programs, from the National Association for the Education of Young Children (NAEYC), provides a model form for an assessment by a health professional. See also Model Child Care Health Policies, from NAEYC and from the American Academy of Pediatrics (AAP).

Concern about the cost of health exams (particularly when many caregivers/teachers do not receive health benefits and earn minimum wage) is a barrier to meeting this standard. When staff members need hepatitis B immunization to meet Occupational Safety and Health Administration (OSHA) requirements (4), the cost of this immunization may or may not be covered under a managed care contract. If not, the cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee’s preparation for work in the child care setting by the prospective employee or the employer. Child care workers are among those for whom annual influenza vaccination is strongly recommended.

Facilities should consult with ADA experts through the U.S. Department of Education funded Disability and Business Technical Assistance Centers (DBTAC) throughout the country. These centers can be reached by calling 1-800-949-4232 (callers are routed to the appropriate region) or by accessing regional center’s contacts directly at http://adata
.org/Static/Home.aspx.

TYPE OF FACILITY

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

RELATED STANDARDS

1.7.0.3 Staff Health Guidelines for Return to Work
1.7.0.4 On-Site Occupational Hazards
7.2.0.1 Immunization Documentation
7.2.0.2 Unimmunized/Underimmunized Children
7.2.0.3 Immunization of Staff
7.3.10.1 Measures for Detection, Control, and Reporting of Tuberculosis
7.3.10.2 Attendance of Children with Latent Tuberculosis Infection or Active Tuberculosis Disease
Appendix E: Child Care Staff Health Assessment

REFERENCES

1. Occupational Safety and Health Administration. 2008. Bloodborne pathogens. Title 29, pt. 1910.1030. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p _id=10051.
2. Centers for Disease Control and Prevention. 2015. Recommended adult immunization schedule – United States, 2015. http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html.
3. Keyes, C. R. 2008. Adults with disabilities in early childhood settings. Child Care Info Exchange 179:82-85.
4. Baldwin, D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female child care providers: Implications for quality of care. J Comm Health Nurs 24:1-7.