Special Collection

Stepping Stones to Caring for Our Children (SS)

Stepping Stones (SS) is the collection of selected CFOC standards which, when put into practice, are most likely to prevent serious adverse outcomes in child care and early education settings.

Adverse outcomes are defined as harm resulting from failure to practice the recommendations in the CFOC standards. These harmful results may include frequent or severe disease or injury, disability, or death (morbidity and mortality).

This valuable resource was developed with our collaborative partners, the American Academy of Pediatrics (AAP) and the American Public Health Association (APHA). Support for this project was provided through a cooperative agreement with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.

Stepping Stones to Caring for Our Children Compliance/Comparison Checklist - PDF (Updated January 2019)

Suggestions for Use of the Compliance/Comparison Checklist:

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

Chapter 1 - Staffing

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
1.2.0.2 Background Screening
1.3.1.1 General Qualifications of Directors
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.3.1 General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home
1.4.1.1 Pre-service Training
1.4.2.2 Orientation for Care of Children with Special Health Care Needs
1.4.2.3 Orientation Topics
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
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
1.5.0.1 Employment of Substitutes
1.5.0.2 Orientation of Substitutes
1.6.0.1 Child Care Health Consultants

Chapter 2 - Program Activities for Healthy Development

2.1.1.4 Monitoring Children’s Development/Obtaining Consent for Screening
2.1.2.1 Personal Caregiver/Teacher Relationships for Infants and Toddlers
2.2.0.1 Methods of Supervision of Children
2.2.0.4 Supervision Near Bodies of Water
2.2.0.6 Discipline Measures
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
2.3.3.1 Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior

Chapter 3 - Health Promotion and Protection

3.1.2.1 Routine Health Supervision and Growth Monitoring
3.1.3.1 Active Opportunities for Physical Activity
3.1.3.2 Playing Outdoors
3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.1.5.1 Routine Oral Hygiene Activities
3.2.1.4 Diaper Changing Procedure
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.3.1 Medical Emergency Procedures
3.4.3.3 Response to Fire and Burns
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.5.1 Sun Safety Including Sunscreen
3.4.6.1 Strangulation Hazards
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.5.0.2 Caring for Children Who Require Medical Procedures
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness
3.6.1.4 Infectious Disease Outbreak Control
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

Chapter 4 - Nutrition and Food Service

4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines
4.2.0.6 Availability of Drinking Water
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.10 Care for Children with Food Allergies
4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.9 Warming Bottles and Infant Foods
4.3.1.11 Introduction of Age-Appropriate Solid Foods to Infants
4.5.0.6 Adult Supervision of Children Who Are Learning to Feed Themselves
4.5.0.9 Hot Liquids and Foods
4.5.0.10 Foods that Are Choking Hazards
4.8.0.1 Food Preparation Area
4.8.0.3 Maintenance of Food Service Surfaces and Equipment
4.9.0.2 Staff Restricted from Food Preparation and Handling
4.9.0.3 Precautions for a Safe Food Supply

Chapter 5 - Facilities, Supplies, Equipment, and Environmental Health

5.1.1.2 Inspection of Buildings
5.1.1.3 Compliance with Fire Prevention Code
5.1.1.5 Assessment of the Environment at the Site Location
5.1.3.2 Possibility of Exit from Windows
5.1.4.1 Alternate Exits and Emergency Shelter
5.1.5.4 Guards at Stairway Access Openings
5.1.6.6 Guardrails and Protective Barriers
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.1.10 Gas, Oil, or Kerosene Heaters, Generators, Portable Gas Stoves, and Charcoal and Gas Grills
5.2.1.11 Portable Electric Space Heaters
5.2.4.2 Safety Covers and Shock Protection Devices for Electrical Outlets
5.2.4.4 Location of Electrical Devices Near Water
5.2.5.1 Smoke Detection Systems and Smoke Alarms
5.2.6.3 Testing for Lead and Copper Levels in Drinking Water
5.2.7.6 Storage and Disposal of Infectious and Toxic Wastes
5.2.8.1 Integrated Pest Management
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.2 Use of a Poison Center
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.13 Testing for and Remediating Lead Hazards
5.3.1.1 Indoor and Outdoor Equipment, Materials, and Furnishing
5.3.1.12 Availability and Use of a Telephone or Wireless Communication Device
5.4.5.2 Cribs
5.5.0.6 Inaccessibility to Matches, Candles, and Lighters
5.5.0.7 Storage of Plastic Bags
5.5.0.8 Firearms
5.6.0.1 First Aid and Emergency Supplies
5.7.0.4 Inaccessibility of Hazardous Equipment

Chapter 6 - Play Areas/Playgrounds and Transportation

6.1.0.6 Location of Play Areas Near Bodies of Water
6.1.0.8 Enclosures for Outdoor Play Areas
6.2.1.9 Entrapment Hazards of Play Equipment
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
6.2.4.4 Trampolines
6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
6.3.1.1 Enclosure of Bodies of Water
6.3.1.4 Safety Covers for Swimming Pools
6.3.1.6 Pool Drain Covers
6.3.2.1 Lifesaving Equipment
6.3.5.1 Hot Tubs, Spas, and Saunas
6.3.5.2 Water in Containers
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age
6.4.1.5 Balloons
6.4.2.2 Helmets
6.5.1.1 Competence and Training of Transportation Staff
6.5.1.2 Qualifications for Drivers
6.5.2.2 Child Passenger Safety
6.5.2.4 Interior Temperature of Vehicles
6.5.3.1 Passenger Vans

Chapter 7 - Infectious Disease

7.2.0.2 Unimmunized/Underimmunized Children
7.2.0.3 Immunization of Staff
7.3.3.1 Influenza Immunizations for Children and Staff
7.3.3.2 Influenza Control
7.3.5.1 Recommended Control Measures for Invasive Meningococcal Infection in Child Care
7.4.0.1 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections
7.5.10.1 Staphylococcus Aureus Skin Infections Including MRSA

Chapter 9 - Policies

9.2.3.2 Policy Development for Care of Children and Staff Who Are Ill
9.2.3.12 Infant Feeding Policy
9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.5 Emergency and Evacuation Drills Policy
9.2.4.7 Sign-In/Sign-Out System
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
9.4.1.12 Record of Valid License, Certificate, or Registration of Facility
9.4.2.6 Contents of Medication Record

Chapter 10 - Licensing and Community Action

10.4.2.1 Frequency of Inspections for Child Care Centers, Large Family Child Care Homes, and Small Family Child Care Homes

Appendices

Appendix A: Signs and Symptoms Chart
Appendix D: Gloving
Appendix F: Enrollment/Attendance/Symptom Record
Appendix G: Recommended Childhood Immunization Schedule
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix L: Cleaning Up Body Fluids
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures
Appendix W: Sample Food Service Cleaning Schedule
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment
Appendix AA: Medication Administration Packet
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America’s Playgrounds Safety Report Card
Appendix JJ: Our Child Care Center Supports Breastfeeding
Appendix NN: First Aid and Emergency Supply Lists
Appendix P: Situations that Require Medical Attention Right Away
Appendix A: Signs and Symptoms Chart
Appendix G: Recommended Childhood Immunization Schedule
Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications
Appendix O: Care Plan for Children with Special Health Care Needs
Appendix P: Situations that Require Medical Attention Right Away
Appendix S: Physical Activity: How Much Is Needed?
Appendix CC: Incident Report Form

Chapter 1 - Staffing

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

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

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

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

RATIONALE

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

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

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

COMMENTS

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

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

Unscheduled inspections encourage compliance with this standard.

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main .zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact _Sheet.pdf.
National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Zigler, E., W. S. Gilliam, S. M. Jones. 2006. A vision for universal preschool education, 107-29. New York: Cambridge University Press.
Stebbins, H. 2007. State policies to improve the odds for the healthy development and school readiness of infants and toddlers. Washington, DC: Zero to Three. http://main.zerotothree.org/site/DocServer/NCCP_article_for_BM_final.pdf.

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

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

Large Family Child Care Homes

Age	Maximum Child:Staff Ratio	Maximum Group Size

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

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

Child Care Centers

Age	Maximum Child:Staff Ratio	Maximum Group Size

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

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

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

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

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

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

RATIONALE

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

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

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

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

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

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

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

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

COMMENTS

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

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

Unscheduled inspections encourage compliance with this standard.

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Zero to Three. 2007. The infant-toddler set-aside of the Child Care and Development Block Grant: Improving quality child care for infants and toddlers. Washington, DC: Zero to Three. http://main
.zerotothree.org/site/DocServer/Jan_07_Child_Care_Fact
_Sheet.pdf.
National Institute of Child Health and Human Development (NICHD). 2006. The NICHD study of early child care and youth development: Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf.
Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and development of babies in child care: What does the research say? Washington, DC: Center for Law and Social Policy (CLASP); Zero to Three. http://main.zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.
National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA.
Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being of children. Arch Ped Adolescent Med 161:669-76.
Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it matter and does it need to be improved? Washington, DC: U.S. Department of Health and Human Services. http://aspe.hhs.gov/hsp/ccquality00/.
De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of child-caregiver ratio on the interactions between caregivers and children in child-care centers: An experimental study. Child Devel 77:861-74.
National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in the United States. Am Socio Rev 70:729-57.

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

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.1.1.4: Ratios and Supervision During Transportation

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

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.6.0.1 First Aid and Emergency Supplies

REFERENCES

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

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

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

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

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

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

RATIONALE

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.2.0.2: Background Screening

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

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

The background screening should include (1-4).

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

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

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

RATIONALE

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

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

COMMENTS

The following resources can help the director screen individual applicants:

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

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

TYPE OF FACILITY

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

REFERENCES

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

NOTES

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

Standard 1.3.1.1: General Qualifications of Directors

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

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

National Association for the Education of Young Children (NAEYC). 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC.
National Association for the Education of Young Children (NAEYC). 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc
.org/files/naeyc/file/positions/ProfPrepStandards09.pdf.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Helburn, S., ed. 1995. Cost, quality and child outcomes in child care centers. Denver, CO: University of Colorado at Denver.
Howes, C. 1997. Children’s experiences in center-based child care as a function of teacher background and adult:child ratio. Merrill-Palmer Q 43:404-24.
Roupp, R., J. Travers, F. M., Glantz, C. Coelen. 1979. Children at the center: Summary findings and their implications. Vol. 1 of Final report of the National day care study. Cambridge, MA: Abt Associates.

Standard 1.3.2.2: Qualifications of Lead Teachers and Teachers

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

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

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

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

RATIONALE

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

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

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

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.4.1.1: Pre-service Training

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

National Association for the Education of Young Children. 2010. Definition of early childhood professional development, 12. Eds. M. S. Donovan, J. D. Bransford, J. W. Pellegrino. Washington, DC: National Academy Press.
Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC early childhood program standard and related accreditation criteria. Washington, DC: National Association for the Education of Young Children (NAEYC).
Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care providers? Pediatrics 112:878-82.
Hayney M. S., J. C. Bartell. 2005. An immunization education program for childcare providers. J of School Health 75:147-49.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

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

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

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

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

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

RATIONALE

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

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 1.4.2.3: Orientation Topics

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

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

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

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

American Academy of Pediatrics, Council on School Health. 2009. Policy statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51.
Centers for Disease Control and Prevention (CDC). 2016. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020:3.

Standard 1.4.3.1: First Aid and Cardiopulmonary Resuscitation Training for Staff

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

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

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

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

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

RATIONALE

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

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

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

COMMENTS

Additional Resources:

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 1.4.3.2: Topics Covered in Pediatric First Aid Training

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

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

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
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 1.4.3.3: Cardiopulmonary Resuscitation Training for Swimming and Water Play

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

Early care and education programs with a swimming pool on-site or that participate in swimming or water play activities should have, at minimum, one staff member with current documentation of successful completion of training in pediatric cardiopulmonary resuscitation (CPR). Pediatric CPR–certified staff should be counted in the child to staff ratio for all swimming and water play activities.

This documentation should require the successful completion of training in the following areas:

Basic water safety
Proper use of swimming pool rescue equipment
Emergency procedures
Pediatric CPR according to the criteria of the American Red Cross or the American Heart Association

For small family child care homes, the person trained in water safety and CPR should be the caregiver/teacher. Written verification of successful completion of CPR and lifesaving training, water safety instructions, and emergency procedures should be kept on file and reviewed and updated annually.

RATIONALE

Drowning can occur very quickly, quietly, and anywhere water is available, such as play areas, bathtubs, swimming pools, and buckets.¹ Children can drown in as little as 2 inches of water, making supervision critical. Active, persistent supervision by a nearby adult is believed to be the most effective drowning prevention strategy for children.² The brain can only survive for several minutes without oxygen. Trained staff members who are able to provide CPR in a timely manner can significantly prevent or offset possible brain damage from drowning.³ The interruption of breathing, as well as possible cardiac arrest, makes prolonged immersion time and drowning an urgent, life-threatening emergency.³

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
9.4.3.3 Training Record
2.2.0.4 Supervision Near Bodies of Water
2.2.0.5 Behavior Around a Pool
6.3.1.7 Pool Safety Rules
6.4.1.1 Pool Toys

REFERENCES

Centers for Disease Control and Prevention. Unintentional drowning: get the facts. https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html. Updated April 28, 2016. Accessed December 20, 2018
Franklin RC, Pearn JH, Peden AE. Drowning fatalities in childhood: the role of pre-existing medical conditions. Arch Dis Child. 2017;102(10):888–893
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

NOTES

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

Standard 1.4.5.1: Training of Staff Who Handle Food

All staff members with food handling responsibilities should obtain training in food service and safety. The director of a center or a large family child care home or the designated supervisor for food service should be a certified food protection manager or equivalent as demonstrated by completing an accredited food protection manager course. Small family child care personnel should secure training in food service and safety appropriate for their setting.

RATIONALE

Outbreaks of foodborne illness have occurred in many settings, including child care facilities. Some of these outbreaks have led to fatalities and severe disabilities. Young children are particularly susceptible to foodborne illness, due to their body size and immature immune systems. Because large centers serve more meals daily than many restaurants do, the supervisors of food handlers in these settings should have successfully completed food service certification, and the food handlers in these settings should have successfully completed courses on appropriate food handling (1).

COMMENTS

Sponsors of the Child and Adult Care Food Program (CACFP) provide this training for some small family child care home caregivers/teachers. For training in food handling, caregivers/teachers should contact the state or local health department, or the delegate agencies that handle nutrition and environmental health inspection programs for the child care facility. Training for food workers is mandatory in some jurisdictions. Other sources for food safety information are the Food and Drug Administration (FDA) Food Code, family child care associations, child care resource and referral agencies, licensing agencies, and state departments of education.

TYPE OF FACILITY

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

RELATED STANDARDS

9.4.3.3 Training Record

REFERENCES

U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. Food code 2009. College Park, MD: FDA. http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/default.htm.

Standard 1.4.5.2: Child Abuse and Neglect Education

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

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

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

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

Admon Livny K, Katz C. Schools, families, and the prevention of child maltreatment: lessons that can be learned from a literature review. Trauma Violence Abuse. 2016;pii:1524838016650186
US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2014. http://www.acf.hhs.gov/sites/default/files/cb/cm2014.pdf. Published 2016. Accessed January 11, 2018
Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical-Package.pdf. Accessed January 11, 2018
Centers for Disease Control and Prevention. Violence prevention. Child abuse and neglect: risk and protective factors. https://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html. Updated April 18, 2017. Accessed January 11, 2018
Centers for Disease Control and Prevention. Child abuse and neglect prevention. https://www.cdc.gov/violenceprevention/childmaltreatment/index.html. Updated April 17, 2017. Accessed March 8, 2018

NOTES

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

Standard 1.5.0.1: Employment of Substitutes

Substitutes should be employed to ensure that child:staff ratios and requirements for direct supervision are maintained at all times. Substitutes and volunteers should be at least eighteen years of age and must meet the requirements specified throughout Standards 1.3.2.1-1.3.2.6. Those without licenses/certificates should work under direct supervision and should not be alone with a group of children.

A substitute should complete the same background screening processes as the caregiver/teacher. Obtaining substitutes to provide medical care for children with special health care needs is particularly challenging. A substitute nurse should be experienced in delivering the expected medical services. Decisions should be made on whether a parent/guardian will be allowed to provide needed on-site medical services. Substitutes should be aware of the care plans (including emergency procedures) for children with special health care needs.

RATIONALE

The risk to children from care by unqualified caregivers/teachers is the same whether the caregiver/teacher is a paid substitute or a volunteer (1).

COMMENTS

Substitutes are difficult to find, especially at the last minute. Planning for a competent substitute pool is essential for child care operation. Requiring substitutes for small family child care homes to obtain first aid and CPR certification forces small family child care home caregivers/teachers to close when they cannot be covered by a competent substitute. Since closing a child care home has a negative impact on the families and children they serve, systems should be developed to provide qualified alternative homes or substitutes for family child care home caregivers/teachers.

The lack of back-up for family child care home caregivers/teachers is an inherent liability in this type of care. Parents/guardians who use family child care must be sure they have suitable alternative care, such as family or friends, for situations in which the child’s usual caregiver/teacher cannot provide the service.

Substitutes should have orientation and training on basic health and safety topics. Substitutes should not have an infectious disease when providing care.

TYPE OF FACILITY

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

RELATED STANDARDS

1.1.1.1 Ratios for Small Family Child Care Homes
1.1.1.2 Ratios for Large Family Child Care Homes and Centers
1.1.1.3 Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities
1.1.1.4 Ratios and Supervision During Transportation
1.1.1.5 Ratios and Supervision for Swimming, Wading, and Water Play
1.3.2.2 Qualifications of Lead Teachers and Teachers
1.3.3.1 General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home
1.3.2.1 Differentiated Roles
1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, and Volunteers
1.3.2.4 Additional Qualifications for Caregivers/Teachers Serving Children Birth to Thirty-Five Months of Age
1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.6 Additional Qualifications for Caregivers/Teachers Serving School-Age Children
1.3.3.2 Support Networks for Family Child Care
1.5.0.2 Orientation of Substitutes
1.7.0.1 Pre-Employment and Ongoing Adult Health Appraisals, Including Immunization

REFERENCES

National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net.

Standard 1.5.0.2: Orientation of Substitutes

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

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

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

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

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

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

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

1. Hand hygiene techniques, including indications for hand hygiene

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

3. Preventing shaken baby syndrome/abusive head trauma

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

5. Early brain development and its vulnerabilities

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

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

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

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

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

_h. Emergency plans and practices

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

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

1.2.0.2 Background Screening
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.2.1.1 Type of Diapers Worn
3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.2.2.3 Assisting Children with Hand Hygiene
3.2.2.4 Training and Monitoring for Hand Hygiene
3.2.2.5 Hand Sanitizers
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.4.3.1 Medical Emergency Procedures
3.4.3.2 Use of Fire Extinguishers
3.4.3.3 Response to Fire and Burns
5.4.1.1 General Requirements for Toilet and Handwashing Areas
5.4.1.2 Location of Toilets and Privacy Issues
5.4.1.3 Ability to Open Toilet Room Doors
5.4.1.4 Preventing Entry to Toilet Rooms by Infants and Toddlers
5.4.1.5 Chemical Toilets
5.4.1.6 Ratios of Toilets, Urinals, and Hand Sinks to Children
5.4.1.7 Toilet Learning and Training Equipment
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
5.4.1.9 Waste Receptacles in the Child Care Facility and in Child Care Facility Toilet Room(s)
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.4 Futons
5.4.5.5 Bunk Beds
9.2.2.3 Exchange of Information at Transitions
9.2.3.11 Food and Nutrition Service Policies and Plans
9.2.3.12 Infant Feeding Policy
9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.2.4.2 Review of Written Plan for Urgent Care and Threatening Incidents
9.4.1.18 Records of Nutrition Service
2.2.0.6 Discipline Measures
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
Appendix D: Gloving

REFERENCES

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

NOTES

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

Standard 1.6.0.1: Child Care Health Consultants

COVID-19 modification as of May 21, 2021

*STANDARD UNDERGOING FULL REVISION*

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

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

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

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

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

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

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

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

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

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

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

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

COVID-19 modification as of May 21, 2021

In response to the Centers for Disease Control and Prevention’s COVID-19 Guidance for Operating Early Care and Education/Child Care Programs, it is recommended that early childhood programs:

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

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

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

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

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

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

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

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

Additional Resources:

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

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

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

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

RATIONALE

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

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

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

COMMENTS

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Crowley, A. A. 2001. Child care health consultation: An ecological model. J Society Pediat Nurs 6:170-81.
Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. Academic Pediatrics 9:366-70.
Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care providers in New Jersey: A pilot study. Pediatric Nurs 32:530-37.
Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health consultation: A conceptual model. J for Specialists in Pediatric Nurs 13:74-88.
Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care health consultant knowledge and practice. Pediatric Nurs 35:93-100.
Heath, J. M., et al. 2005. Creating a statewide system of multi-disciplinary consultation system for early care and education in Connecticut. Farmington, CT: Child Health and Development Institute of Connecticut. http://nitcci.nccic.acf.hhs.gov/resources/10262005_93815_901828.pdf.
Farrer, J., A. Alkon, K. To. 2007. Child care health consultation programs: Barriers and opportunities. Maternal Child Health J 11:111-18.
Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505.
Crowley, A. A. 2000. Child care health consultation: The Connecticut experience. Maternal Child Health J 4:67-75.
Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21.
Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and facilitators. Public Health Nurs 25:126-39.

NOTES

COVID-19 modification as of May 21, 2021

Chapter 2 - Program Activities for Healthy Development

Standard 2.1.1.4: Monitoring Children’s Development/Obtaining Consent for Screening

Child care settings provide daily indoor and outdoor opportunities for promoting and monitoring children’s development. Caregivers/teachers should monitor the children’s development, share observations with parents/guardians, and provide resource information as needed for screenings, evaluations, and early intervention and treatment. Caregivers/teachers should work in collaboration to monitor a child’s development with parents/guardians and in conjunction with the child’s primary care provider and health, education, mental health, and early intervention consultants. Caregivers/teachers should utilize the services of health and safety, education, mental health, and early intervention consultants to strengthen their observation skills, collaborate with families, and be knowledgeable of community resources.

Programs should have a formalized system of developmental screening with all children that can be used near the beginning of a child’s placement in the program, at least yearly thereafter, and as developmental concerns become apparent to staff and/or parents/guardians. The use of authentic assessment and curricular-based assessments should be an ongoing part of the services provided to all children (5-9). The facility’s formalized system should include a process for determining when a health or developmental screening or evaluation for a child is necessary. This process should include parental/guardian consent and participation.

Parents/guardians should be explicitly invited to:

Discuss reasons for a health or developmental assessment;
Participate in discussions of the results of their child’s evaluations and the relationship of their child’s needs to the caregivers’/teachers’ ability to serve that child appropriately;
Give alternative perspectives;
Share their expectations and goals for their child and have these expectations and goals integrated with any plan for their child;
Explore community resources and supports that might assist in meeting any identified needs that child care centers and family child care homes can provide;
Give written permission to share health information with primary health care professionals (medical home), child care health consultants and other professionals as appropriate;

The facility should document parents’/guardians’ presence at these meetings and invitations to attend.

If the parents/guardians do not attend the screening, the caregiver/teacher should inform the parents/guardians of the results, and offer an opportunity for discussion. Efforts should be made to provide notification of meetings in the primary language of the parents/guardians. Formal evaluations of a child’s health or development should also be shared with the child’s medical home with parent/guardian consent.

Programs are encouraged to utilize validated screening tools to monitor children’s development, as well as various measures that may inform their work facilitating children’s development and providing an enriching indoor and outdoor environment, such as authentic-based assessment, work sampling methods, observational assessments, and assessments intended to support curricular implementation (5,9). Programs should have clear policies for using reliable and valid methods of developmental screening with all children and for making referrals for diagnostic assessment and possible intervention for children who screen positive. All programs should use methods of ongoing developmental assessment that inform the curricular approaches used by the staff. Care must be taken in communicating the results. Screening is a way to identify a child at risk of a developmental delay or disorder. It is not a diagnosis.

If the screening or any observation of the child results in any concern about the child’s development, after consultation with the parents/guardians, the child should be referred to his or her primary care provider (medical home), or to an appropriate specialist or clinic for further evaluation. In some situations, a direct referral to the Early Intervention System in the respective state may also be required.

RATIONALE

Seventy percent of children with developmental disabilities and mental health problems are not identified until school entry (10). Daily interaction with children and families in early care and education settings offers an important opportunity for promoting children’s development as well as monitoring developmental milestones and early signs of delay (1-3). Caregivers/teachers play an essential role in the early identification and treatment of children with developmental concerns and disabilities (6-8) because of their knowledge in child development principles and milestones and relationship with families (4). Coordination of observation findings and services with children’s primary care providers in collaboration with families will enhance children’s outcomes (6).

COMMENTS

Parents/guardians need to be included in the process of considering, identifying and shaping decisions about their children, (e.g., adding, deleting, or changing a service). To provide services effectively, facilities must recognize parents’/guardians’ observations and reports about the child and their expectations for the child, as well as the family’s need of child care services. A marked discrepancy between professional and parent/guardian observations of, or expectations for, a child necessitates further discussion and development of a consensus on a plan of action.

Consideration should be given to utilizing parent/guardian-completed screening tools, such as the Ages and Stages Questionnaire (ASQ) (for a list of validated developmental screening tools, see the American Academy of Pediatric’s [AAP] list of developmental screening tools at http://www
.medicalhomeinfo.org/downloads/pdfs/DPIPscreeningtool
grid.pdf). The caregiver/teacher should explain the results to parents/guardians honestly, with sensitivity, and without using technical jargon (11).

Resources for implementing a program that involves a formalized system of developmental screening are available at the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncbddd/actearly/ and the AAP at http://www.healthychildcare.org.

Scheduling meetings at times convenient for parent/guardian participation is optimal. Those conducting an evaluation, and when subsequently discussing the findings with the family, should consider parents’/guardians’ input. Parents/guardians have both the motive and the legal right to be included in decision-making and to seek other opinions.

A second, independent opinion could be provided by the program’s child care health consultant or the child’s primary care provider.

TYPE OF FACILITY

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

RELATED STANDARDS

1.3.2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age
1.3.2.7 Qualifications and Responsibilities for Health Advocates
3.1.4.5 Unscheduled Access to Rest Areas
9.4.1.3 Written Policy on Confidentiality of Records

REFERENCES

O’Connor, S., et al. 1996. ASQ: Assessing school age child care quality. Wellesly, MA: Center for Research on Women.
Glascoe, F. P. 2005. Screening for developmental and behavioral problems. Mental Retardation Develop Disabilities 11:173-79.
Gilliam, W. S., S. Meisels, L. Mayes. 2005. Screening and surveillance in early intervention systems. In A developmental systems approach to early intervention: National and international perspectives, ed. M. J. Guralnick, 73-98. Baltimore, MD: Brookes Publishing.
American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children With Special Needs Project Advisory Committee. 2006. Identifying infants and young children with developmental disorders in the medical home: An alogorithm for developmental surveillance and screening. Pediatrics 118:405-20.
Squires, J., D. Bricker. 2009. Ages and stages questionnaires. Baltimore: Brookes Publishing.
Kostelnik, M. J., A. K. Soderman, A. P. Whiren. 2006. Developmentally appropriate curriculum best practices in early childhood education. Upper Saddle River, NJ: Prentice Hall.
Brothers, K. l., F. Glascoe, N. Robertshaw. 2008. PEDS: Developmental milestones - An accurate brief tool for surveillance and screening. Clinical Pediatrics 47:271-79.
Dworkin, P. H. 1989. British and American recommendations for developmental monitoring: The role of surveillance. Pediatrics 84:1000-1010.
Copple, C., S. Bredekamp. 2009. Developmentally appropriate practice in early childhood programs serving children at birth through age 8. 3rd ed. Washington, DC: National Association for the Education of Young Children.
Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/.

Standard 2.1.2.1: Personal Caregiver/Teacher Relationships for Infants and Toddlers

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

The facility should practice a relationship-based philosophy that promotes consistency and continuity of caregivers/teachers for infants and toddlers (1-3). Facilities should implement continuity of care practices into established policies and procedures as a means to foster strong, positive relationships that will act as a secure basis for exploration and learning in the classroom (1-4). Child–caregiver relationships based on high-quality care are central to brain development, emotional regulation, and overall learning (5). The facility should encourage practices of continuity of care that give infants and toddlers the added benefit of the same caregiver for the first three years of life of the child or during the time of enrollment (6). The facility should limit the number of caregivers/teachers who interact with any one infant or toddler (1).

The caregiver/teacher should:

Use a variety of safe and appropriate individualized soothing methods of holding and comforting infants and toddlers who are upset (7).
Engage in frequent, multiple, and rich social interchanges, such as smiling, talking, appropriate forms of touch, singing, and eating.
Be play partners as well as protectors.
Be attuned to infants’ and toddlers’ feelings and reflect them back.
Communicate consistently with parents/guardians.
Interact with infants and toddlers and develop a relationship in the context of everyday routines (eg, diapering, feeding).

Opportunities should be provided for each infant and toddler to develop meaningful relationships with caregivers.

The facility’s touch policy should be direct in addressing that children may be touched when it is appropriate for, respectful to, and safe for the child. Caregivers/teachers should respect the wishes of children, regardless of their age, for physical contact and their comfort or discomfort with it. Caregivers/teachers should avoid even “friendly” contact (eg, touching the shoulder or arm) with a child if the child expresses that he or she is uncomfortable.

RATIONALE

When children trust caregivers and are comfortable in the environment that surrounds them, they are allowed to focus on educational discoveries in their physical, social, and emotional development.

Holding, and hugging, in a positive, respectful, and safe manner is an essential part of providing care for infants and toddlers.

Quality caregivers/teachers provide care and learning experiences that play a key role in a child’s development as an active, self-knowing, self-respecting, thinking, feeling, and loving person (8). Limiting the number of adults with whom an infant or a toddler interacts fosters reciprocal understanding of communication cues that are unique to each infant or toddler. This leads to a sense of trust of the adult by the infant or toddler that the infant’s or toddler’s needs will be understood and met promptly (5,6). Studies of infant behavior show that infants have difficulty forming trusting relationships in settings where many adults interact with infants (eg, in hospitalization of infants when shifts of adults provide care) (9).

Sexual abuse in the form of inappropriate touching is an act that induces or coerces children in a sexually suggestive manner or for the sexual gratification of the adult, such as sexual penetration and/or overall inappropriate touching or kissing (10).

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

Zero to Three. Primary caregiving and continuity of care. https://www.zerotothree.org/resources/85-primary-caregiving-and-continuity-of-care. Published February 8, 2010. Accessed January 11, 2018
National Scientific Council on the Developing Child. The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper 12. https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2012/05/The-Science-of-Neglect-The-Persistent-Absence-of-Responsive-Care-Disrupts-the-Developing-Brain.pdf. Published December 2012. Accessed January 11, 2018
Harvard University Center on the Developing Child. Three principles to improve outcomes for children and families. https://developingchild.harvard.edu/resources/three-early-childhood-development-principles-improve-child-family-outcomes. Accessed January 11, 2018
Recchia SL. Caregiver–child relationships as a context for continuity in child care. Early Years. 2012;32(2):143–157
US Department of Health and Human Services, Child Care State Capacity Building Center. Six essential program practices. Program for infant/toddler care. https://childcareta.acf.hhs.gov/sites/default/files/public/pitc_rationale_-_continuity_of_care_508_0.pdf. Published January 2017. Accessed January 11, 2018
Ruprecht K, Elicker J, Choi J. Continuity of care, caregiver–child interactions, toddler social competence and problem behaviors. Early Educ Dev. 2015;27:221–239
Kim Y. Relationship-based developmentally supportive approach to infant childcare practice. Early Child Dev Care. 2015:734-749
Understanding children’s behavior. In: Miller DF. Positive Child Guidance. 8th ed. Boston, MA: Cengage Learning; 2016
Sandstrom H, Huerta S. The negative effects of instability on child development: a research synthesis. Urban Institute Web site. https://www.urban.org/research/publication/negative-effects-instability-child-development-research-synthesis. Published September 18, 2013. Accessed January 11, 2018
Al Odhayani A, Watson WJ, Watson L. Behavioural consequences of child abuse. Can Fam Physician. 2013;59(8):831–836

NOTES

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

Standard 2.2.0.1: Methods of Supervision of Children

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

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

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

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

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

6. Engage and Redirect

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

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

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

COMMENTS

TYPE OF FACILITY

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

RELATED STANDARDS

REFERENCES

National Center on Early Childhood Health and Wellness. Active Supervision. https://eclkc.ohs.acf.hhs.gov/safety-practices/article/active-supervision. Published February 5th 2018. Accessed August 28, 2018.
National Association for the Education of Young Children: Program Administrator Guide to Evaluating Child Supervision Practices. http://www.naeyc.org/academy/files/
academy/Supervision%20Resource_0.pdf. 2016. Accessed August 28, 2018.
United States Department of Agriculture, National Institute of Food and Agriculture. Cooperative Extension. Creating safe and appropriate diapering, toileting, and hand washing areas in child care. http://articles.extension.org/pages/63292/creating-safe-and-appropriate-diapering-toileting-and-hand-washing-areas-in-child-care. Published October 2, 2015. Accessed June 25, 2018
American Academy of Pediatrics. Child abuse and neglect. HealthyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/What-to-Know-about-Child-Abuse.aspx. Updated April 13, 2018. Accessed June 25, 2018
Schwebel, D. Internet-based training to improve preschool playground safety: Evaluation of the Stamp-in-Safety Programme. The Health Education Journal. 74(1), 37. Published January 20, 2015. Accessed August 28, 2018.
National Safety Council. Landing lightly: playgrounds don’t have to hurt. http://www.nsc.org/learn/safety-knowledge/Pages/news-and-resources-playground-safety.aspx. Accessed June 25, 2018

NOTES

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

Standard 2.2.0.4: Supervision Near Bodies of Water

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

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

RATIONALE

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

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

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

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

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

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

The American Academy of Pediatrics (AAP) recommends:

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

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

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

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 2.2.0.6: Discipline Measures

Reader’s Note: The word discipline means to teach and guide. Discipline is not punishment. The discipline standard therefore reflects an approach that focuses on preventing behavior problems by supporting children in learning appropriate social skills and emotional responses.

Caregivers/teachers should guide children to develop self-control and appropriate behaviors in the context of relationships with peers and adults. Caregivers/teachers should care for children without ever resorting to physical punishment or abusive language. When a child needs assistance to resolve a conflict, manage a transition, engage in a challenging situation, or express feelings, needs, and wants, the adult should help the child learn strategies for dealing with the situation. Discipline should be an ongoing process to help children learn to manage their own behavior in a socially acceptable manner, and should not just occur in response to a problem behavior. Rather, the adult’s guidance helps children respond to difficult situations using socially appropriate strategies. To develop self-control, children should receive adult support that is individual to the child and adapts as the child develops internal controls. This process should include:

Forming a positive relationship with the child. When children have a positive relationship with the adult, they are more likely to follow that person’s directions. This positive relationship occurs when the adult spends time talking to the child, listening to the child, following the child’s lead, playing with the child, and responding to the child’s needs;
Basing expectations on children’s developmental level;
Establishing simple rules children can understand (e.g., you can’t hurt others, our things, or yourself) and being proactive in teaching and supporting children in learning the rules;
Adapting the physical indoor and outdoor learning/play environment or family child care home to encourage positive behavior and self regulation by providing engaging materials based on children’s interests and ensuring that the learning environment promotes active participation of each child. Well-designed child care environments are ones that are supportive of appropriate behavior in children, and are designed to help children learn about what to expect in that environment and to promote positive interactions and engagement with others;
Modifying the learning/play environment (e.g., schedule, routine, activities, transitions) to support the child’s appropriate behavior;
Creating a predictable daily routine and schedule. When a routine is predictable, children are more likely to know what to do and what is expected of them. This may decrease anxiety in the child. When there is less anxiety, there may be less acting out. Reminders need to be given to the children so they can anticipate and prepare themselves for transitions within the schedule. Reminders should be individualized such that each child understands and anticipates the transition;
Using encouragement and descriptive praise. When clear encouragement and descriptive praise are used to give attention to appropriate behaviors, those behaviors are likely to be repeated. Encouragement and praise should be stated positively and descriptively. Encouragement and praise should provide information that the behavior the child engaged in was appropriate. Examples: “I can tell you are ready for circle time because you are sitting on your name and looking at me.” “Your friend looked so happy when you helped him clean up his toys.” “You must be so proud of yourself for putting on your coat all by yourself.” Encouragement and praise should label the behaviors, not the child (e.g., good listening, good eating, instead of good boy);
Using clear, direct, and simple commands. When clear commands are used with children, they are more likely to follow them. The caregiver/teacher should tell the child what to do rather than what NOT to do. The caregiver/teacher should limit the number of commands. The caregiver/teacher should use if/then and when/then statements with logical and natural consequences. These practices help children understand they can make choices and that choices have consequences;
Showing children positive alternatives rather than just telling children “no”;
Modeling desired behavior;
Using planned ignoring and redirection. Certain behaviors can be ignored while at the same time the adult is able to redirect the children to another activity. If the behavior cannot be ignored, the adult should prompt the child to use a more appropriate behavior and provide positive feedback when the child engages in the behavior;
Individualizing discipline based on the individual needs of children. For example, if a child has a hard time transitioning, the caregiver/teacher can identify strategies to help the child with the transition (individualized warning, job during transition, individual schedule, peer buddy to help, etc.) If a child has a difficult time during a large group activity, the child might be taught to ask for a break;
Using time-out for behaviors that are persistent and unacceptable. Time-out should only be used in combination with instructional approaches that teach children what to do in place of the behavior problem. (See guidance for time-outs below.)

Expectations for children’s behavior and the facility’s policies regarding their response to behaviors should be written and shared with families and children of appropriate age. Further, the policies should address proactive as well as reactive strategies. Programs should work with families to support their children’s appropriate behaviors before it becomes a problem.

RATIONALE

Common usage of the word “discipline” has corrupted the word so that many consider discipline as synonymous with punishment, most particularly corporal punishment (2,3). Discipline is most effective when it is consistent, reinforces desired behaviors, and offers natural and logical consequences for negative behaviors. Research studies find that corporal punishment has limited effectiveness and potentially harmful side effects (4-9). Children have to be taught expectations for their behavior if they are to develop internal control of their actions. The goal is to help children learn to control their own behavior.

COMMENTS

Children respond well when they receive descriptive praise/attention for behaviors that the caregiver/teacher wants to see again. It is best if caregivers/teachers are sincere and enthusiastic when using descriptive praise. On the contrary, children should not receive praise for undesirable behaviors, but instead be praised for honest efforts towards the behaviors the caregivers/teachers want to see repeated (1). Discipline is best received when it includes positive guidance, redirection, and setting clear-cut limits that foster the child’s ability to become self-disciplined. In order to respond effectively when children display challenging behavior, it is beneficial for caregivers/teachers to understand typical social and emotional development and behaviors. Discipline is an ongoing process to help children develop inner control so they can manage their own behavior in a socially approved manner. A comprehensive behavior plan is often based first on a positive, affectionate relationship between the child and the caregiver/teacher. Measures that prevent behavior problems often include developmentally appropriate environments, supervision, routines, and transitions. Children can benefit from receiving guidance and repeated instructions for navigating the various social interactions that take place in the child care setting such as friendship development, problem-solving, and conflict-resolution.

Time-out (also known as temporary separation) is one strategy to help children change their behavior and should be used in the context of a positive behavioral support approach which works to understand undesired behaviors and teach new skills to replace the behavior. Listed below are guidelines when using time-out (8):

Time-outs should be used for behaviors that are persistent and unacceptable, used infrequently and used only for children who are at least two years of age. Time-outs can be considered an extended ignore or a time-out from positive enforcement;
The caregiver/teacher should explain how time-out works to the child BEFORE s/he uses it the first time. The adult should be clear about the behavior that will lead to time-out;
When placing the child in time-out, the caregiver/teacher should stay calm;
While the child is in time-out, the caregiver/teacher should not talk to or look at the child (as an extended ignore). However, the adult should keep the child in sight. The child could 1) remain sitting quietly in a chair or on a pillow within the room or 2) participate in some activity that requires solitary pursuit (painting, coloring, puzzle, etc.) If the child cannot remain in the room, s/he will spend time in an alternate space, with supervision;
Time-outs do not need to be long. The caregiver/teacher should use the one minute of time-out for each year of the child’s age (e.g., three-years-old = three minutes of time-out);
The caregiver/teacher should end the time-out on a positive note and allow the child to feel good again. Discussions with the child to “explain WHY you were in time-out” are not usually effective;
If the child is unable to be distracted or consoled, parents/guardians should be contacted.

How to respond to failure to cooperate during time-out:

Caregivers/teachers should expect resistance from children who are new to the time-out procedure. If a child has never experienced time-out, s/he may respond by becoming very emotional. Time-out should not turn into a power struggle with the child. If the child is refusing to stay on time-out, the caregiver/teacher should give the child an if/then statement. For example, “if you cannot take your time-out, then you cannot join story time.” If the child continues to refuse the time-out, then the child cannot join story time. Note that children should not be restrained to keep them in time-out.

More resources for caregivers/teachers on discipline can be found at the following organizations’ Websites: a) Center on the Social and Emotional Foundations for Early Learning (CSEFEL) at http://csefel.vanderbilt.edu and b) Technical Assistance Center on Social Emotional Intervention (TACSEI) at http://challengingbehavior.fmhi.usf.edu/.

ADDITIONAL RESOURCES

Gross, D., C. Garvey, W. Julion, L. Fogg, S. Tucker, H. Mokos. 2009. Efficacy of the Chicago Parent Program with low-income multi-ethnic parents of young children. Preventions Science 10:54-65.

Breitenstein, S., D. Gross, I. Ordaz, W. Julion, C. Garvey, A. Ridge. 2007. Promoting mental health in early childhood programs serving families from low income neighborhoods. J Am Psychiatric Nurses Assoc 13:313-20.

Gross, D., C. Garvey, W. Julion, L. Fogg. 2007. Preventive parent training with low-income ethnic minority parents of preschoolers. In Handbook of parent training: Helping parents prevent and solve problem behaviors. Ed. J. M. Briesmeister, C. E. Schaefer. 3rd ed. Hoboken, NJ: Wiley.

Gartrell, D. 2007. He did it on purpose! Young Children 62:62-64.

Gartrell, D. 2004. The power of guidance: Teaching social-emotional skills in early childhood classrooms. Clifton Park, NY: Thomson Delmar Learning; Washington, DC: NAEYC.

Gartrell, D., K. Sonsteng. 2008. Promoting physical activity: It’s pro-active guidance. Young Children 63:51-53.

Shiller, V. M., J. C. O’Flynn. 2008. Using rewards in the early childhood classroom: A reexamination of the issues. Young Children 63:88, 90-93.

Reineke, J., K. Sonsteng, D. Gartrell. 2008. Nurturing mastery motivation: No need for rewards. Young Children 63:89, 93-97.

Ryan, R. M., E. L. Deci. 2000. When rewards compete with nature: The undermining of intrinsic motivation and self-regulation. In Intrinsic and extrinsic motivation: The search for optimal motivation and performance, ed. C. Sanstone, J. M. Harackiewicz, 13-54. San Diego, CA: Academic Press

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.2.1.6 Written Discipline Policies
9.4.1.6 Availability of Documents to Parents/Guardians
2.1.1.6 Transitioning within Programs and Indoor and Outdoor Learning/Play Environments
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.8 Preventing Expulsions, Suspensions, and Other Limitations in Services

REFERENCES

Henderlong, J., M. Lepper. 2002 The effects of praise on children’s intrinsic motivation: A review and synthesis. Psychological Bulletin 128:774-95.
Hodgkin, R. 1997. Why the “gentle smack” should go: Policy review. Child Soc 11:201-4.
Fraiberg, S. H. 1959. The Magic Years. New York: Charles Scribner’s Sons.
Straus, M. A., et al. 1997. Spanking by parents and subsequent antisocial behavior of children. Arch Pediatric Adolescent Medicine 151:761-67.
Deater-Deckard, K., et al. 1996. Physical discipline among African American and European American mothers: Links to children’s externalizing behaviors. Dev Psychol 32:1065-72.
Weiss, B., et al. 1992. Some consequences of early harsh discipline: Child aggression and a maladaptive social information processing style. Child Dev 63:1321-35.
American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in schools. Pediatrics 118:1266.
Dunlap, S., L. Fox, M. L. Hemmeter, P. Strain. 2004. The role of time-out in a comprehensive approach for addressing challenging behaviors of preschool children. CSEFEL What Works Series. http://csefel.vanderbilt.edu/briefs/wwb14.pdf.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 2.2.0.8: Preventing Expulsions, Suspensions, and Other Limitations in Services

Child care programs should not expel, suspend, or otherwise limit the amount of services (including denying outdoor time, withholding food, or using food as a reward/punishment) provided to a child or family on the basis of challenging behaviors or a health/safety condition or situation unless the condition or situation meets one of the two exceptions listed in this standard.

Expulsion refers to terminating the enrollment of a child or family in the regular group setting because of a challenging behavior or a health condition. Suspension and other limitations in services include all other reductions in the amount of time a child may be in attendance of the regular group setting, either by requiring the child to cease attendance for a particular period of time or reducing the number of days or amount of time that a child may attend. Requiring a child to attend the program in a special place away from the other children in the regular group setting is included in this definition.

Child care programs should have a comprehensive discipline policy that includes an explicit description of alternatives to expulsion for children exhibiting extreme levels of challenging behaviors, and should include the program’s protocol for preventing challenging behaviors. These policies should be in writing and clearly articulated and communicated to parents/guardians, staff and others. These policies should also explicitly state how the program plans to use any available internal mental health and other support staff during behavioral crises to eliminate to the degree possible any need for external supports (e.g., local police departments) during crises.

Staff should have access to in-service training on both a proactive and as-needed basis on how to reduce the likelihood of problem behaviors escalating to the level of risk for expulsion and how to more effectively manage behaviors throughout the entire class/group. Staff should also have access to in-service training, resources, and child care health consultation to manage children’s health conditions in collaboration with parents/guardians and the child’s primary care provider. Programs should attempt to obtain access to behavioral or mental health consultation to help establish and maintain environments that will support children’s mental well-being and social-emotional health, and have access to such a consultant when more targeted child-specific interventions are needed. Mental health consultation may be obtained from a variety of sources, as described in Standard 1.6.0.3.

When children exhibit or engage in challenging behaviors that cannot be resolved easily, as above, staff should:

Assess the health of the child and the adequacy of the curriculum in meeting the developmental and educational needs of the child;
Immediately engage the parents/guardians/family in a spirit of collaboration regarding how the child’s behaviors may be best handled, including appropriate solutions that have worked at home or in other settings;
Access an early childhood mental health consultant to assist in developing an effective plan to address the child’s challenging behaviors and to assist the child in developing age-appropriate, pro-social skills;
Facilitate, with the family’s assistance, a referral for an evaluation for either Part C (early intervention) or Part B (preschool special education), as well as any other appropriate community-based services (e.g., child mental health clinic);
Facilitate with the family communication with the child’s primary care provider (e.g., pediatrician, family medicine provider, etc.), so that the primary care provider can assess for any related health concerns and help facilitate appropriate referrals.

The only possible reasons for considering expelling, suspending or otherwise limiting services to a child on the basis of challenging behaviors are:

Continued placement in the class and/or program clearly jeopardizes the physical safety of the child and/or his/her classmates as assessed by a qualified early childhood mental health consultant AND all possible interventions and supports recommended by a qualified early childhood mental health consultant aimed at providing a physically safe environment have been exhausted; or
The family is unwilling to participate in mental health consultation that has been provided through the child care program or independently obtain and participate in child mental health assistance available in the community; or
Continued placement in this class and/or program clearly fails to meet the mental health and/or social-emotional needs of the child as agreed by both the staff and the family AND a different program that is better able to meet these needs has been identified and can immediately provide services to the child.

In either of the above three cases, a qualified early childhood mental health consultant, qualified special education staff, and/or qualified community-based mental health care provider should be consulted, referrals for special education services and other community-based services should be facilitated, and a detailed transition plan from this program to a more appropriate setting should be developed with the family and followed. This transition could include a different private or public-funded child care or early education program in the community that is better equipped to address the behavioral concerns (e.g., therapeutic preschool programs, Head Start or Early Head Start, prekindergarten programs in the public schools that have access to additional support staff, etc.), or public-funded special education services for infants and toddlers (i.e., Part C early intervention) or preschoolers (i.e., Part B preschool special education).

To the degree that safety can be maintained, the child should be transitioned directly to the receiving program. The program should assist parents/guardians in securing the more appropriate placement, perhaps using the services of a local child care resource and referral agency. With parent/guardian permission, the child’s primary care provider should be consulted and a referral for a comprehensive assessment by qualified mental health provider and the appropriate special education system should be initiated. If abuse or neglect is suspected, then appropriate child protection services should be informed. Finally, no child should ever be expelled or suspended from care without first conducting an assessment of the safety of alternative arrangements (e.g., Who will care for the child? Will the child be adequately and safely supervised at all times?) (1).

RATIONALE

The rate of expulsion in child care programs has been estimated to be as high as one in every thirty-six children enrolled, with 39% of all child care classes per year expelling at least one child. In state-funded prekindergarten programs, the rate has been estimated as one in every 149 children enrolled, with 10% of prekindergarten classes per year expelling at least one child. These expulsions prevent children from receiving potentially beneficial mental health services and deny the child the benefit of continuity of quality early education and child care services. Mental health consultation has been shown in rigorous research to help reduce the likelihood of behaviors leading to expulsion decisions. Also, research suggests that expulsion decisions may be related to teacher job stress and depression, large group sizes, and high child:staff ratios (1-6).

Mental health services should be available to staff to help address challenging behaviors in the program, to help improve the mental health climate of indoor and outdoor learning/play environments and child care systems, to better provide mental health services to families, and to address job stress and mental health needs of staff.

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
2.2.0.6 Discipline Measures
1.6.0.3 Infant and Early Childhood Mental Health Consultants
1.6.0.5 Specialized Consultation for Facilities Serving Children with Disabilities
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.9 Prohibited Caregiver/Teacher Behaviors
2.2.0.10 Using Physical Restraint

REFERENCES

Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing the risk for preschool expulsion: Mental health consultation for young children with challenging behaviors. J Child Family Studies 17:44-54.
National Scientific Council on the Developing Child. 2008. Mental health problems in early childhood can impair learning and behavior for life. Working paper #6. http://developingchild.harvard.edu/library/reports_and_working_papers/working_papers/wp6/.
Gilliam, W. S. 2008. Implementing policies to reduce the likelihood of preschool expulsion. Foundation for Child Development, Policy Brief Series no. 7. http://medicine.yale.edu/childstudy/zigler/Images/PreKExpulsionBrief2_tcm350-34772.pdf.
Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and suspension: Rates and predictors in one state. Infants Young Children 19:228-45.
Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development, Policy Brief Series no. 3. http://medicine.yale.edu/childstudy/zigler/Images/National Prek Study_expulsion brief_tcm350-34775.pdf.
American Academy of Pediatrics, Committee on School Health. 2008. Policy statement: Out-of-school suspension and expulsion. Pediatrics 122:450.

Standard 2.2.0.9: Prohibited Caregiver/Teacher Behaviors

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

Child care programs must not tolerate, or in any manner condone, an act of abuse or neglect of a child. The following behaviors by an older child, caregiver/teacher, substitute or any other person employed by the facility, volunteer, or visitor should be prohibited in all child care settings:

The use of corporal punishment/physical abuse (1) (punishment inflicted directly on the body), including, but not limited to
1. Hitting, spanking (striking a child with an open hand or instrument on the buttocks or extremities with the intention of modifying behavior without causing physical injury), shaking, slapping, twisting, pulling, squeezing, or biting
2. Demanding excessive physical exercise, excessive rest, or strenuous or bizarre postures
3. Forcing and/or demanding physical touch from the child
4. Compelling a child to eat or have soap, food, spices, or foreign substances in his or her mouth
5. Exposing a child to extreme temperatures
Isolating a child in an adjacent room, hallway, closet, darkened area, play area, or any other area where the child cannot be seen or supervised
Binding or tying to restrict movement, such as in a car seat (except when traveling) or taping the mouth
Using or withholding food as a punishment or reward
Toilet learning/training methods that punish, demean, or humiliate a child
Any form of emotional abuse, including rejecting, terrorizing, extended ignoring, isolating, or corrupting a child
Any form of sexual abuse (Sexual abuse in the form of inappropriate touching is an act that induces or coerces children in a sexually suggestive manner or for the sexual gratification of the adult, such as sexual penetration and/or overall inappropriate touching or kissing.)
Abusive, profane, or sarcastic language or verbal abuse, threats, or derogatory remarks about the child or child’s family
Any form of public or private humiliation, including threats of physical punishment (2)
Physical activity/outdoor time taken away as punishment

Children should not see hitting, ridicule, and/or similar types of behavior among staff members.

RATIONALE

The behaviors mentioned in the standard threaten the safety and security of children. This would include behaviors that occur among or between staff. Even though adults may state that the behaviors are “playful,” children cannot distinguish this. Corporal punishment may be physical abuse or may easily become abusive. Corporal punishment is clearly prohibited in family child care homes and centers in most states (3).Research links corporal punishment with negative effects such as later aggression, behavior problems in school, antisocial and criminal behavior, and learning impairment (3-6).

The American Academy of Pediatrics is opposed to the use of corporal punishment (7). Factors supporting prohibition of certain methods of discipline include current child development theory and practice, legal aspects (namely, that a caregiver/teacher does not foster a relationship with the child in place of the parents/guardians to prevent the development of an inappropriate adult-child relationship), and increasing liability suits.

Appropriate alternatives to corporal punishment vary as children grow and develop. As infants become more mobile, the caregiver/teacher must create a safe space and redirect children’s difficult or emotional outbursts when necessary. Recognizing a child’s desires and offering a brief explanation of the rules to support infants and toddlers in developing increased understanding over time as developmentally appropriate. Preschoolers can beginning to develop an understanding of rules; therefore brief verbal expressions help prepare reasoning skills in infants and toddlers. School-aged children begin to develop a sense of personal responsibility and self-control and can learn using healthy and safe incentives (8). In the wake of well-publicized allegations of child abuse in out-of-home settings and increased concerns about liability, some programs have instituted no-touch policies, either explicitly or implicitly. No-touch policies are misguided efforts that fail to recognize the importance of touch to children’s healthy development. Touch is especially important for infants and toddlers. Warm, responsive, safe, and appropriate touches convey regard and concern for children of any age. Adults should be sensitive to ensure their touches (eg, pats on the back, hugs, ruffling a child’s hair) are welcomed by the children and appropriate to their individual characteristics and cultural experience. Careful, open communication between the program and families about the value of touch in children’s development can help to achieve consensus on the acceptable ways for adults to show their respect and support for children in the program (5).

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.6 Discipline Measures
3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect, and Exploitation
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
3.4.4.5 Facility Layout to Reduce Risk of Child Abuse and Neglect
4.5.0.11 Prohibited Uses of Food
9.2.1.6 Written Discipline Policies
2.2.0.7 Handling Physical Aggression, Biting, and Hitting
2.2.0.10 Using Physical Restraint

REFERENCES

Zolotor AJ. Corporal punishment. Pediatr Clin North Am. 2014;61(5):971–978
Fréchette S, Zoratti M, Romano E. What is the link between corporal punishment and child physical abuse? J Fam Violence. 2015;30(2):135–148
Centers for Disease Control and Prevention. Violence prevention. Child abuse and neglect: definitions. https://www.cdc.gov/violenceprevention/childmaltreatment/definitions.html. Updated April 5, 2016. Accessed January 11, 2018
Gershoff ET, Purtell KM, Holas I. Education and advocacy efforts to reduce school corporal punishment. In: Corporal Punishment in U.S. Public Schools: Legal Precedents, Current Practices, and Future Policy. New York, NY: Springer International Publishing; 2015:87–98
Hornor G, Bretl D, Chapman E, et al. Corporal punishment: evaluation of an intervention by PNPs. J Pediatr Health Care. 2015;29(6):526–535
Afifi TO, Ford D, Gershoff ET, et al. Spanking and adult mental health impairment: The case for the designation of spanking as an adverse childhood experience. Child Abuse Negl. 2017;(71):24-31
American Academy of Pediatrics Councils on Early Childhood and School Health. The pediatrician’s role in school readiness. Pediatrics. 2016;138(3):1-7
Carr A. The Handbook of Child and Adolescent Clinical Psychology. 3rd ed. New York, NY: Routledge; 2016
Ferguson CJ. Spanking, corporal punishment and negative long-term outcomes: a meta-analytic review of longitudinal studies. Clin Psychol Rev. 2013;33(1):196–208

NOTES

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

Standard 2.2.0.10: Using Physical Restraint

Reader’s Note: It should never be necessary to physically restrain a typically developing child unless his/her safety and/or that of others are at risk.

When a child with special behavioral or mental health issues is enrolled who may frequently need the cautious use of restraint in the event of behavior that endangers his or her safety or the safety of others, a behavioral care plan should be developed with input from the child’s primary care provider, mental health provider, parents/guardians, center director/family child care home caregiver/teacher, child care health consultant, and possibly early childhood mental health consultant in order to address underlying issues and reduce the need for physical restraint.

That behavioral care plan should include:

An indication and documentation of the use of other behavioral strategies before the use of restraint and a precise definition of when the child could be restrained;
That the restraint be limited to holding the child as gently as possible to accomplish the restraint;
That such child restraint techniques do not violate the state’s mental health code;
That the amount of time the child is physically restrained should be the minimum necessary to control the situation and be age-appropriate; reevaluation and change of strategy should be used every few minutes;
That no bonds, ties, blankets, straps, car seats, heavy weights (such as adult body sitting on child), or abusive words should be used;
That a designated and trained staff person, who should be on the premises whenever this specific child is present, would be the only person to carry out the restraint.

RATIONALE

A child could be harmed if not restrained properly (1). Therefore, staff who are doing the restraining must be trained. A clear behavioral care plan needs to be in place. And, clear documentation with parent/guardian notification needs to be done after a restraining incident occurs in order to conform with the mental health code.

COMMENTS

If all strategies described in Standard 2.2.0.6 are followed and a child continues to behave in an unsafe manner, staff need to physically remove the child from the situation to a less stimulating environment. Physical removal of a child is defined according the development of the child. If the child is able to walk, staff should hold the child’s hand and walk him/her away from the situation. If the child is not ambulatory, staff should pick the child up and remove him/her to a quiet place where s/he cannot hurt themselves or others. Staff need to remain calm and use a calm voice when directing the child. Certain procedures described in Standard 2.2.0.6 can be used at this time, including not giving a lot of attention to the behavior, distracting the child and/or giving a time-out to the child. If the behavior persists, a plan needs to be made with parental/guardian involvement. This plan could include rewards or a sticker chart and/or praise and attention for appropriate behavior. Or, loss of privileges for inappropriate behavior can be implemented, if age-appropriate. Staff should request or agree to step out of the situation if they sense a loss of their own self-control and concern for the child.

The use of safe physical restraint should occur rarely and only for brief periods to protect the child and others. Staff should be alert to repeated instances of restraint for individual children or within a indoor and outdoor learning/play environment and seek consultation from health and mental health consultants in collaboration with families to develop more appropriate strategies.

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.6 Discipline Measures

REFERENCES

Safe and Responsive Schools. 2003. Effective responses: Physical restraint. http://www.unl.edu/srs/pdfs/physrest.pdf.

Standard 2.3.3.1: Parents’/Guardians’ Provision of Information on Their Child’s Health and Behavior

The facility should ask parents/guardians for information regarding the child’s health, nutrition, level of physical activity, and behavioral status upon registration or when there has been an extended gap in the child’s attendance at the facility. The child’s health record should be updated if s/he have had any changes in their health or immunization status. Parents/guardians should be encouraged to sign a release of information/agreement so that child care workers can communicate directly with the child’s medical home/primary care provider.

RATIONALE

Admission of children without this information will leave the center unprepared to deal with daily and emergent health needs of the child, other children, and staff if there is a question of communicability of disease.

COMMENTS

It would be helpful to also have updated information about the health status of parents/guardians and siblings, noting any special conditions, circumstances, or stress that may be affecting the child in care. Some parents/guardians may resist providing this information. If so, the caregiver/teacher should invite them to view this exchange of information as an opportunity to express their own concerns about the facility (1).

TYPE OF FACILITY

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

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness
9.2.1.3 Enrollment Information to Parents/Guardians and Caregivers/Teachers
9.4.2.1 Contents of Child’s Records

REFERENCES

Crowley, A. A., G. C. Whitney. 2005. Connecticut’s new comprehensive and universal early childhood health assessment form. J School Health 75:281-85.

Chapter 3 - Health Promotion and Protection

Standard 3.1.2.1: Routine Health Supervision and Growth Monitoring

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

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

RATIONALE

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

4.2.0.2 Assessment and Planning of Nutrition for Individual Children

REFERENCES

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

Standard 3.1.3.1: Active Opportunities for Physical Activity

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

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

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

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

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

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

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

Outdoor play

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

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

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

Total time allotted for moderate to vigorous activities:

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

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

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

There are many ways to promote tummy time with infants:

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

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

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

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

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

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

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

Children should have adequate space for indoor and outdoor play.

RATIONALE

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

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

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

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

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

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

COMMENTS

Additional Resources

Choosy Kids (https://choosykids.com)

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

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

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

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

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

Spark (www.sparkpe.org)

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.3.2 Playing Outdoors
3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical Activity
5.3.1.10 Restrictive Infant Equipment Requirements
9.2.3.1 Policies and Practices that Promote Physical Activity
2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness
Appendix S: Physical Activity: How Much Is Needed?

REFERENCES

Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta‐analysis. Obes Rev. 2016;17(2)95–107
Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272
Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292–2299
Centers for Disease Control and Prevention. Overweight & obesity. Childhood obesity facts. Prevalence of childhood obesity in the United States, 2011-2014. https://www.cdc.gov/obesity/data/childhood.html. Updated April 10, 2017. Accessed January 11, 2018
Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, cognitive function, and academic achievement in children: a systematic review. Med Sci Sports Exerc. 2016;48(6):1197–1222
Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical activity and health in the early years (aged 0-4 years). Appl Physiol Nutr Metab. 2012;37(4):773–792
Jayasuriya A, Williams M, Edwards T, Tandon P. Parents’ perceptions of preschool activities: exploring outdoor play. Early Educ Dev. 2016;27(7):1004–1017
Bento G, Dias G. The importance of outdoor play for young children’s healthy development. Porto Biomed J. 2017;2(5):157–160
Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43
Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889
American Academy of Pediatrics. Back to sleep, tummy to play. HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/Back-to-Sleep-Tummy-to-Play.aspx. Updated January 20, 2017. Accessed January 11, 2018
Zachry AH. Tummy time activities. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/The-Importance-of-Tummy-Time.aspx. Updated November 21, 2015. Accessed January 11, 2018
US Department of Agriculture, US Department of Health and Human Services. Provide opportunities for active play every day. Nutrition and wellness tips for young children: provider handbook for the Child and Adult Care Food Program. https://fns-prod.azureedge.net/sites/default/files/opportunities_play.pdf. Published June 2013. Accessed January 11, 2018
Centers for Disease Control and Prevention and SHAPE America-Society of Health and Physical Educators. Physical activity during school: Providing recess to all students. 2017. https://www.cdc.gov/healthyschools/physicalactivity/pdf/Recess_All_Students.pdf. Accessed January 11, 2018
Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. J Phys Act Health. 2015;12(6):879–889
Society of Health and Physical Educators. Active Start: A Statement of Physical Activity Guidelines for Children From Birth to Age 5. 2nd ed. Reston, VA: SHAPE America; 2009. https://www.shapeamerica.org/standards/guidelines/activestart.aspx. Accessed January 11, 2018
Hnatiuk JA, Salmon J, Hinkley T, Okely AD, Trost S. A review of preschool children’s physical activity and sedentary time using objective measures. Am J Prev Med. 2014;47(4):487–497
Moir C, Meredith-Jones K, Taylor BJ, et al. Early intervention to encourage physical activity in infants and toddlers: a randomized controlled trial. Med Sci Sports Exerc. 2016;48(12):2446–2453

NOTES

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

Standard 3.1.3.2: Playing Outdoors

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

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

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

Sunny weather

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

Warm weather

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

Cold weather

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

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

RATIONALE

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

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

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

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

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

COMMENTS

Additional Resources

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

National Weather Service, National Oceanic and Atmospheric Administration. Wind chill safety. https://www.weather.gov/bou/windchill. Accessed January 11, 2018
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
Söderström M, Boldemann C, Sahlin U, Mårtensson F, Raustorp A, Blennow M. The quality of the outdoor environment influences children’s health—a cross-sectional study of preschoolers. Acta Paediatr. 2013;102(1):83–91
KidsHealth from Nemours. Heat illness. http://kidshealth.org/en/parents/heat.html. Reviewed February 2014. Accessed January 11, 2018
American Academy of Pediatrics. Children & disasters. Extreme temperatures: heat and cold. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Extreme-Temperatures-Heat-and-Cold.aspx. Accessed January 11, 2018
Cleland V, Crawford D, Baur LA, Hume C, Timperio A, Salmon J. A prospective examination of children’s time spent outdoors, objectively measured physical activity and overweight. Int J Obes (Lond). 2008;32(11):1685–1693
American Academy of Pediatrics. Winter safety tips from the American Academy of Pediatrics. https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/AAP-Winter-Safety-Tips.aspx. Published January 2018. Accessed January 11, 2018
American Academy of Pediatrics. Extreme temperature exposure. HealthyChildren.org Web site. https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Extreme-Temperature-Exposure.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

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

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

1) Facilities do not have or use written “safe sleep” policies or guidelines;
2) State child care regulations do not mandate the use of supine (wholly on their back) sleep position for infants in child care and/or training for infant caregivers/teachers;
3) Other caregivers/teachers or parents/guardians have objections to use of safe sleep practices, either because of their concern for choking or aspiration, and/or their concern that some infants do not sleep well in the supine position; and
4) Parents/guardians model their practices after what happens in the hospital or what others recommend. Infants who were placed to sleep in other positions in the hospital or home environments may have difficulty transitioning to supine positioning at home and later in child care.

COMMENTS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

2.2.0.1 Methods of Supervision of Children
3.1.4.2 Swaddling
3.1.4.3 Pacifier Use
3.1.4.4 Scheduled Rest Periods and Sleep Arrangements
3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.4.6.1 Strangulation Hazards
3.6.4.5 Death
4.3.1.1 General Plan for Feeding Infants
4.5.0.3 Activities that Are Incompatible with Eating
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.2 Cribs
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
6.4.1.3 Crib Toys

REFERENCES

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

NOTES

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

Standard 3.1.5.1: Routine Oral Hygiene Activities

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

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

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.
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
Centers for Disease Control and Prevention. 2013. Community water fluoridation. http://www.cdc.gov/fluoridation/faqs/http://www.cdc.gov/fluoridation/faqs/
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.
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.
American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94.
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
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
American Dental Association. ADA positions and statements. ADA statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx.
American Academy of Pediatric Dentistry. Early childhood caries. Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf.
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 3.2.1.4: Diaper Changing Procedure

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.4

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Is the recommendation for an Environmental Protection Agency (EPA)-registered disinfectant different from the previous cleaning and sanitizing definitions? What’s the difference between a disinfectant and sanitizing agent?

Answer:

For some surfaces it is important to disinfect to be healthy and safe (this is the deepest “clean”). For some surfaces sanitizing is enough to be healthy and safe, and for some surfaces cleaning is adequate. Remember that before some surfaces are disinfected or sanitized, the visible “dirt” must first be cleaned off.

Please see Appendix J, Selecting an Appropriate Sanitizer or Disinfectant for more information.

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.4

Date: 11/22/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
What is the rationale for requiring hand washing before diaper changing?

Answer:
The diaper changing process may require many interactions with the child before the process, for example evaluating whether the diaper contains stool. Because of the potential for contamination of hands during this process, hand hygiene should be performed before collection of diaper supplies and further handling of the child to avoid contaminating the remaining diaper supplies. However, activities in child care do not occur in isolation. If hand hygiene has been done for another reason prior to a diaper changing event, the process does not have to be repeated if no contamination of hands has occurred.

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.1.4

Date: 07/21/2014

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.1.4: Diaper Changing Procedure

Question:
Step 6 of Standard 3.2.1.4: Diaper Changing Procedure states to "Use soap and warm water, between 60°F and 120°F, at a sink to wash the child’s hands, if you can." If the child is too heavy to hold at the sink, or has a special health care need that prevents him/her from standing at the sink, it is OK to use several wipes (one after the other) to clean the child's hands?

Answer:
Wipes that have chemicals should not be used as a replacement for washing an infant's/toddler's hands.

However, Managing Infectious Diseases in Child Care and Schools, 4th Edition and Model Child Care Health Policies, 5th Edition offers an alternative method to washing the hands of an infant/toddler at the sink if they are too heavy to hold or have a special need that prevents standing at the sink. This ”three paper towel” method is as follows:

1. Wipe the child’s hands with a damp paper towel moistened with a drop of liquid soap.
2. Wipe the child’s hands with a 2nd paper towel wet with clear water.
3. Dry the child’s hands with a 3^rd paper towel.

Additionally, as stated in CFOC Standard 3.2.2.5: Hand Sanitizers, the use of hand sanitizers by children over twenty-four months of age and adults in child care programs is an appropriate alternative to the use of traditional handwashing with soap and water if the hands are not visibly soiled.

Last, please remember to check your local and/or state regulations before implementing this strategy.

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

The following diaper-changing procedure should be posted in the changing area, followed for all diaper changes, and used as part of staff evaluation of caregivers/teachers who diaper. The signage should be simple and in multiple languages if caregivers/teachers who speak multiple languages are involved in diapering. All employees who will change diapers should undergo training and periodic assessment of diapering practices. Caregivers/teachers should never leave a child unattended on a table or countertop, even for an instant. A safety strap or harness should not be used on the diaper-changing table. If an emergency arises, caregivers/teachers should bring any child on an elevated surface to the floor or take the child with them.
Use a fragrance-free bleach that is US Environmental Protection Agency (EPA) registered as a sanitizing or disinfecting solution. If other products are used for sanitizing or disinfecting, they should also be fragrance-free and EPA registered (1).
All cleaning and disinfecting solutions should be stored to be accessible to the caregiver/teacher but out of reach of any child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting.

Step 1: Get organized. Before bringing the child to the diaper changing area, perform hand hygiene if hands have been contaminated since the last time hand hygiene was performed(2), gather, and bring supplies to the diaper changing area.

Nonabsorbent paper liner large enough to cover the changing surface from the child’s shoulders to beyond the child’s feet
Unused diaper, clean clothes (if you need them)
Readily available wipes, dampened cloths, or wet paper towels for cleaning the child’s genitalia and buttocks
A plastic bag for any soiled clothes or cloth diapers
Disposable gloves, if you plan to use them (put gloves on before handling soiled clothing or diapers; remove them before handling clean diapers and clothing)
A thick application of any diaper cream (e.g., zinc oxide ointment), when appropriate, removed from the container to a piece of disposable material such as facial or toilet tissue

Step 2: Carry the child to the changing table, keeping soiled clothing away from you and any surfaces you cannot easily clean and sanitize after the change.

Always keep a hand on the child.
If the child’s feet cannot be kept out of the diaper or from contact with soiled skin during the changing process, remove the child’s shoes and socks so the child does not contaminate these surfaces with stool or urine during the diaper changing.

Step 3: Clean the child’s diaper area.

Place the child on the diaper-changing surface and unfasten the diaper but leave the soiled diaper under the child.
If safety pins are used, close each pin immediately once it is removed and keep pins out of the child’s reach (never hold pins in your mouth).
Lift the child’s legs as needed to use disposable wipes, a dampened cloth, or a wet paper towel to clean the skin on the child’s genitalia and buttocks and prevent recontamination from a soiled diaper. Remove stool and urine from front to back and use a fresh wipe, dampened cloth, or wet paper towel each time you swipe. Put the soiled wipes, cloth, or paper towels into the soiled diaper or directly into a plastic-lined, hands-free covered can. Reusable cloths should be stored in a washable, plastic-lined, tightly covered receptacle (within arm’s reach of diaper changing tables) until they can be laundered. The cover should not require touching with contaminated hands or objects.

Step 4: Remove the soiled diaper and clothing without contaminating any surface not already in contact with stool or urine.

Fold the soiled surface of the diaper inward.
Put soiled disposable diapers in a covered, plastic-lined, hands-free covered can. If reusable cloth diapers are used, put the soiled cloth diaper and its contents (without emptying or rinsing) in a plastic bag or into a plastic-lined, hands-free covered can to give to parents/guardians or laundry service.
Put soiled clothes in a plastic-lined, hands-free plastic bag.
Check for spills under the child. If there are any, use the corner of the paper that extends beyond or under the child’s feet to fold over the soiled area so a fresh, unsoiled paper surface is now under the child’s buttocks.
If gloves were used, remove them using the proper technique (see Appendix D) and put them into a plastic-lined, hands-free covered can.
Whether or not gloves were used, use a fresh wipe to wipe the hands of the caregiver/teacher and another fresh wipe to wipe the child’s hands. Put the wipes into the plastic-lined, hands-free covered can.

Step 5: Put on a clean diaper and dress the child.

Slide a fresh diaper under the child.
Use a facial or toilet tissue or wear clean disposable gloves to apply any necessary diaper creams, discarding the tissue or gloves in a covered, plastic-lined, hands-free covered can.
Note and plan to report any skin problems such as redness, cracks, or bleeding.
Fasten the diaper; if pins are used, place your hand between the child and the diaper when inserting the pin.

Step 6: Wash the child’s hands and return the child to a supervised area.

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

Step 7: Clean and disinfect the diaper-changing surface.

Dispose of the disposable paper liner used on the diaper-changing surface in a plastic-lined, hands-free covered can.
If clothing was soiled, securely tie the plastic bag used to store the clothing and send the bag home.
Remove any visible soil from the changing surface with a disposable paper towel saturated with water and detergent, and then rinse.
Wet the entire changing surface with a disinfectant that is appropriate for the surface material you are treating. Follow the manufacturer’s instructions for use.
Put away the disinfectant. Some types of disinfectants may require rinsing the changing table surface with fresh water afterward.

Step 8: Perform hand hygiene according to the procedure in Standard 3.2.2.2 and record the diaper change in the child’s daily log.

In the daily log, record what was in the diaper and any problems (e.g., a loose stool, an unusual odor, blood in the stool, any skin irritation) and report as necessary (3).

RATIONALE

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

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

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

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

University of California, San Francisco School of Nursing Institute for Health and Aging; University of California, Berkeley Center for Environmental Research and Children’s Health; Informed Green Solutions. Green Cleaning, Sanitizing, and Disinfecting: A Checklist for Early Care and Education. https://www.epa.gov/sites/production/files/2013-08/documents/checklist_8.1.2013.pdf. Published 2013. Accessed June 26, 2018
Early Childhood Education Linkage System, Healthy Child Care Pennsylvania. Diapering poster. http://www.ecels-healthychildcarepa.org/tools/posters/item/279-diapering-poster. Reaffirmed April 2018. Accessed June 26, 2018
American Academy of Pediatrics. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018
National Association for the Education of Young Children. Healthy Young Children: A Manual for Programs. Aronson SS, ed. 5th ed. Washington, DC: National Association for the Education of Young Children; 2012
Children’s Environmental Health Network. 2016. Household chemicals. https://sharemylesson.com/teaching-resource/household-chemicals-fact-sheet-298286.
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.25.

NOTES

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

Standard 3.2.2.1: Situations that Require Hand Hygiene

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

COVID-19 modification as of August 10, 2022.

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

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

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

b. Before and after

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

c. After

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

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

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

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

COVID-19 modification as of August 10, 2022:

In response to the Centers for Disease Control and Prevention’s COVID-19 Guidance for Operating Early Care and Education/Child Care Programs, it is recommended that program staff, and children:

Practice hand hygiene during key times in the day (for example, before/after eating, after recess and after touching or handling masks.)

Provide adequate handwashing supplies, including soap and water.

Provide hand sanitizer containing at least 60% alcohol if hand washing with soap and water is not available.
- Store hand sanitizers up, away, and out of sight of younger children and only with adult supervision for children ages 5 years and younger.

Additional Resources:

Centers for Disease Control and Prevention. Your Guide to Masks

CFOC Standard 3.2.2.5 Hand Sanitizers

RATIONALE

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

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

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

Thorough handwashing with soap for at least twenty seconds using clean running water at a comfortable temperature removes organisms from the skin and allows them to be rinsed away.⁶ Hand hygiene with an alcohol-based sanitizer is an alternative to traditional handwashing with soap and water when visible soiling is not present.

Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands after cleaning. It is important for caregivers/teachers to monitor children’s use of hand sanitizers to ensure the product is being used appropriately.⁷

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

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

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5.
Palmer, S. R., L. Soulsby, D. I. H. Simpson, eds. 1998. Zoonoses: Biology, clinical practice, and public health control. New York: Oxford University Press.
Centers for Disease Control and Prevention. 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/.
Mayo Clinic. 2010. Secondhand smoke: Avoid dangers in the air. http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/secondhand-smoke/art-20043914.
American Academy of Pediatrics. Hand Hygiene In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 148-149, 154, 164
American Academy of Pediatrics. Enterovirus D68 In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 331-334, 658, 692
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.26.
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 5th ed. Itasca, IL: American Academy of Pediatrics; 2020.20.

NOTES

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

COVID-19 modification as of August 10, 2022.

Standard 3.2.2.2: Handwashing Procedure

Frequently Asked Questions/CFOC Clarifications

Reference: 3.2.2.2

Date: 10/13/2011

Topic & Location:
Chapter 3
Health Promotion
Standard 3.2.2.2: Handwashing Procedure

Question:
This standard recommends that children and staff members rub their hands with a soapy lather for at least 20 seconds. Why was this changed from 10 seconds?

Answer:
This recommendation follows the recommendation of the Centers for Disease Control (CDC). This reference can be found at: http://www.cdc.gov/handwashing/.

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

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

Check to be sure a clean, disposable paper (or single-use cloth) towel is available.
Turn on clean, running water to a comfortable temperature.¹
Moisten hands with water and apply liquid or powder soap to hands.

Antibacterial soap should not be used.
Bar soaps should not be used.

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

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

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

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

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

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

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

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

RATIONALE

Running clean water over the hands removes visible soil. Wetting the hands before applying soap helps to create a lather that can loosen soil. The soap lather loosens soil and brings it into solution on the surface of the skin. Rinsing the lather off into a sink removes the soil from the hands that the soap brought into solution.

Alcohol-based hand sanitizers do not kill norovirus and spore-forming organisms, which are common causes of diarrhea in child care settings.⁴ This is enough reason to limit or even avoid the use of hand sanitizers with infants and toddlers (children younger than 2 years) because they are the age group at greatest risk of spreading diarrheal disease due to frequent diaper changing. Handwashing is the preferred method. However, while hand sanitizers are not recommended for children younger than 2 years, they are not prohibited.

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

COMMENTS

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Ogunsola FT, Adesiji YO. Comparison of four methods of hand washing in situations of inadequate water supply. West Afr J Med. 2008;27(1):24–28
Centers for Disease Control and Prevention. CDC features. Wash your hands. https://www.cdc.gov/features/handwashing/index.html. Updated December 6, 2018. Accessed January 28, 2019
Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—how to wash your hands. https://www.cdc.gov/handwashing/show-me-the-science-handwashing.html. Reviewed October 2, 2018. Accessed January 28, 2019
American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017
Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002;51(RR-16):1–45
American Academy of Pediatrics. Isolation precautions. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018–2021 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:148–157
Centers for Disease Control and Prevention. Handwashing: clean hands save lives. http://www.cdc.gov/handwashing. Reviewed October 9, 2018. Accessed January 28, 2019
Centers for Disease Control and Prevention. Handwashing: clean hands save lives. Show me the science—situations where hand sanitizer can be effective & how to use it in community settings. http://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Reviewed October 15, 2018. Accessed January 28, 2019
Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers—United States, 2011–2014. MMWR Morb Mortal Wkly Rep. 2017;66(8):223–226

NOTES

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

Standard 3.2.2.3: Assisting Children with Hand Hygiene

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

RATIONALE

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

For examples of handwashing posters, see:

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 3.2.3.4: Prevention of Exposure to Blood and Body Fluids

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

In child care settings:

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

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

Procedures for Standard Precautions should include:

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

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

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

RATIONALE

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

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

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

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

COMMENTS

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

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
7.6.1.3 Staff Education on Prevention of Bloodborne Diseases
Appendix D: Gloving
Appendix L: Cleaning Up Body Fluids

REFERENCES

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

Standard 3.3.0.1: Routine Cleaning, Sanitizing, and Disinfecting

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

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

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

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

ADDITIONAL RESOURCES

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

POSTERS

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.1.4 Diaper Changing Procedure
3.2.3.4 Prevention of Exposure to Blood and Body Fluids
3.3.0.2 Cleaning and Sanitizing Toys
3.3.0.3 Cleaning and Sanitizing Objects Intended for the Mouth
3.3.0.4 Cleaning Individual Bedding
3.3.0.5 Cleaning Crib and Other Sleep Surfaces
4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding
4.9.0.9 Cleaning Food Areas and Equipment
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.7.5 Labeling, Cleaning, and Disposal of Waste and Diaper Containers
5.4.1.8 Cleaning and Disinfecting Toileting Equipment
9.2.3.10 Sanitation Policies and Procedures
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting
Appendix L: Cleaning Up Body Fluids
Appendix W: Sample Food Service Cleaning Schedule

REFERENCES

Bright KR, Boone SA, Gerba CP. Occurrence of bacteria and viruses on elementary classroom surfaces and the potential role of classroom hygiene in the spread of infectious diseases. J Sch Nurs. 2010 Feb;26(1):3341. doi: 10.1177/1059840509354383. Epub 2009 Nov 10. PMID: 19903773.
Martínez-Bastidas T, Castro-del Campo N, Mena KD, Castro-del Campo N, León-Félix J, Gerba CP, Chaidez C. Detection of pathogenic micro-organisms on children’s hands and toys during play. J Appl Microbiol. 2014 Jun;116(6):16681675. doi: 10.1111/jam.12473. Epub 2014 Mar 20. PMID: 24524673.
Ibfelt T, Engelund EH, Permin A, Madsen JS, Schultz AC, Andersen LP. Presence of pathogenic bacteria and viruses in the daycare environment. J Environ Health. 2015 Oct;78(3):2429. PMID: 26591334.

NOTES

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

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

Frequently Asked Questions/CFOC Clarifications

Reference: 3.4.1.1

Date: 11/07/2012

Topic & Location:
Chapter 3
Health Promotion
Standard 3.4.1.1: Use of Tobacco, Alcohol, and Illegal Drugs

Question:
Should child care providers and other adults who have contact with children be allowed to smoke electronic cigarettes in the presence of children?

Answer:

Electronic cigarettes, also known as e-cigarettes, are a fairly new alternative to traditional smoking cigarettes. E-cigarettes are battery-operated products designed to deliver nicotine, flavor and other chemicals. They turn nicotine, which is highly addictive, and other chemicals into a vapor that is inhaled by the user (U.S. FDA, 2012).

Currently, the research on the safety of this product is limited. However, the use of e-cigarettes would fall into the same category tobacco, alcohol, and illegal drugs products that are prohibited from being used on the premises of the program (both indoor and outdoor environments) and in any vehicles used by the program at all times. Additionally, children model adult behavior. Cigarette smoking in any form is not a healthy behavior.

U.S. FDA, 2013 article

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

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

RATIONALE

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

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

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

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.9.1 Use and Storage of Toxic Substances
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances

REFERENCES

ADDITIONAL REFERENCES:

Centers for Disease Control and Prevention. 2009. Facts: Preventing residential fire injuries. http://www.cdc.gov/injury/pdfs/Fires2009CDCFactSheet-FINAL-a.pdf.

American Lung Association. E-cigarettes and Lung Health. 2016. http://www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health.html?referrer=https://www.google.com/.

Children’s Hospital Colorado. 2016. Acute marijuana intoxication. https://www.childrenscolorado.org/conditions-and-advice/conditions-and-symptoms/conditions/acute-marijuana-intoxication/.
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
Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, M. F. Hovell, R. C. McMillen. 2009. Beliefs about the health effects of “thirdhand” smoke and home smoking bans. Pediatrics 123: e74-e79.
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf.
U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke-consumer.pdf.
Schwartz, J., K. L. Timonen, J. Pekkanen. 2000. Respiratory effects of environmental tobacco smoke in a panel study of asthmatic and symptomatic children. Am J Resp Crit Care Med 161:802-6.
U.S. Department of Health and Human Services. 2007. Children and secondhand smoke exposure. Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
American Academy of Pediatrics. Healthychildren.org. 2015. The dangers of secondhand smoke. https://www.healthychildren.org/English/health-issues/conditions/tobacco/Pages/Dangers-of-Secondhand-Smoke.aspx.
Centers for Disease Control and Prevention. 2016. Health effects of secondhand smoke. http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommenations for a safe infant sleeping environment. Pediatrics. 2016;138(6):e20162938.
http://pediatrics.aappublications.org/content/early/2016/10/20/peds.2016-2938.

NOTES

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

Standard 3.4.3.1: Medical Emergency Procedures

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

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

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

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

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

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

RATIONALE

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

COMMENTS

Additional Resources

First aid training is available from:

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.1.1 Pre-service Training
1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.4.3.2 Topics Covered in Pediatric First Aid Training
3.5.0.1 Care Plan for Children with Special Health Care Needs
3.6.2.9 Information Required for Children Who Are Ill
5.1.4.1 Alternate Exits and Emergency Shelter
5.1.4.2 Evacuation of Children with Special Health Care Needs and Children with Disabilities
9.2.4.3 Disaster Planning, Training, and Communication
9.2.4.5 Emergency and Evacuation Drills Policy
9.4.1.16 Evacuation and Shelter-In-Place Drill Record
5.2.9.2 Use of a Poison Center

REFERENCES

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

NOTES

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

Standard 3.4.3.3: Response to Fire and Burns

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

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

Fire Emergency Action Plan

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

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

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

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

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

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

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

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

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

Cool the burned area with water.
Call for help.

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

RATIONALE

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.3.2 Use of Fire Extinguishers
5.1.1.3 Compliance with Fire Prevention Code
5.2.5.2 Portable Fire Extinguishers
9.2.4.3 Disaster Planning, Training, and Communication

REFERENCES

National Center on Early Childhood Health and Wellness, US Department of Health and Human Services Administration for Children and Families Office of Head Start. Emergency Preparedness Manual for Early Childhood Programs. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/emergency-preparedness-manual-early-childhood-programs.pdf. Accessed December 20, 2018
National Emergency Number Association. 9-1-1 tips & guidelines. https://www.nena.org/page/911tipsguidelines. Accessed August 21, 2019
Sheridan RL. Fire-related inhalation injury. N Engl J Med. 2016;375(19):1905
National Fire Protection Association. Fire extinguishers one element of fire response plan for students on college campuses. https://community.nfpa.org/community/safety-source/blog/2014/10/29/fire-extinguishers-one-element-of-fire-response-plan-for-students-on-college-campuses. Updated April 21, 2016. Accessed August 21, 2019
American Academy of Pediatrics. Fire safety. HealthyChildren.org website. https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Fire-Safety.aspx. Updated February 29, 2012. Accessed August 21, 2019

NOTES

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

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

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

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

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

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

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

RATIONALE

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

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

COMMENTS

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

1.6.0.1 Child Care Health Consultants
1.7.0.5 Stress Management for Staff
3.4.4.2 Immunity for Reporters of Child Abuse and Neglect
3.4.4.3 Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma
3.4.4.4 Care for Children Who Have Experienced Abuse/Neglect
9.4.1.9 Records of Injury
Appendix M: Recognizing Child Abuse and Neglect
Appendix N: Protective Factors Regarding Child Abuse and Neglect

REFERENCES

Rheingold AA, Zajac K, Chapman JE, et al. Child sexual abuse prevention training for childcare professionals: an independent multi-site randomized controlled trial of Stewards of Children. Prev Sci. 2015;16(3):374–385
Smith M, Robinson L, Segal J. Child abuse and neglect: how to spot the signs and make a difference. Helpguide.org Web site. https://www.helpguide.org/articles/abuse/child-abuse-and-neglect.htm. Updated October 2017. Accessed January 11, 2018
Darkness to Light. Reporting child sexual abuse. https://www.d2l.org/get-help/reporting. Accessed January 11, 2018
Child Welfare Information Gateway. What Is Child Abuse and Neglect? Recognizing the Signs and Symptoms. Washington, DC: Child Welfare Information Gateway; 2013. https://www.childwelfare.gov/pubpdfs/whatiscan.pdf. Accessed January 11, 2018

NOTES

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

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

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

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

RATIONALE

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

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

COMMENTS

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

Irritability
Trouble staying awake
Trouble breathing
Vomiting
Unable to be woken up

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: characteristic features, diagnosis, and management. Neurol Med Chir (Tokyo). 2017;57(2):82–93
Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical-Package.pdf. Accessed January 11, 2018
Child Care Aware. Health and safety training. http://childcareaware.org/providers/training-essentials/health-and-safety-training. Accessed January 11, 2018
American Academy of Pediatrics. Abusive head trauma: how to protect your baby. HeathyChildren.org Web site. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Abusive-Head-Trauma-Shaken-Baby-Syndrome.aspx. Updated November 21, 2015. Accessed January 11, 2018

NOTES

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

Standard 3.4.5.1: Sun Safety Including Sunscreen

Frequently Asked Questions/CFOC Clarifications

Reference: 3.4.5.1

Date: 02/17/2012

Topic & Location:
Chapter 3
Health Promotion
3.4.5.1: Sun Safety Including Sunscreen

Question:
Why does this standard state that sunscreen should be applied thirty minutes before going outdoors, but the AAP reference listed on page 127 states that sunscreen should be applied 15-30 minutes before going outside?

Answer:
The recommendation of how many minutes prior to going outside sunscreen should be applied was revised from 30 minutes to 15-30 minutes on January 30, 2012, which was after the publication of CFOC, 3rd Edition.

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

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

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

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

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

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

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

RATIONALE

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

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

COMMENTS

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.3.1 Medication Administration
6.1.0.7 Shading of Play Area

REFERENCES

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

NOTES

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

Standard 3.4.6.1: Strangulation Hazards

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

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

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

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

RATIONALE

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

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.3.1.1 Indoor and Outdoor Equipment, Materials, and Furnishing

REFERENCES

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

Standard 3.5.0.1: Care Plan for Children with Special Health Care Needs

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

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

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

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

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

RATIONALE

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

COMMENTS

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

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

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

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

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

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.6.3.1 Medication Administration
4.2.0.10 Care for Children with Food Allergies
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

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

Standard 3.5.0.2: Caring for Children Who Require Medical Procedures

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

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

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

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

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

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

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

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

RATIONALE

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.3.1 First Aid and Cardiopulmonary Resuscitation Training for Staff
1.6.0.1 Child Care Health Consultants
3.5.0.1 Care Plan for Children with Special Health Care Needs
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

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

NOTES

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

Standard 3.6.1.1: Inclusion/Exclusion/Dismissal of Ill Children

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

COVID-19 modification as of March 20, 2023.

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

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

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

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

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

Programs should prepare to manage illnesses by:¹

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

When children are ill, staff should:

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

If the child is a possible health risk to others
Or if the program needs more information about special care the child needs

Conditions That Do Not Require Exclusion^1–2
Conditions	Notes
Common cold, runny nose, and cough	No exclusion regardless of color or consistency of nasal discharge. For allergies that have similar symptoms to a common cold (e.g., runny nose, sneezing, cough), programs can encourage parents or guardians to get documentation from a healthcare provider to avoid unnecessary exclusions. During outbreaks such as COVID-19, follow recommendations from the Centers for Disease Control and Prevention (CDC) or the local health department.
Cytomegalovirus infection (CMV)	No exclusion required.
Diarrhea	No exclusion if stool is contained in the diaper, there are no toileting accidents, and there are no more than 2 stools per day above the normal for that child.
Eye drainage	No exclusion unless the child has watery discharge that is yellow or white; without fever, eye pain, or eyelid redness.
Fever	Temperature above 100.4° F (38° C) (axillary, temporal, or oral) is a fever. Children over 4 months old without signs of illness do not need to be excluded. Only take a child’s temperature if the child seems ill. (During outbreaks such as COVID-19, follow CDC or local health department recommendations.)
Fifth’s Disease (Parvovirus B19 or slapped cheek disease)	No exclusion for children who have normal immune systems and who don’t have an underlying blood disorder like sickle cell disease.
Hand, foot, and mouth (Coxsackie virus)	No exclusion unless the child has a fever with symptoms, mouth sores, and constant drooling, or if recommended by public health authorities to control an outbreak.³
Hepatitis B virus, chronic	No exclusion required.
HIV infection	No exclusion required.
Impetigo	Cover skin lesions until the end of the day if there is no fever or changes in behavior. If medical treatment starts before returning the next day, no exclusion is needed.
Lice or nits	Treatment may start at the end of the day. If treatment starts before returning the next day, no exclusion needed. “No-nit” policies are not effective in controlling spread of lice and are not recommended.²
Methicillin-resistant (MRSA) and methicillin-sensitive (MSSA) colonization	Colonization is the presence of bacteria on the body without illness. Active lesions or illness may require exclusion.
Molluscum contagiosum	No exclusion or covering of lesions is needed.
Pinkeye	No exclusion needed if pink or red on the white of the eye with or without drainage, without fever or behavioral change.²
Rash without fever or behavior changes	No exclusion necessary. Exception: Call EMS (911) for children who have a new rash with rapidly spreading bruising or small blood spots under the skin.
Ringworm	Cover skin lesions until the end of the day. If medical treatment starts before returning the next day, no exclusion is needed.
Roseola	No exclusion needed unless there is a fever and behavior changes.
Scabies	Treatment may be delayed until the end of the day. As long as treatment starts before returning the next day, no exclusion is needed.
Thrush	No exclusion needed. (The signs of thrush are white spots or patches in the mouth, cheeks, or gums.)

Conditions That Require Temporary Exclusion

Key Guidelines for Exclusion of Children Who Are Ill²
When a child becomes ill but does not need immediate medical help, programs should decide if the child should be sent home (temporarily excluded from the program). Most illnesses do not need exclusion. Three main reasons to keep children at home: The child does not feel well enough to comfortably take part in usual activities (i.e., overtired, fussy, will not stop crying). A child needs more care than teachers and staff can give while still caring for the other children. The illness has a risk of spreading harmful disease to others as noted in Specific Conditions Needing Temporary Exclusion, below.

Key Guidelines for Exclusion of Children Who Are Ill²

When a child becomes ill but does not need immediate medical help, programs should decide if the child should be sent home (temporarily excluded from the program). Most illnesses do not need exclusion.
Three main reasons to keep children at home:

The child does not feel well enough to comfortably take part in usual activities (i.e., overtired, fussy, will not stop crying).
A child needs more care than teachers and staff can give while still caring for the other children.
The illness has a risk of spreading harmful disease to others as noted in Specific Conditions Needing Temporary Exclusion, below.

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

When children need temporary exclusion, staff should¹:

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

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

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

Reportable/Notifiable Conditions¹

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

Staff should contact the local health department:

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

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

COVID-19 modification as of March 20, 2023:

Children who are experiencing any of the symptoms listed below should not enter the program and get tested:

COVID-19 symptoms most likely seen in children:

Congestion, runny nose or other allergy like symptoms
Sore throat
Headache
Vomiting
Diarrhea
Fever (100.4^oF/38^oC or higher)

Children who have been exposed and are waiting on the results of a COVID-19 test should:

Stay home while waiting for the results if they have symptoms
Children over two years of age should wear a well fitted mask for 10 days while attending the program if they do not have symptoms.

If a child shows symptoms or becomes sick during the day, program staff should have the child wear a well fitted mask while in the building, send the child home, and encourage the child and any symptomatic parents/caregivers/family members to get tested.

If a child in care is confirmed to have COVID-19:

Follow the Cleaning and Disinfecting Your Facility
Ensure families understand their child cannot return to in-person care until they have met CDC’s guidance,
Maintain the sick child’s confidentiality, as required by the Americans with Disabilities Act (ADA), Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA).

Additional Resources:

Centers for Disease Control and Prevention
Operational Guidance for K-12 Schools and Early Care and Education Programs to Support Safe In-Person Learning
Masks

RATIONALE

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

COMMENTS

ADDITIONAL RESOURCES

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

American Academy of Pediatrics. Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide. Aronson SS, Shope TR, eds. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2022
American Academy of Pediatrics, Section 2 recommendation for care of children in special circumstances; children in group childcare and schools. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2021:116-126
Centers for Disease Control and Prevention. Hand, foot, and mouth disease (HFMD) Causes & Transmission. CDC.gov Web site. Last reviewed February 2, 2021. Accessed August 8, 2022. https://www.cdc.gov/hand-foot-mouth/about/transmission.html

NOTES

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

COVID-19 modification as of March 20, 2023.

Standard 3.6.1.2: Staff Exclusion for Illness

Content in the STANDARD was modified on 4/5/2017.
COVID-19 modification as of March 20, 2023.

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

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

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

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

Caregivers/teachers who have herpes cold sores should not be excluded from the child care facility, but should:

1. Cover and not touch their lesions;
2. Carefully observe hand hygiene policies; and

3. Not kiss any children.

COVID-19 modification as of March 20, 2023:

In response to the Centers for Disease Control and Prevention’s Guidance for Operating Child Care Programs during COVID-19, it is recommended that early childhood programs implement daily screening procedures for staff, or other support services, to self-screen with temperature checks at home or when they arrive to the program. Refer to COVID-19 modifications of CFOC Standard 1.7.0.2: Daily Staff Health Check.

Staff who are experiencing any of the symptoms listed below should not enter the program and get tested:

COVID-19 symptoms

Fever (100.4^oF/38^oC or higher); feeling feverish (chills, sweating)
New cough
Fatigue
New loss of taste or smell
Sore throat
Headache
Runny or stuffy nose
Muscle pain or body aches
Nausea, vomiting or diarrhea

Staff who have been exposed and are waiting on the results of a COVID-19 test should:

Stay home while waiting for the results if they have symptoms
Should wear a well fitted mask for 10 days while working if they do not have symptoms

If staff develop symptoms upon arrival or become sick during the day, they should be asked to wear a well fitted mask while in the building, sent home, and encouraged to get tested.

If the staff member is confirmed to have COVID-19:

Sick staff members should not return to work until they have met the CDC’s criteria to discontinue isolation. For more information, refer to Isolation and Precautions for People with COVID-19.
Staff should report positive COVID-19 test to their program.
Follow the Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes | CDC

Facilities are encouraged to develop policies that encourage sick employees to stay home without fear of negative consequences.

ADDITIONAL RESOURCES

Centers for Disease Control and Prevention

American Academy of Pediatrics

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

3.2.2.1 Situations that Require Hand Hygiene
3.2.2.2 Handwashing Procedure
3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.2.3.2 Cough and Sneeze Etiquette
3.6.1.4 Infectious Disease Outbreak Control

REFERENCES

Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4^th Edition. Elk Grove Village, IL: American Academy of Pediatrics.
American Academy of Pediatrics. School Health In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st Edition. Itasca, IL: American Academy of Pediatrics; 2018: 138-146

NOTES

Content in the STANDARD was modified on 4/5/2017.
COVID-19 modification as of March 20, 2023.

Standard 3.6.1.4: Infectious Disease Outbreak Control

During the course of an identified outbreak of any reportable illness at the facility, a child or staff member should be excluded if the health department official or primary care provider suspects that the child or staff member is contributing to transmission of the illness at the facility, is not adequately immunized when there is an outbreak of a vaccine preventable disease, or the circulating pathogen poses an increased risk to the individual. The child or staff member should be readmitted when the health department official or primary care provider who made the initial determination decides that the risk of transmission is no longer present.

RATIONALE

Secondary spread of infectious disease has been proven to occur in child care. Control of outbreaks of infectious diseases in child care may include age-appropriate immunization, antibiotic prophylaxis, observing well children for signs and symptoms of disease and for decreasing opportunities for transmission of that may sustain an outbreak. Removal of children known or suspected of contributing to an outbreak may help to limit transmission of the disease by preventing the development of new cases of the disease (1).

TYPE OF FACILITY

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

RELATED STANDARDS

3.6.1.1 Inclusion/Exclusion/Dismissal of Ill Children
3.6.1.2 Staff Exclusion for Illness
3.6.4.1 Procedure for Parent/Guardian Notification About Exposure of Children to Infectious Disease
3.6.4.2 Infectious Diseases That Require Parent/Guardian Notification
9.2.4.4 Written Plan for Seasonal and Pandemic Influenza

REFERENCES

Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection Control Practices Advisory Committee. 2007. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf.

Standard 3.6.3.1: Medication Administration

The administration of medicines at the facility should be limited to:

Prescription or non-prescription medication (over-the-counter [OTC]) ordered by the prescribing health professional for a specific child with written permission of the parent/guardian. Written orders from the prescribing health professional should specify medical need, medication, dosage, and length of time to give medication;
Labeled medications brought to the child care facility by the parent/guardian in the original container (with a label that includes the child’s name, date filled, prescribing clinician’s name, pharmacy name and phone number, dosage/instructions, and relevant warnings).

Facilities should not administer folk or homemade remedy medications or treatment. Facilities should not administer a medication that is prescribed for one child in the family to another child in the family.

No prescription or non-prescription medication (OTC) should be given to any child without written orders from a prescribing health professional and written permission from a parent/guardian. Exception: Non-prescription sunscreen and insect repellent always require parental consent but do not require instructions from each child’s prescribing health professional.

Documentation that the medicine/agent is administered to the child as prescribed is required.

“Standing orders” guidance should include directions for facilities to be equipped, staffed, and monitored by the primary care provider capable of having the special health care plan modified as needed. Standing orders for medication should only be allowed for individual children with a documented medical need if a special care plan is provided by the child’s primary care provider in conjunction with the standing order or for OTC medications for which a primary care provider has provided specific instructions that define the children, conditions and methods for administration of the medication. Signatures from the primary care provider and one of the child’s parents/guardians must be obtained on the special care plan. Care plans should be updated as needed, but at least yearly.

RATIONALE

Medicines can be crucial to the health and wellness of children. They can also be very dangerous if the wrong type or wrong amount is given to the wrong person or at the wrong time. Prevention is the key to prevent poisonings by making sure medications are inaccessible to children.

All medicines require clear, accurate instruction and medical confirmation of the need for the medication to be given while the child is in the facility. Prescription medications can often be timed to be given at home and this should be encouraged. Because of the potential for errors in medication administration in child care facilities, it may be safer for a parent/guardian to administer their child’s medicine at home.

Over the counter medications, such as acetaminophen and ibuprofen, can be just as dangerous as prescription medications and can result in illness or even death when these products are misused or unintentional poisoning occurs. Many children’s over the counter medications contain a combination of ingredients. It is important to make sure the child isn’t receiving the same medications in two different products which may result in an overdose. Facilities should not stock OTC medications (1).

Cough and cold medications are widely used for children to treat upper respiratory infections and allergy symptoms. Recently, concern has been raised that there is no proven benefit and some of these products may be dangerous (2,3,5). Leading organizations such as the Consumer Healthcare Products Association (CHPA) and the American Academy of Pediatrics (AAP) have recommended restrictions on these products for children under age six (4-7).

If a medication mistake or unintentional poisoning does occur, call your local poison center immediately at 1-800-222-1222.

Parents/guardians should always be notified in every instance when medication is used. Telephone instructions from a primary care provider are acceptable if the caregiver/teacher fully documents them and if the parent/guardian initiates the request for primary care provider or child care health consultant instruction. In the event medication for a child becomes necessary during the day or in the event of an emergency, administration instructions from a parent/ guardian and the child’s prescribing health professional are required before a caregiver/teacher may administer medication.

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.5.1 Sun Safety Including Sunscreen
3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases
3.6.2.9 Information Required for Children Who Are Ill
3.6.3.2 Labeling, Storage, and Disposal of Medications

REFERENCES

Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events from cough and cold medications in children. Pediatrics 121:783-87.
American Academy of Pediatrics, Committee on Drugs. 2009. Policy statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22.
Consumer Healthcare Products Association. Makers of OTC cough and cold medicines announce voluntary withdrawal of oral infant medicines. http://www.chpa-info.org/10_11_07_OralInfantMedicines.aspx.
Centers for Disease Control and Prevention. 2007. Infant deaths associated with cough and cold medications: Two states. MMWR 56:1-4.
American Academy of Pediatrics. 2008. AAP Urges caution in use of over-the-counter cough and cold medicines. http://www.generaterecords.net/PicGallery/AAP_CC.pdf
Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold medication use by U.S. children, 1999-2006: Results from the Slone Survey. Pediatrics 122: e323-29.
U.S. Department of Health and Human Services, Food and Drug Administration. 2008. Public Health advisory: FDA recomends that over-the-counter (OTC) cough and cold products not be used for infants and children under 2 years of age. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2008/ucm051137.htm

Standard 3.6.3.2: Labeling, Storage, and Disposal of Medications

Any prescription medication should be dated and kept in the original container. The container should be labeled by a pharmacist with:

The child’s first and last names;
The date the prescription was filled;
The name of the prescribing health professional who wrote the prescription, the medication’s expiration date;
The manufacturer’s instructions or prescription label with specific, legible instructions for administration, storage, and disposal;
The name and strength of the medication.

Over-the-counter medications should be kept in the original container as sold by the manufacturer, labeled by the parent/guardian, with the child’s name and specific instructions given by the child’s prescribing health professional for administration.

All medications, refrigerated or unrefrigerated, should:

Have child-resistant caps;
Be kept in an organized fashion;
Be stored away from food;
Be stored at the proper temperature;
Be completely inaccessible to children.

Medication should not be used beyond the date of expiration. Unused medications should be returned to the parent/guardian for disposal. In the event medication cannot be returned to the parent or guardian, it should be disposed of according to the recommendations of the US Food and Drug Administration (FDA) (1). Documentation should be kept with the child care facility of all disposed medications. The current guidelines are as follows:

If a medication lists any specific instructions on how to dispose of it, follow those directions.
If there are community drug take back programs, participate in those.
Remove medications from their original containers and put them in a sealable bag. Mix medications with an undesirable substance such as used coffee grounds or kitty litter. Throw the mixture into the regular trash. Make sure children do not have access to the trash (1).

RATIONALE

Child-resistant safety packaging has been shown to significantly decrease poison exposure incidents in young children (1).

Proper disposal of medications is important to help ensure a healthy environment for children in our communities. There is growing evidence that throwing out or flushing medications into our sewer systems may have harmful effects on the environment (1-3).

TYPE OF FACILITY

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

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.3 Training of Caregivers/Teachers to Administer Medication

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
U.S. Environmental Protection Agency. 2009. Pharmaceuticals and personal care products as pollutants (PPCPs). http://www.epa
.gov/ppcp/.
U.S. Food and Drug Administration. 2010. Disposal by flushing of certain unused medicines: What you should know. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/
EnsuringSafeUseofMedicine/SafeDisposalofMedicines/
ucm186187.htm.

Standard 3.6.3.3: Training of Caregivers/Teachers to Administer Medication

Any caregiver/teacher who administers medication should complete a standardized training course that includes skill and competency assessment in medication administration. The trainer in medication administration should be a licensed health professional. The course should be repeated according to state and/or local regulation. At a minimum, skill and competency should be monitored annually or whenever medication administration error occurs. In facilities with large numbers of children with special health care needs involving daily medication, best practice would indicate strong consideration to the hiring of a licensed health care professional. Lacking that, caregivers/teachers should be trained to:

Check that the name of the child on the medication and the child receiving the medication are the same;
Check that the name of the medication is the same as the name of the medication on the instructions to give the medication if the instructions are not on the medication container that is labeled with the child’s name;
Read and understand the label/prescription directions or the separate written instructions in relation to the measured dose, frequency, route of administration (ex. by mouth, ear canal, eye, etc.) and other special instructions relative to the medication;
Observe and report any side effects from medications;
Document the administration of each dose by the time and the amount given;
Document the person giving the administration and any side effects noted;
Handle and store all medications according to label instructions and regulations.

The trainer in medication administration should be a licensed health professional: Registered Nurse, Advanced Practice Registered Nurse (APRN), MD, Physician’s Assistant, or Pharmacist.

RATIONALE

Administration of medicines is unavoidable as increasing numbers of children entering child care take medications. National data indicate that at any one time, a significant portion of the pediatric population is taking medication, mostly vitamins, but between 16% and 40% are taking antipyretics/analgesics (5). Safe medication administration in child care is extremely important and training of caregivers/teachers is essential (1).

Caregivers/teachers need to know what medication the child is receiving, who prescribed the medicine and when, for what purpose the medicine has been prescribed and what the known reactions or side effects may be if a child has a negative reaction to the medicine (2,3). A child’s reaction to medication can be occasionally extreme enough to initiate the protocol developed for emergencies. The medication record is especially important if medications are frequently prescribed or if long-term medications are being used (4).

COMMENTS

Caregivers/teachers need to know the state laws and regulations on training requirements for the administration of medications in out-of-home child care settings. These laws may include requirements for delegation of medication administration from a primary care provider. Training on medication administration for caregivers/teachers is available in several states. Model Child Care Health Policies, 2nd Ed. from Healthy Child Care Pennsylvania is available at http://www.ecels-healthychildcarepa.org/publications/manuals-pamphlets-policies/item/248-model-child-care-health-policies and contains sample polices and forms related to medication administration.

TYPE OF FACILITY

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

RELATED STANDARDS

3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
9.2.3.9 Written Policy on Use of Medications
Appendix AA: Medication Administration Packet
Appendix O: Care Plan for Children with Special Health Care Needs

REFERENCES

Vernacchio, L., J. P. Kelly, D. W. Kaufman, A. A. Mitchell. 2009. Medication use among children <12 years of age in the United States: Results from the Slone Survey. Pediatrics 124:446-54.
Calder, J. 2004. Medication administration in child care programs. Health and Safety Notes. Berkeley, CA: California Childcare Health Program. http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/medadminEN102004_adr.pdf.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
Qualistar Early Learning. 2008. Colorado Medication Administration Curriculum. 5th ed. http://www.qualistar.org/medication-administration.html.
Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding nursing delegation and administration in child care settings: A case study. Policy, Politics, and Nursing Practice 6:86-98.

Chapter 4 - Nutrition and Food Service

Standard 4.2.0.3: Use of US Department of Agriculture Child and Adult Care Food Program Guidelines

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

All meals and snacks and their preparation, service, and storage should meet the requirements for meals (7 CFR §226.20) of the child care component of the US Department of Agriculture Child and Adult Care Food Program (CACFP) (1-3).

RATIONALE

The CACFP regulations, policies, and guidance materials on meal requirements provide basic guidelines for sound nutrition and sanitation practices. The CACFP guidance for meals and snack patterns ensures that the nutritional needs of infants and children, including school-aged children through 12 years, are met based on the Dietary Guidelines for Americans (4,5) as well as other evidence-based recommendations (6,7). Programs not eligible for reimbursement under the regulations of CACFP should still use the CACFP food guidance.

COMMENTS

Staff should use information about the child’s growth and CACFP meal patterns to develop individual feeding plans (6).

ADDITIONAL RESOURCE

US Department of Agriculture. Child and Adult Care Food Program: best practices. US Department of Agriculture, Food and Nutrition Service Web site. https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf. Accessed September 7, 2017

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.2.1 Routine Health Supervision and Growth Monitoring
4.2.0.4 Categories of Foods
4.2.0.5 Meal and Snack Patterns
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.3.2.1 Meal and Snack Patterns for Toddlers and Preschoolers
4.3.3.1 Meal and Snack Patterns for School-Age Children

REFERENCES

US Department of Agriculture, Food and Nutrition Service. Independent Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod.azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20Centers%20Handbook.pdf. Accessed September 7, 2017
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 7, 2017
US Department of Agriculture, Food and Nutrition Service. Child and Adult Food Program (CACFP). Nutrition standards for CACFP meals and snacks. https://www.fns.usda.gov/cacfp/meals-and-snacks. Updated March 27, 2017. Accessed September 7, 2017
US Department of Agriculture, Healthy Meals Resource System, Team Nutrition. CACFP wellness resources for child care providers. https://healthymeals.fns.usda.gov/cacfp-wellness-resources-child-care-providers. Accessed September 7, 2017
US Department of Agriculture, Food and Nutrition Service. Requirements for meals. US Government Publishing Office Web site. https://www.ecfr.gov/cgi-bin/text-idx?SID=9c3a6681dbf6aada3632967c4bfeb030&mc=true&node=pt7.4.226&rgn=div5#se7.4.226_120. Accessed September 7, 2017
US Department of Agriculture, Food and Nutrition Service. Child and Adult Care Food Program (CACFP). Regulations. https://www.fns.usda.gov/cacfp/regulations. Updated September 7, 2017. Accessed September 7, 2017
Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. 2nd ed. Arlington, VA: Zero to Three; 2008

NOTES

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

Standard 4.2.0.6: Availability of Drinking Water

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

Clean, sanitary drinking water should be readily available and offered throughout the day in indoor and outdoor areas.^1,2Water 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

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
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
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
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
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
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
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 4.2.0.8: Feeding Plans and Dietary Modifications

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

Before a child enters an early care and education facility, the facility should obtain a written history that contains any special nutrition or feeding needs for the child, including use of human milk or any special feeding utensils. The staff should review this history with the child’s parents/guardians, clarifying and discussing how the parents’/guardians’ home feeding routines may differ from the facility’s planned routine. The child’s primary health care provider should provide written information to the parent/guardian about any dietary modifications or special feeding techniques that are required at the early care and education program so they can be shared with and implemented by the program.

If dietary modifications are indicated, based on a child’s medical or special dietary needs, caregivers/teachers should modify or supplement the child’s diet to meet the individual child’s specific needs. Dietary modifications should be made in consultation with the parents/guardians and the child’s primary health care provider. Caregivers/teachers can consult with a nutritionist/registered dietitian.

A child’s diet may be modified because of food sensitivity, a food allergy, or many other reasons. Food sensitivity includes a range of conditions in which a child exhibits an adverse reaction to a food that, in some instances, can be life-threatening. Modification of a child’s diet may also be related to a food allergy, an inability to digest or to tolerate certain foods, a need for extra calories, a need for special positioning while eating, diabetes and the need to match food with insulin, food idiosyncrasies, and other identified feeding issues, including celiac disease, phenylketonuria, diabetes, and severe food allergy (anaphylaxis). In some cases, a child may become ill if he/she is unable to eat, so missing a meal could have a negative consequence, especially for children with diabetes.

For a child with special health care needs who requires dietary modifications or special feeding techniques, written instructions from the child’s parent/guardian and the child’s primary health care provider should be provided in the child’s record and carried out accordingly. Dietary modifications should be recorded. These written instructions must identify

a. The child’s full name and date of instructions
b. The child’s special health care needs
c. Any dietary restrictions based on those special needs
d. Any special feeding or eating utensils
e. Any foods to be omitted from the diet and any foods to be substituted
f. Any other pertinent information about the child’s special health care needs
g. What, if anything, needs to be done if the child is exposed to restricted foods

The written history of special nutrition or feeding needs should be used to develop individual feeding plans and, collectively, to develop facility menus. Health care providers with experience in disciplines related to special nutrition needs, including nutrition, nursing, speech therapy, occupational therapy, and physical therapy, should participate when needed and/or when they are available to the facility. If available, the nutritionist/registered dietitian should approve menus that accommodate needed dietary modifications.

The feeding plan should include steps to take when a situation arises that requires rapid response by the staff, such as a child choking during mealtime or a child with a known history of food allergies demonstrating signs and symptoms of anaphylaxis (severe allergic reaction), such as difficulty breathing and severe redness and swelling of the face or mouth. The completed plan should be on file and accessible to staff and available to parents/guardians on request.

RATIONALE

Children with special health care needs may have individual requirements related to diet and swallowing, involving special feeding utensils and feeding needs that will necessitate the development of an individual plan prior to their entry into the facility (1). Many children with special health care needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent feeding skills. Food, eating style, food utensils, and equipment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (2,3,).

Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. Others, such as those with diabetes, may need to have their diet matched to their medication (e.g., insulin, if they are on a fixed dose of insulin). Some children are unable to tolerate certain foods because of their allergy to the food or their inability to digest it. The 8 most common foods to cause anaphylaxis in children are cow’s milk, eggs, soy, wheat, fish, shellfish, peanuts, and tree nuts (3). Staff members must know ahead of time what procedures to follow, as well as their designated roles, during an emergency.

As a safety and health precaution, staff should know in advance whether a child has food allergies, inborn errors of metabolism, diabetes, celiac disease, tongue thrust, or special health care needs related to feeding, such as requiring special feeding utensils or equipment, nasogastric or gastric tube feedings, or special positioning. These situations require individual planning prior to the child’s entry into an early care and education program and on an ongoing basis (2).

In some cases, dietary modifications are based on religious or cultural beliefs. Detailed information on each child’s special needs, whether stemming from dietary, feeding equipment, or cultural needs, is invaluable to the facility staff in meeting the nutritional needs of all the children in their care.

COMMENTS

Close collaboration between families and the facility is necessary for children on special diets. Parents/guardians may have to provide food on a temporary, or even permanent, basis, if the facility, after exploring all community resources, is unable to provide the special diet.

Programs may consider using the American Academy of Pediatrics (AAP) Allergy and Anaphylaxis Emergency Plan, which is included in the AAP clinical report, Guidance on Completing a Written Allergy and Anaphylaxis Emergency Plan (4).

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
4.2.0.1 Written Nutrition Plan
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
4.2.0.12 Vegetarian/Vegan Diets
4.3.1.2 Responsive Feeding of Infants by a Consistent Caregiver/Teacher
4.5.0.10 Foods that Are Choking Hazards

REFERENCES

Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014
Kaczkowski CH, Caffrey C. Pediatric nutrition. In: Blanchfield DS, ed. The Gale Encyclopedia of Children's Health: Infancy Through Adolescence. Vol 3. 3rd ed. Farmington Hills, MI: Gale; 2016:2063–2066
Samour PQ, King K. Pediatric Nutrition. 4th ed. Sunbury, MA: Jones and Bartlett Learning; 2010

NOTES

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

Standard 4.2.0.10: Care for Children with Food Allergies

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

When children with food allergies attend an early care and education facility, here is what should occur.
a. Each child with a food allergy should have a care plan prepared for the facility by the child’s primary health care provider, to include
1. A written list of the food(s) to which the child is allergic and instructions for steps that need to be taken to avoid that food.
2. A detailed treatment plan to be implemented in the event of an allergic reaction, including the names, doses, and methods of administration of any medications that the child should receive in the event of a reaction. The plan should include specific symptoms that would indicate the need to administer one or more medications.

b. Based on the child’s care plan, the child’s caregivers/teachers should receive training, demonstrate competence in, and implement measures for
1. Preventing exposure to the specific food(s) to which the child is allergic
2. Recognizing the symptoms of an allergic reaction
3. Treating allergic reactions

c.   Parents/guardians and staff should arrange for the facility to have the necessary medications, proper storage of such medications, and the equipment and training to manage the child’s food allergy while the child is at the early care and education facility.

d. Caregivers/teachers should promptly and properly administer prescribed medications in the event of an allergic reaction according to the instructions in the care plan.

e. The facility should notify parents/guardians immediately of any suspected allergic reactions, the ingestion of the problem food, or contact with the problem food, even if a reaction did not occur.

f.    The facility should recommend to the family that the child’s primary health care provider be notified if the child has required treatment by the facility for a food allergic reaction.

g. The facility should contact the emergency medical services (EMS) system immediately if the child has any serious allergic reaction and/or whenever epinephrine (eg, EpiPen, EpiPen Jr) has been administered, even if the child appears to have recovered from the allergic reaction.

h. Parents/guardians of all children in the child’s class should be advised to avoid any known allergens in class treats or special foods brought into the early care and education setting.

i.    Individual child’s food allergies should be posted prominently in the classroom where staff can view them and/or wherever food is served.

j.    The written child care plan, a mobile phone, and a list of the proper medications for appropriate treatment if the child develops an acute allergic reaction should be routinely carried on field trips or transport out of the early care and education setting.

For all children with a history of anaphylaxis (severe allergic reaction), or for those with peanut and/or tree nut allergy (whether or not they have had anaphylaxis), epinephrine should be readily available. This will usually be provided as a premeasured dose in an auto-injector, such as EpiPen or EpiPen Jr. Specific indications for administration of epinephrine should be provided in the detailed care plan. Within the context of state laws, appropriate personnel should be prepared to administer epinephrine when needed.

Food sharing between children must be prevented by careful supervision and repeated instruction to children about this issue. Exposure may also occur through contact between children or by contact with contaminated surfaces, such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just from being in proximity to the offending food, without actually ingesting it. Such contact should be minimized by washing children’s hands and faces and all surfaces that were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such as the use of peanut butter to make a bird feeder or wheat to make modeling compound.

RATIONALE

Food allergy is common, occurring in between 2% and 8% of infants and children (1). Allergic reactions to food can range from mild skin or gastrointestinal symptoms to severe, life-threatening reactions with respiratory and/or cardiovascular compromise. Hospitalizations from food allergy are being reported in increasing numbers, especially among children with asthma who have one or more food sensitivities (2). A major factor in death from anaphylaxis has been a delay in the administration of lifesaving emergency medication, particularly epinephrine (3). Intensive efforts to avoid exposure to the offending food(s) are, therefore, warranted. The maintenance of detailed care plans and the ability to implement such plans for the treatment of reactions are essential for all children with food allergies (4).

COMMENTS

Successful food avoidance requires a cooperative effort that must include the parents/guardians, child, child’s primary health care provider, and early care and education staff. In some cases, especially for a child with multiple food allergies, parents/guardians may need to take responsibility for providing all the child’s food. In other cases, early care and education staff may be able to provide safe foods as long as they have been fully educated about effective food avoidance.
Effective food avoidance has several facets. Foods can be listed on an ingredient list under a variety of names; for example, milk could be listed as casein, caseinate, whey, and/or lactoglobulin.

Some children with a food allergy will have mild reactions and will only need to avoid the problem food(s). Others will need to have antihistamine or epinephrine available to be used in the event of a reaction.

For more information on food allergies, contact Food Allergy Research & Education (FARE) at www.foodallergy.org.
Some early care and education/school settings require that all foods brought into the classroom are store-bought and in their original packaging so that a list of ingredients is included, to prevent exposure to allergens. However, packaged foods may mistakenly include allergen-type ingredients. Alerts and ingredient recalls can be found on the FARE Web site (5).

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
4.2.0.8 Feeding Plans and Dietary Modifications
4.2.0.2 Assessment and Planning of Nutrition for Individual Children
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

Wang J, Sicherer SH; American Academy of Pediatrics Section on Allergy and Immunology. Guidance on completing a written allergy and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005
Tsuang A, Demain H, Patrick K, Pistiner M, Wang J. Epinephrine use and training in schools for food-induced anaphylaxis among non-nursing staff. J Allergy Clin Immunol Pract. 2017;5(5):1418–1420.e3
Caffarelli C, Garrubba M, Greco C, Mastrorilli C, Povesi Dascola C. Asthma and food allergy in children: is there a connection or interaction? Front Pediatr. 2016;4:34
Bugden EA, Martinez AK, Greene BZ, Eig K. Safe at School and Ready to Learn: A Comprehensive Policy Guide for Protecting Students with Life-threatening Food Allergies. 2nd ed. Alexandria, VA: National School Boards Association; 2012. http://www.nsba.org/sites/default/files/reports/Safe-at-School-and-Ready-to-Learn.pdf. Accessed September 20, 2017
ADDITIONAL RESOURCES
Centers for Disease Control and Prevention. Healthy schools. Food allergies in schools. https://www.cdc.gov/healthyschools/foodallergies/index.htm. Reviewed May 9, 2017. Accessed September 20, 2017

Centers for Disease Control and Prevention. Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. Washington, DC: US Department of Health and Human Services; 2013. https://www.cdc.gov/healthyschools/foodallergies/pdf/13_243135_A_Food_Allergy_Web_508.pdf. Accessed September 20, 2017
Food Allergy Research & Education. Allergy alerts. https://www.foodallergy.org/alerts. Accessed September 20, 2017

NOTES

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

Standard 4.3.1.3: Preparing, Feeding, and Storing Human Milk

Frequently Asked Questions/CFOC Clarifications

Reference: 4.3.1.3

Date: 10/17/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.3: Preparing, Feed-ing, and Storing Human Milk

Question:
I cannot find any information in the new CFOC as to how long a bottle of breast milk can be kept after it is fed to an infant. It states that a bottle of formula should be discarded after one hour. I would think that it should be the same, since saliva is introduced into the bottle regardless of its contents, but I want to make sure.
Can you offer some guidance?

Answer:
This Standard provides two references at the end of the “Guide-lines for Storage of Human Milk” chart on page 166. Both re-sources state that breast milk should be discarded after it is fed to an infant.

The Academy of Breastfeeding Medicine Protocol Committee states: “Milk left in the feeding container after a feeding should be discarded and not used again.”
The Centers for Disease Control (CDC) states: “Do not save milk from a used bottle for use at another feeding.”

A specific amount of time is not given (similar to the formula standard). The milk could be used again if it’s the same feeding (for example, if the infant takes a short break from eating), but if it is clearly a different feeding, it should be thrown away.

Content in the STANDARD was modified on 8/23/2016 and 06/10/2020.

Expressed human milk should be transported and stored in clean and sanitary bottles with nipples that fit tightly or in equivalent clean and sanitary sealed containers to prevent spilling during transport to home or to the facility. Only cleaned and sanitized bottles, or their equivalent, and nipples should be used in feeding. The bottle or container should be properly labeled with the child’s full name and the date and time the milk was expressed.¹The filled, labeled bottles or containers of human milk should immediately be stored in the refrigerator on arrival.

Frozen human milk may be transported and stored in single-use plastic bags and placed in a freezer with a separate door or a stand-alone freezer, and not in a compartment within a refrigerator. To prevent intermittent rewarming due to opening the freezer door regularly, frozen human milk should be stored in the back of the freezer and caregivers/teachers should carefully monitor, with daily log sheets, temperature of freezers used to store human milk using an appropriate working thermometer.

Expressed milk brought by a parent/guardian should only be used for that child. Likewise, infant formula should not be used for a breastfed child without the parent/guardian’s written permission. Labels for containers of human milk should be resistant to loss of the name and date/time when washing and handling. This is especially important when a frozen bottle is thawed in running tap water. There may be several bottles for different children being thawed and warmed at the same time in the same place.

The caregiver/teacher should check the child’s full name and the date on the bottle so that the oldest milk is used first. Human milk should be thawed in the refrigerator if frozen. If there is insufficient time to thaw the milk in the refrigerator before serving, it may be thawed in a container of warm water, gently swirling the bottle periodically to evenly distribute the temperature in the milk and mix the fat, which may have separated. Frozen milk should never be thawed in a microwave oven because uneven hot spots in the milk may cause burns in the child and excessive heat may destroy beneficial components of the milk.^1–3

Human milk containers with significant amount of contents remaining after a feeding (>1 oz) may be returned to the parent/guardian at the end of the day as long as the child has not fed directly from the bottle. Returning unused human milk to the parent/guardian informs the parent/guardian of the quantity taken while in the early care and education program.

Although human milk does not need to be warmed, some children prefer their milk warmed to body temperature, around 98.6°F (37°C). When warming human milk, it is important to keep the container sealed while warming to prevent contamination. Human milk can be warmed

In a waterless warmer
By placing the container of human milk into a separate container of warm water
By placing the container of human milk under running warm (not hot) tap water for a few minutes

Human milk should never be warmed directly on the stove or in the microwave. After warming the milk, caregivers/teachers should test the temperature before feeding by putting a few drops on their wrist. It should feel warm, not hot.²

Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates, sometimes labeled with recycling code 3, 6, or 7.⁴ Use glass bottles with a silicone sleeve or silicone bottle jacket to prevent breakage, or use those made with safer plastics, such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of 1, 2, 4, or 5.

Expressed human milk that presents a threat to a child, such as human milk that is in an unsanitary bottle, is curdled, smells rotten, and/or has not been stored following the storage guidelines of the Academy of Breastfeeding Medicine (see Human Milk Storage Guidelines table), should be returned to the parent/guardian.² Written guidance for staff and parents/guardians should be available to determine when milk provided by parents/guardians will not be served. Human milk cannot be served if it does not meet the requirements for sanitary and safe milk.¹

Although human milk is a body fluid, it is not necessary to wear gloves when feeding or handling human milk.⁵ The risk of exposure to infectious organisms during feeding or from milk that the child regurgitates is not significant.²

Some infants around 6 months to 1 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 family should work together on cup feeding of human milk to ensure the child is receiving adequate nourishment and to avoid having a large amount of human milk remaining at the end of the feeding.⁶ Two to 3 ounces of human milk can be placed in a clean cup and additional milk can be offered as needed. Small amounts of human milk (≤1 oz) can be discarded.

There are many different factors that can affect how long human milk can be stored in various locations, such as storage temperature, temperature fluctuations, and cleanliness while expressing and handling human milk. These factors make it difficult to recommend exact times for storing human milk in various locations, but the Human Milk Storage Guidelines table can be helpful.

Human Milk Storage Guidelines
Storage Locations and Temperatures
	Countertop 77°F (25°C) or colder (room temperature)	Refrigerator 40°F (4°C)	Freezer 0°F (-18°C) or colder
Freshly Expressed or Pumped Human Milk	Up to 4 hours	Up to 4 days	Within 6 months is best. Up to 12 months is acceptable.
Thawed, Previously Frozen Human Milk	1–2 hours	Up to 1 day (24 hours)	Never refreeze human milk after it has been thawed.
Leftover Human Milk From a Feeding (baby did not finish the bottle)	Use within 2 hours after the baby is finished feeding.
Sources Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390–395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf. Accessed October 24, 2019 Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. Reviewed August 6, 2019. Accessed October 24, 2019

RATIONALE

By following this standard, early care and education staff is able, when necessary, to prepare human milk and feed a child safely, thereby reducing the risk of inaccuracy or feeding the child unsanitary or incorrect human milk.^1,2 In addition, following safe preparation and storage techniques helps nursing mothers and caregivers/teachers of breastfed children maintain the high quality of expressed human milk and the health of the child.^7,8

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.4 Feeding Human Milk to Another Mother’s Child
4.3.1.7 Feeding Cow’s Milk
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

Centers for Disease Control and Prevention. Proper storage and preparation of breast milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. Reviewed August 6, 2019. Accessed October 24, 2019
Eglash A, Simon L; Academy of Breastfeeding Medicine. ABM clinical protocol #8: human milk storage information for home use for full-term infants, revised 2017. Breastfeed Med. 2017;12(7):390–395. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf. Accessed October 24, 2019
Extension Alliance for Better Child Care. Guidelines for child care providers to prepare and feed bottles to infants. https://articles.extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare-and-feed-bottles-to-infants. Published August 15, 2019. Accessed October 24, 2019
Eco-Healthy Child Care. Plastics & plastic toys. Children’s Environmental Health Network website. https://cehn.org/wp-content/uploads/2017/07/Plastics_Plastic_Toys_6_16.pdf. Published June 2016. Accessed October 24, 2019
La Leche League International. Storing human milk. https://www.llli.org/breastfeeding-info/storingmilk. Accessed October 24, 2019
American Academy of Pediatrics. Working together: breastfeeding and solid foods. HealthyChildren.org website. https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Working-Together-Breastfeeding-and-Solid-Foods.aspx. Updated February 23, 2012. Accessed October 24, 2019
Boué G, Cummins E, Guillou S, Antignac JP, Le Bizec B, Membré JM. Public health risks and benefits associated with breast milk and infant formula consumption. Crit Rev Food Sci Nutr. 2018;58(1):126–145
Binns C, Lee M, Low WY. The long-term public health benefits of breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14

NOTES

Content in the STANDARD was modified on 8/23/2016 and 06/10/2020.

Standard 4.3.1.5: Preparing, Feeding, and Storing Infant Formula

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Formula provided by parents/guardians or by the facility should come in a factory-sealed container. The formula should be of the same brand that is served at home and should be of ready-to-feed strength or liquid concentrate to be diluted using cold water from a source approved by the health department. Powdered infant formula, though it is the least expensive formula, requires special handling in mixing because it cannot be sterilized. The primary source for proper and safe handling and mixing is the manufacturer’s instructions that appear on the can of powdered formula. Before opening the can, hands should be washed. The can and plastic lid should be thoroughly rinsed and dried. Caregivers/teachers should read and follow the manufacturer’s directions. Caregivers/teachers should only use the scoop that comes with the can and not interchange the scoop from one product to another, since the volume of the scoop may vary from manufacturer to manufacturer and product to product. Also, a scoop can be contaminated with a potential allergen from another type of formula. If instructions are not readily available, caregivers/teachers should obtain information from their local WIC program or the World Health Organization’s Safe Preparation, Storage and Handling of Powdered Infant Formula Guidelines at: http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf (1).

Formula mixed with cereal, fruit juice, or any other foods should not be served unless the child’s primary care provider provides written documentation that the child has a medical reason for this type of feeding.

Iron-fortified formula should be refrigerated until immediately before feeding. For bottles containing formula, any contents remaining after a feeding should be discarded.

Bottles of formula prepared from powder or concentrate or ready-to-feed formula should be labeled with the child’s full name and time and date of preparation. Any prepared formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been given to an infant should be covered, labeled with date and time of preparation and child’s full name, and may be stored in the refrigerator for up to twenty-four hours. An open container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening and child’s full name, and discarded at forty-eight hours if not used (2). The caregiver/teacher should always follow manufacturer’s instructions for mixing and storing of any formula preparation. Some infants will require specialized formula because of allergy, inability to digest certain formulas, or need for extra calories. The appropriate formula should always be available and should be fed as directed. For those infants getting supplemental calories, the formula may be prepared in a different way from the directions on the container. In those circumstances, either the family should provide the prepared formula or the caregiver/teacher should receive special training, as noted in the infant’s care plan, on how to prepare the formula. Formula should not be used beyond the stated shelf life period (3).

Parents/guardians should supply enough clean and sterilized bottles to be used throughout the day. The bottles must be sanitary, properly prepared and stored, and must be the same brand in the early care and education program and at home. Avoid bottles made of plastics containing bisphenol A (BPA) or phthalates (sometimes labeled with #3, #6, or #7). Use glass bottles with a silicone sleeve (a silicone bottle jacket to prevent breakage) or those made with safer plastics such as polypropylene or polyethylene (labeled BPA-free) or plastics with a recycling code of #1, #2, #4, or #5.

RATIONALE

Caregivers/teachers help in promoting the feeding of infant formula that is familiar to the infant and supports family feeding practice. By following this standard, the staff is able, when necessary, to prepare formula and feed an infant safely, thereby reducing the risk of inaccuracy or feeding the infant unsanitary or incorrect formula. Written guidance for both staff and parents/guardians must be available to determine when formula provided by parents/guardians will not be served. Formula cannot be served if it does not meet the requirements for sanitary and safe formula.

Staff preparing formula should thoroughly wash their hands prior to beginning preparation of infant feedings of any type. Water used for mixing infant formula must be from a safe water source as defined by the local or state health department. If the caregiver/teacher is concerned or uncertain about the safety of the tap water, s/he should "flush" the water system by running the tap on cold for 1-2 minutes or use bottled water (4). Warmed water should be tested in advance to make sure it is not too hot for the infant. To test the temperature, the caregiver/teacher should shake a few drops on the inside of her/his wrist. A bottle can be prepared by adding powdered formula and room temperature water from the tap just before feeding. Bottles made in this way from powdered formula can be ready for feeding as no additional refrigeration or warming would be required.

Adding too little water to formula puts a burden on an infant’s kidneys and digestive system and may lead to dehydration (5). Adding too much water dilutes the formula. Diluted formula may interfere with an infant’s growth and health because it provides inadequate calories and nutrients and can cause water intoxication. Water intoxication can occur in breastfed or formula-fed infants or children over one year of age who are fed an excessive amount of water. Water intoxication can be life-threatening to an infant or young child (6).If a child has a special health problem, such as reflux, or inability to take in nutrients because of delayed development of feeding skills, the child’s primary care provider should provide a written plan for the staff to follow so that the child is fed appropriately. Some infants are allergic to milk and soy and need to be fed an elemental formula which does not contain allergens. Other infants need supplemental calories because of poor weight gain.

Infants should not be fed a formula different from the one the parents/guardians feed at home, as even minor differences in formula can cause gastrointestinal upsets and other problems (7).

Excessive shaking of formula may cause foaming that increases the likelihood of feeding air to the infant.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.1 General Plan for Feeding Infants
4.3.1.8 Techniques for Bottle Feeding
4.3.1.9 Warming Bottles and Infant Foods
5.2.9.9 Plastic Containers and Toys

REFERENCES

United States Department of Agriculture, Food and Nutrition Service. 2017. Feeding infants: A guide for use in the child nutrition programs. https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs.
Brown, J., Krasowski, M. D., & Hesse, M. 2015. Forced water intoxication: A deadly form of child abuse. The Journal of Law Enforcement. 4(4).
Seattle Children's Hospital. 2014. Topics covered for formula feeding: Is this your child's symptoms? Seattle, WA. http://www.seattlechildrens.org/medical-conditions/symptom-index/bottle-feeding-formula-questions/.
Centers for Disease Control and Prevention. 2016. Water. https://www.cdc.gov/nceh/lead/tips/water.htm.
Seltzer, H. 2012. U.S Department of Health & Human Services. Keeping infant formula safe. https://www.foodsafety.gov/blog/infant_formula.html.
U.S. Department of Health & Human Services, U.S. Food & Drug Administration. 2016. Food safety for moms to be: Once baby arrives. College Park, MD. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm.
World Health Organization. 2007. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/powdered-infant-formula/en/.

NOTES

Content in the STANDARD was modified on 11/5/2013 and 8/25/2016.

Standard 4.3.1.9: Warming Bottles and Infant Foods

Frequently Asked Questions/CFOC Clarifications

Reference: 4.3.1.9

Date: 10/13/2011

Topic & Location:
Chapter 4
Nutrition and Food Service
Standard 4.3.1.9: Warming Bottles and Infant Foods

Question:
I have concerns about the standards recommending glass and ceramic containers due to concerns about using plastic. Once again, it is good in theory, but I don’t feel it is safe. I had a center that had a glass bottle drop and shatter in their infant room.

Answer:
BPA-free plastic bottles, those labeled #1, #2, #4, or #5, can be used to avoid the use of glass.

For those child care and early education facilities that choose to use glass bottles, a relatively new option is to use a bottle sleeve with the glass bottle to reduce the risk of shattered glass. Efficacy on this product is still being proven. Overall, glass is safer than plastic with BPA.

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

Bottles and infant foods do not have to be warmed; they can be served cold from the refrigerator. If a caregiver/teacher chooses to warm them, bottles or containers of infant foods should be warmed under running, warm tap water or by placing them in a container of water that is no warmer than 120°F (49°C). Bottles should not be left in a pot of water to warm for more than 5 minutes. Bottles and infant foods should never be warmed in a microwave oven because uneven hot spots in milk and/or food may burn the infant (1,2).

Infant foods should be stirred carefully to distribute the heat evenly. A caregiver/teacher should not hold an infant while removing a bottle or infant food from the container of warm water or while preparing a bottle or stirring infant food that has been warmed in some other way. Bottles used for infant feeding should be made of the following substances (3):

a. Bisphenol A (BPA)-free plastic; plastic labeled #1, #2, #4, or #5, or

b. Glass (a silicone sleeve/jacket covering a glass bottle to prevent breakage is permissible).

When a slow-cooking device, such as a crock-pot, is used for warming human milk, infant formula, or infant food, the device (and cord) should be out of children’s reach. The device should contain water at a temperature that does not exceed 120°F (49°C), and be emptied, cleaned, sanitized, and refilled with fresh water daily. When a bottle warmer is used for warming human milk, infant formula, or infant food, it should be out of children’s reach and used according to manufacturer’s instructions.

RATIONALE

Bottles of human milk or infant formula that are warmed at room temperature or in warm water for an inappropriate period provide an ideal medium for bacteria to grow. Infants have received burns from hot water dripping from an infant bottle that was removed from a crock-pot or by pulling the crock-pot down on themselves by means of a dangling cord. Caution should be exercised to avoid raising the water temperature above a safe level for warming infant formula or infant food.

Additional Resource

Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture Food and Nutrition Service (https://www.fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs)

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.3 Preparing, Feeding, and Storing Human Milk
4.3.1.5 Preparing, Feeding, and Storing Infant Formula
4.3.1.8 Techniques for Bottle Feeding
4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants

REFERENCES

US Department of Health and Human Services, US Food and Drug Administration. Food safety for moms to be: once baby arrives. https://www.fda.gov/food/resourcesforyou/healtheducators/ucm089629.htm. Updated November 8, 2017. Accessed January 11, 2018
Cowan D, Ho B, Sykes KJ, Wei JL. Pediatric oral burns: a ten-year review of patient characteristics, etiologies and treatment outcomes. Int J Pediatr Otorhinolaryngol. 2013;77(8):1325–1328
Environmental Working Group. Guide to baby-safe bottles and formula. https://www.ewg.org/research/ewg%E2%80%99s-guide-baby-safe-bottles-and-formula#.WlfPqWeWzct. Updated October, 2015. Accessed January 11, 2018

NOTES

Content in the STANDARD was modified on 11/5/2013, 8/25/2016 and 05/31/2018.

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

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

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

3.6.3.1 Medication Administration
4.2.0.10 Care for Children with Food Allergies
4.2.0.7 100% Fruit Juice
4.2.0.9 Written Menus and Introduction of New Foods
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

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
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
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
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
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
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
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
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

TYPE OF FACILITY

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

REFERENCES

Benjamin, S. E., ed. 2007. Making food healthy and safe for children: How to meet the national health and safety performance standards – Guidelines for out of home child care programs. 2nd ed. Chapel Hill, NC: National Training Institute for Child Care Health Consultants. http://nti.unc.edu/course_files/curriculum/nutrition/making_food_healthy_and_safe.pdf.
Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
U.S. Department of Agriculture (USDA), Child and Adult Care Food Program (CACFP). 2002. Menu magic for children: A menu planning guide for child care. Washington, DC: USDA. http://www.fns.usda.gov/tn/resources/menu_magic.pdf.
Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
Morley, R. E., J. P. Ludemann, J. P. Moxham, F. K. Kozak, K. H. Riding. 2004. Foreign body aspiration in infants and toddlers: Recent trends in British Columbia. J Otolaryngology 33:37-41.
Baker, S. B., R. S. Fisher. 1980. Childhood asphyxiation by choking or suffocation. JAMA 244:1343-46.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.
Rimell, F. L., A. Thome Jr., S. Stool, et al. 1995. Characteristics of objects that cause choking in children. JAMA 274:1763-66.

Standard 4.8.0.1: Food Preparation Area

The food preparation area of the kitchen should be separate from eating, play, laundry, toilet, and bathroom areas and from areas where animals are permitted. The food preparation area should not be used as a passageway while food is being prepared. Food preparation areas should be separated by a door, gate, counter, or room divider from areas the children use for activities unrelated to food, except in small family child care homes when separation may limit supervision of children.

Infants and toddlers should not have access to the kitchen in child care centers. Access by older children to the kitchen of centers should be permitted only when supervised by staff members who have been certified by the nutritionist/registered dietitian or the center director as qualified to follow the facility’s sanitation and safety procedures.

In all types of child care facilities, children should never be in the kitchen unless they are directly supervised by a caregiver/teacher. Children of preschool-age and older should be restricted from access to areas where hot food is being prepared. School-age children may engage in food preparation activities with adult supervision in the kitchen or the classroom. Parents/guardians and other adults should be permitted to use the kitchen only if they know and follow the food safety rules of the facility. The facility should check with local health authorities about any additional regulations that apply.

RATIONALE

The presence of children in the kitchen increases the risk of contamination of food and the risk of injury to children from burns. Use of kitchen appliances and cooking techniques may require more skill than can be expected for children’s developmental level. The most common burn in young children is scalding from hot liquids tipped over in the kitchen (1).

The kitchen should be used only by authorized individuals who have met the requirements of the local health authority and who know and follow the food safety rules of the facility so they do not contaminate food and food surfaces for food-related activities. Under adult supervision, school-age children may be encouraged to help with developmentally appropriate food preparation, which increases the likelihood that they will eat new foods.

TYPE OF FACILITY

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

RELATED STANDARDS

Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications

REFERENCES

Ring, L. M. 2007. Kids and hot liquids–A burning reality. J Pediatric Health Care 21:192-94.

Standard 4.8.0.3: Maintenance of Food Service Surfaces and Equipment

All surfaces that come into contact with food, including tables and countertops, as well as floors and shelving in the food preparation area should be in good repair, free of cracks or crevices, and should be made of smooth, nonporous material that is kept clean and sanitized. All kitchen equipment should be clean and should be maintained in operable condition according to the manufacturer’s guidelines for maintenance and operation. The facility should maintain an inventory of food service equipment that includes the date of purchase, the warranty date, and a history of repairs.

RATIONALE

Cracked or porous materials should be replaced because they trap food and other organic materials in which microorganisms can grow (1). Harsh scrubbing of these areas tends to create even more areas where organic material can lodge and increase the risk of contamination. Repairs with duct tape, package tapes, and other commonly used materials add surfaces that trap organic materials.

Food service equipment is designed by the manufacturer for specific types of use. The equipment must be maintained to meet those performance standards or food will become contaminated and spoil (1). An accurate and ongoing inventory of food service equipment tracks maintenance requirements and can provide important information when a breakdown occurs.

TYPE OF FACILITY

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

REFERENCES

National Restaurant Association. 2008. ServSafe essentials. 5th ed. Upper Saddle River, NJ: Prentice Hall.

Standard 4.9.0.2: Staff Restricted from Food Preparation and Handling

Anyone who has signs or symptoms of illness, including vomiting, diarrhea, and infectious skin sores that cannot be covered, or who potentially or actually is infected with bacteria, viruses or parasites that can be carried in food, should be excluded from food preparation and handling. Staff members may not contact exposed, ready-to-eat food with their bare hands and should use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. No one with open or infected skin eruptions should work in the food preparation area unless the injuries are covered with nonporous (such as latex or vinyl), single use gloves.

In centers and large family child care homes, staff members who are involved in the process of preparing or handling food should not change diapers. Staff members who work with diapered children should not prepare or serve food for older groups of children. When staff members who are caring for infants and toddlers are responsible for changing diapers, they should handle food only for the infants and toddlers in their groups and only after thoroughly washing their hands. Caregivers/teachers who prepare food should wash their hands carefully before handling any food, regardless of whether they change diapers. When caregivers/teachers must handle food, staffing assignments should be made to foster completion of the food handling activities by caregivers/teachers of older children, or by caregivers/teachers of infants and toddlers before the caregiver/teacher assumes other caregiving duties for that day. Aprons worn in the food service area must be clean and should be removed when diaper changing or when using the toilet.

RATIONALE

Food handlers who are ill can easily transmit their illness to others by contaminating the food they prepare with the infectious agents they are carrying. Frequent and proper handwashing before and after using plastic gloves reduces food contamination (1,2,4).

Caregivers/teachers who work with infants and toddlers are frequently exposed to feces and to children with infections of the intestines (often with diarrhea) or of the liver. Education of child care staff regarding handwashing and other cleaning procedures can reduce the occurrence of illness in the group of children with whom they work (1,2,4).

The possibility of involving a larger number of people in a foodborne outbreak is greater in child care than in most households. Cooking larger volumes of food requires special caution to avoid contamination of the food with even small amounts of infectious materials. With larger volumes of food, staff must exercise greater diligence to avoid contamination because larger quantities of food take longer to heat or to cool to safe temperatures. Larger volumes of food spend more time in the danger zone of temperatures (between 41°F and 135°F) where more rapid multiplication of microorganisms occurs (3).

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.
Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

Standard 4.9.0.3: Precautions for a Safe Food Supply

All foods stored, prepared, or served should be safe for human consumption by observation and smell (1-2). The following precautions should be observed for a safe food supply:

Home-canned food; food from dented, rusted, bulging, or leaking cans, and food from cans without labels should not be used;
Foods should be inspected daily for spoilage or signs of mold, and foods that are spoiled or moldy should be promptly and appropriately discarded;
Meat should be from government-inspected sources or otherwise approved by the governing health authority (3);
All dairy products should be pasteurized and Grade A where applicable;
Raw, unpasteurized milk, milk products; unpasteurized fruit juices; and raw or undercooked eggs should not be used. Freshly squeezed fruit or vegetable juice prepared just prior to serving in the child care facility is permissible;
Unless a child’s health care professional documents a different milk product, children from twelve months to two years of age should be served only human milk, formula, whole milk or 2% milk (6). Note: For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older should be served skim or 1% milk. If cost-saving is required to accommodate a tight budget, dry milk and milk products may be reconstituted in the facility for cooking purposes only, provided that they are prepared, refrigerated, and stored in a sanitary manner, labeled with the date of preparation, and used or discarded within twenty-four hours of preparation;
Meat, fish, poultry, milk, and egg products should be refrigerated or frozen until immediately before use (5);
Frozen foods should be defrosted in one of four ways: In the refrigerator; under cold running water; as part of the cooking process, or by removing food from packaging and using the defrost setting of a microwave oven (5). Note: Frozen human milk should not be defrosted in the microwave;
Frozen foods should never be defrosted by leaving them at room temperature or standing in water that is not kept at refrigerator temperature (5);
All fruits and vegetables should be washed thoroughly with water prior to use (5);
Food should be served promptly after preparation or cooking or should be maintained at temperatures of not less than 135°F for hot foods and not more than 41°F for cold foods (12);
All opened moist foods that have not been served should be covered, dated, and maintained at a temperature of 41°F or lower in the refrigerator or frozen in the freezer, verified by a working thermometer kept in the refrigerator or freezer (12);
Fully cooked and ready-to-serve hot foods should be held for no longer than thirty minutes before being served, or promptly covered and refrigerated;
Pasteurized eggs or egg products should be substituted for raw eggs in the preparation of foods such as Caesar salad, mayonnaise, meringue, eggnog, and ice cream. Pasteurized eggs or egg products should be substituted for recipes in which more than one egg is broken and the eggs are combined, unless the eggs are cooked for an individual child at a single meal and served immediately, such as in omelets or scrambled eggs; or the raw eggs are combined as an ingredient immediately before baking and the eggs are fully cooked to a ready-to-eat form, such as a cake, muffin or bread;
Raw animal foods should be fully cooked to heat all parts of the food to a temperature and for a time of; 145°F or above for fifteen seconds for fish and meat; 160°F for fifteen seconds for chopped or ground fish, chopped or ground meat or raw eggs; or 165°F or above for fifteen seconds for poultry or stuffed fish, stuffed meat, stuffed pasta, stuffed poultry or stuffing containing fish, meat or poultry.

RATIONALE

Safe handling of all food is a basic principle to prevent and reduce foodborne illnesses (14). For children, a small dose of infectious or toxic material can lead to serious illness (13). Some molds produce toxins that may cause illness or even death (such as aflatoxin or ergot).

Keeping cold food below 41°F and hot food above 135°F prevents bacterial growth (1,6,12). Food intended for human consumption can become contaminated if left at room temperature.

Foodborne illnesses from Salmonella and E. coli 0157:H7 have been associated with consumption of contaminated, raw, or undercooked egg products, meat, poultry, and seafood. Children tend to be more susceptible to E. coli 0157:H7 infections from consumption of undercooked meats, and such infections can lead to kidney failure and death.

Home-canned food, food from dented, rusted, bulging or leaking cans, or leaking packages/bags of frozen foods, have an increased risk of containing microorganisms or toxins. Users of unlabeled food cans cannot be sure what is in the can and how long the can has been stored.

Excessive heating of foods results in loss of nutritional content and causes foods to lose appeal by altering color, consistency, texture, and taste. Positive learning activities for children, using their senses of seeing and smelling, help them to learn about the food they eat. These sensory experiences are counterproductive when food is overcooked. Children are not only shortchanged of nutrients, but are denied the chance to use their senses fully to learn about foods.

Caregivers/teachers should discourage parents/guardians from bringing home-baked items for the children to share as it is difficult to determine the quality of the ingredients used and the cleanliness of the environment in which the items are baked and transported. Parents/guardians should be informed why home baked items like birthday cake and cupcakes are not the healthiest choice and the facility should provide ideas for healthier alternatives such as fruit cups or fruit salad to celebrate birthdays and other festive events.

Several states allow the sale of raw milk or milk products. These products have been implicated in outbreaks of salmonellosis, listeriosis, toxoplasmosis, and campylobacteriosis and should never be served in child care facilities (7,8). Only pasteurized milk and fruit juices should be served. Foods made with uncooked eggs have been involved in a number of outbreaks of Salmonella infections. Eggs should be well-cooked before being eaten, and only pasteurized eggs or egg substitutes should be used in foods requiring raw eggs.

The American Academy of Pediatrics (AAP) recommends that children from twelve months to two years of age receive human milk, formula, whole milk, or 2% milk. For children between twelve months and two years of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or CVD, the use of reduced-fat milk is appropriate only with written documentation from the child’s primary health care professional (4). Children two years of age and older can drink skim, or 1%, milk (6,9-11).

Soil particles and contaminants that adhere to fruits and vegetables can cause illness. Therefore, all fruits or vegetables to be eaten and used to make fresh juice at the facility should be thoroughly washed first.

Thawing frozen foods under conditions that expose any of the food’s surfaces to temperatures between 41°F and 135°F promotes the growth of bacteria that may cause illness if ingested. Storing perishable foods at safe temperatures in the refrigerator or freezer reduces the rate at which microorganisms in these foods multiply (12).

COMMENTS

The use of dairy products fortified with vitamins A and D is recommended (4).

The FDA provides the following Website for caregivers/teachers to check status of foods and food products that have been recalled, see http://www.fda.gov.

Temperatures come from the FDA 2009 Food Code (12). Local or state regulations may differ. Caregivers/teachers should consult with the health department concerning questions on proper cooking temperatures for specific foods.

TYPE OF FACILITY

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

RELATED STANDARDS

4.3.1.7 Feeding Cow’s Milk
4.8.0.6 Maintaining Safe Food Temperatures
Appendix U: Recommended Safe Minimum Internal Cooking Temperatures

REFERENCES

U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
Food Marketing Institute (FMI), U.S. Department of Agriculture, Food Safety and Inspection Service. 1996. Facts about food and floods: A consumer guide to food quality and safe handling after a flood or power outage. Washington, DC: FMI.
Potter, M. E. 1984. Unpasteurized milk: The hazards of a health fetish. JAMA 252:2048-52.
Sacks, J. J. 1982. Toxoplasmosis infection associated with raw goat’s milk. JAMA 246:1728-32.
Chicago Dietetic Association. 1996. Manual of clinical dietetics. 5th ed. Chicago, IL: American Dietetic Association.
Dietz, W.H., L. Stern, eds. 1998. Guide to your child’s nutrition. Elk Grove Village, IL: American Academy of Pediatrics.
Enders, J. B. 1994. Food, nutrition and the young child. New York: Merrill.
U.S. Department of Agriculture (USDA). 2002. Making nutrition count for children - Nutrition guidance for child care homes. Washington, DC: USDA. http://www/gpo.gov/fdsys/pkg/ERIC-ED482991/pdf/ERIC-ED482991.pdf.
Kleinman, R. E., ed. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics.
Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. 6th ed. New York: McGraw-Hill.
Daniels, S. R., F. R. Greer, Committee on Nutrition. 2008. Lipid screening and cardiovascular health in childhood. Pediatrics 122:198-208.
U.S. Department of Agriculture (USDA), Food Safety and Inspection Service. 2000. Keeping kids safe: A guide for safe handling and sanitation, for child care providers. Rev ed. Washington, DC: USDA. http://teamnutrition.usda.gov/resources/appendj.pdf.
Cowell, C., S. Schlosser. 1998. Food safety in infant and preschool day care. Top Clin Nutr 14:9-15.
U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. 2009 Food code. College Park, MD: FDA. http://www.fda.gov/downloads/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/UCM189448.pdf.

Chapter 5 - Facilities, Supplies, Equipment, and Environmental Health

Standard 5.1.1.2: Inspection of Buildings

Content in the standard was modified on 04/27/2021.

Before an early care and education (ECE) space is made accessible to children, a qualified inspector should ensure compliance with applicable building and fire codes for all newly constructed, renovated, remodeled, or altered buildings. ECE programs should follow all applicable local and state requirements.

RATIONALE

Inspections of facilities are used to help make sure that the space is safe for occupants. Building and fire code inspections help ensure compliance with critical structural and fire safety concerns. Inspections are especially important for older buildings or spaces that were not previously used for child care and that might contain materials that, when present or disturbed, can be hazardous for children. When facilities are inspected prior to beginning operations and before and after renovation or construction activities, the risks of exposure to potential environmental hazards are lessened. For example, floor tiles with asbestos would need to be properly handled during renovations to avoid releasing asbestos into the space.¹

COMMENTS

In addition, past use of the site may have left remaining environmental health hazards, such as chemicals in soil or groundwater, which could still be present. Thus, in addition to fire and building code inspections, assessing the facility for the presence of environmental hazards is important to identify potential contaminants that need to be addressed before children are exposed.^2-4Inspections vary in scope but are often focused on areas such as food service and drinking water. State and local health agencies may provide information about a range of environmental health hazards, assess facilities, and help answer questions about concerns that are identified in a facility assessment.

ADDITIONAL RESOURCES

US Environmental Protection Agency. Healthy Child Care web site - https://www.epa.gov/childcare

Agency for Toxic Substances and Disease Registry Choose Safe Places for Early Care and Education - https://www.atsdr.cdc.gov/safeplacesforece/index.html

National Fire Protection Association (NFPA). List of NFPA Codes and Standards. https://www.nfpa.org/Codes-and-Standards/All-Codes-and-Standards/List-of-Codes-and-Standards

TYPE OF FACILITY

Center, Early Head Start, Head Start

RELATED STANDARDS

5.1.1.3 Compliance with Fire Prevention Code
5.1.1.5 Assessment of the Environment at the Site Location
5.2.1.1 Ensuring Access to Fresh Air Indoors
5.2.6.1 Water Supply
5.2.6.2 Testing of Drinking Water Not From Public System
5.2.6.7 Cross-Connections
5.2.7.1 On-Site Sewage Systems
5.2.7.5 Labeling, Cleaning, and Disposal of Waste and Diaper Containers
5.2.9.4 Radon Concentrations
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.2.9.13 Testing for and Remediating Lead Hazards
5.2.9.15 Construction and Remodeling

REFERENCES

US Environmental Protection Agency. Information for owners and managers of buildings that contain asbestos. Renovation and demolition requirements. Updated December 19, 2016. Accessed March 9, 2021. https://www.epa.gov/asbestos/information-owners-and-managers-buildings-contain-asbestos#renovation
Agency for Toxic Substances and Disease Registry. Choose Safe Places for Early Care and Education (CSPECE) Guidance Manual.Reviewed October 30, 2018. Accessed March 9, 2021. https://www.atsdr.cdc.gov/safeplacesforECE/cspece_guidance/index.html
Somers TS, Harvey ML, Rusnak SM. Making child care centers SAFER: a non-regulatory approach to improving child care center siting. Public Health Rep.2011;126(suppl 1):34–40 PMID: 21563710 https://doi.org/10.1177/00333549111260s106
Environmental Law Institute, Children’s Environmental Health Network. Reducing Environmental Exposures in Child Care Facilities: A Review of State Policy.Washington, DC: Environmental Law Institute; 2015. Accessed March 9, 2021. https://www.eli.org/research-report/reducing-environmental-exposures-child-care-facilities-review-state-policy

NOTES

Content in the standard was modified on 04/27/2021.

Standard 5.1.1.3: Compliance with Fire Prevention Code

Every twelve months, the child care facility should obtain written documentation to submit to the regulatory licensing authority that the facility complies with a state-approved or nationally recognized Fire Prevention Code. If available, this documentation should be obtained from a fire prevention official with jurisdiction where the facility is located. Where fire safety inspections or a Fire Prevention Code applicable to child care centers is not available from local authorities, the facility should arrange for a fire safety inspection by an inspector who is qualified to conduct such inspections using the National Fire Protection Association’s NFPA 101: Life Safety Code.

RATIONALE

Regular fire safety checks by trained officials will ensure that a child care facility continues to meet all applicable fire safety codes. NFPA 101: Life Safety Code addresses child care facilities in two chapters devoted exclusively to this occupancy – chapter 16, “New Day-Care Occupancies” and chapter 17, “Existing Day-Care Occupancies” (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start

Standard 5.1.1.5: Assessment of the Environment at the Site Location

Frequently Asked Questions/CFOC Clarifications

Reference: 5.1.1.5

Date: 10/13/2011

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

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

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

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

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

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

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

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

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

RATIONALE

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

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

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

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

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 5.1.3.2: Possibility of Exit from Windows

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

RATIONALE

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

COMMENTS

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

TYPE OF FACILITY

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

REFERENCES

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

Standard 5.1.4.1: Alternate Exits and Emergency Shelter

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

Each building or structure, new or old, should have a minimum of 2 exits, at different sides of the building or home, leading to an open space at ground level.

If the basement in a small family child care home is being used, one exit should lead directly to the outside. Exits should be unobstructed, easily accessed by adults, yet inaccessible to children, allowing occupants to escape to an outside door or exit stair enclosure in case of a fire or other emergency. Using an outdoor playground as a safe place to exit may not always be possible. If an alternative or emergency exit leads to an enclosed outdoor play area, fences, barriers, and all latches or other closing mechanisms should be easily accessible by adults yet inaccessible to children. Some child care facilities do not have a playground located adjacent to the child care building and use local parks as the playground site. Access to these parks may require crossing a street at an intersection with a crosswalk. This would normally be considered safe, especially in areas of low traffic; however, when sirens go off, a route that otherwise may be considered safe becomes chaotic and dangerous.

Each floor above or below ground level used for child care should have at least 2 unobstructed exits that lead to an open area at ground level and, thereafter, to an area that meets safety requirements for a child care indoor or outdoor area.

In the event of a fire, chemical release, or gas leak, staff members and children should be able to get at least 50 feet away from the building or structure. If the children cannot return to their usual building, a suitable shelter containing all items necessary for child care should be available where the children can be protected from the elements (eg, weather, extreme conditions) and safely remain until their parents/guardians arrive.

An evacuation plan should take into consideration all available open areas to which staff and children can safely retreat in an emergency.¹ Cribs designed to be used as evacuation cribs can be used to evacuate infants and/or children with special health care needs or disabilities, if rolling is possible on the evacuation route(s).² Refer to Standard 5.1.4.2 for more information about crib/wheelchair use and proper evacuation in early care and education programs.

During evacuation or an emergency, children, as well as staff, become excited and may run into the street when the playground is not fenced or immediately adjacent to the center.¹ Planning should also consider that severe weather or extreme conditions (hot or cold) might require that children be quickly relocated into a facility that protects them from the elements.

Entrance and exit routes should be reviewed and approved by the applicable fire inspector. Exiting should meet all the requirements of the current edition of the NFPA 101: Life Safety Code from the National Fire Protection Association.¹

RATIONALE

Unobstructed exit routes are essential to protect children and staff during prompt evacuation. The purpose of having 2 ways to exit when child care is provided on a floor above or below ground level is to ensure an alternative exit exists if fire blocks one exit.¹ Some authorities will permit a fenced area with sufficient accumulation space at least 50 feet from the building to serve in lieu of a gated opening.

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
5.1.4.2 Evacuation of Children with Special Health Care Needs and Children with Disabilities
5.1.4.6 Labeled Emergency Exits
5.1.4.7 Access to and Awareness of Exits
6.1.0.8 Enclosures for Outdoor Play Areas

REFERENCES

National Fire Protection Association. NFPA 101: Life Safety Code. https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=101. Accessed December 20, 2018
National Center on Early Childhood Health and Wellness, US Department of Health and Human Services Administration for Children and Families Office of Head Start. Emergency Preparedness Manual for Early Childhood Programs. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/emergency-preparedness-manual-early-childhood-programs.pdf. Accessed December 20, 2018

NOTES

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

Standard 5.1.5.4: Guards at Stairway Access Openings

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

RATIONALE

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

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.6.6 Guardrails and Protective Barriers

REFERENCES

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

Standard 5.1.6.6: Guardrails and Protective Barriers

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

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

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

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

RATIONALE

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

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

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

TYPE OF FACILITY

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

REFERENCES

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

Standard 5.2.1.1: Ensuring Access to Fresh Air Indoors

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

COVID-19 Modification as of March 20, 2023.

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

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

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

COVID-19 modification as of March 20, 2023:

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

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

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

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

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

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

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

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

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

Spend more time outside, as weather permits.

When Transporting Children

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

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

Additional Resources:

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

California Childcare Health Program

Centers for Disease Control and Prevention

Children’s Environmental Health Network

New Jersey Department of Health

Guidance on Air Cleaning Devices for Indoor Spaces

Environmental Protection Agency (EPA)

Harvard School of Public Health and UC, Colorado Boulder

RATIONALE

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

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

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

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

COMMENTS

ADDITIONAL RESOURCES

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

COVID-19 Modification as of March 20, 2023.

Standard 5.2.1.10: Gas, Oil, or Kerosene Heaters, Generators, Portable Gas Stoves, and Charcoal and Gas Grills

Unvented gas or oil heaters and portable open-flame kerosene space heaters should be prohibited. Gas cooking appliances, including portable gas stoves, should not be used for heating purposes. Charcoal grills should not be used for space heating or any other indoor purposes.

Heat in units that involve flame should be vented properly to the outside and should be supplied with a source of combustion air that meets the manufacturer’s installation requirements.

RATIONALE

Due to improper ventilation, worn or faulty parts, or malfunctioning equipment, dangerous gases can accumulate and cause a fire or carbon monoxide poisoning. Carbon monoxide is a colorless, odorless, gas that is formed when carbon-containing fuel is not burned completely and can cause illness or death. See Standard 5.2.9.5 on installation of carbon monoxide detectors.

Many burns have been caused by contact with space heaters and other hot surfaces such as charcoal and gas grills (1). If charcoal grills are used outside, adequate staff ratios must be maintained and the person operating the grill should not be counted in the ratio.

COMMENTS

For more information on carbon monoxide poisoning and poison prevention, contact your local poison center by calling 1-800-222-1222 begin_of_the_skype_highlighting 1-800-222-1222 end_of_the_skype_highlighting.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.13 Barriers/Guards for Heating Equipment and Units
5.2.9.5 Carbon Monoxide Detectors

REFERENCES

Palmieri, T. L., D. G. Greenhalgh. 2002. Increased incidence of heater-related burn injury during a power crisis. Arch Surg 137:1106-8.

Standard 5.2.1.11: Portable Electric Space Heaters

Portable electric space heaters should:

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

The heater cord should be inaccessible to children as well.

RATIONALE

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

COMMENTS

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

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

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

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

Manufacturer’s instructions should be kept on file.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.1.13 Barriers/Guards for Heating Equipment and Units

REFERENCES

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

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

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

In existing child care facilities that do not have “tamper-resistant electrical outlets,” outlets should have “safety covers” that are attached to the electrical outlet by a screw or other means to prevent easy removal by a child. “Safety plugs” should not be used since they can be removed from an electrical outlet by children (2,3).

All newly installed or replaced electrical outlets that are accessible to children should use “tamper-resistant electrical outlets.”

In areas where electrical products might come into contact with water, a special type of outlet called Ground Fault Circuit Interrupters (GFCIs) should be installed (2). A GFCI is designed to trip before a deadly electrical shock can occur (1). To ensure that GFCIs are functioning correctly, they should be tested at least monthly (2). GFCIs are also available in a tamper-resistant design.

RATIONALE

Tamper-resistant electrical outlets or securely attached safety covers prevent children from placing fingers or sticking objects into exposed electrical outlets and reduce the risk of electrical shock, electrical burns, and potential fires (2). GFCIs provide protection from electrocution when an electric outlet or electric product may come into contact with water (1).

Approximately 2,400 children are injured annually by inserting objects into the slots of electrical outlets (2,3). The majority of these injuries involve children under the age of six (2,3).

Plastic safety plugs inserted into electric outlets are not the safest option since they can easily be removed by children and, depending on their size, present a potential choking hazard if placed in a child’s mouth (3).

COMMENTS

One type of outlet cover replaces the outlet face plate with a plate that has a spring-loaded outlet cover, which will stay in place when the receptacle is not in use. For receptacles where the facility does not intend to unplug the appliance, a more permanent cap-type cover that screws into the outlet receptacle is available. Several effective outlet safety devices are available in home hardware and infant/children stores (4).

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.4.3 Ground-Fault Circuit-Interrupter for Outlets Near Water

REFERENCES

National Electrical Manufacturers Association. Real safety with tamper-resistant receptacles.http://www.childoutletsafety.org.
National Fire Protection Association. National electrical code fact sheet: Tamper-resistant electrical receptacles. http://www.nfpa.org/public-education/by-topic/top-causes-of-fire/electrical/tamper-resistant-electrical-receptacles.
Electrical Safety Foundation International (ESFI). 2008. Know the dangers in your older home Rosslyn, VA: ESFI. http://files.esfi.org/file/Know-The-Dangers-of-Your-Older-Home.pdf
National Fire Protection Association (NFPA). 2010. NFPA 70: National electrical code. 2011 ed. Quincy, MA: NFPA.

Standard 5.2.4.4: Location of Electrical Devices Near Water

No electrical device or apparatus accessible to children should be located so it could be plugged into an electrical outlet while a person is in contact with a water source, such as a sink, tub, shower area, water table, or swimming pool.

RATIONALE

Contact with a water source while using an electrical device provides a path for electricity through the person who is using the device (1,2). This can lead to electrical injury.

TYPE OF FACILITY

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

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). CPSC safety alert: Install Ground-Fault Circuit-Interrupter Protection for Pools, Spas and Hot Tubs. http://www.cpsc.gov//PageFiles/118868/5039.pdf.
National Fire Protection Association (NFPA). 2011. NFPA 70: National electrical code. 2011 ed. Quincy, MA: NFPA.

Standard 5.2.5.1: Smoke Detection Systems and Smoke Alarms

In centers with new installations, a smoke detection system (such as hard-wired system detectors with battery back-up system and control panel) or monitored wireless battery operated detectors that automatically signal an alarm through a central control panel when the battery is low or when the detector is triggered by a hazardous condition should be installed with placement of the smoke detectors in the following areas:

Each story in front of doors to the stairway;
Corridors of all floors;
Lounges and recreation areas;
Sleeping rooms.

In large and small family child care homes, smoke alarms that receive their operating power from the building electrical system or are of the wireless signal-monitored-alarm system type should be installed. Battery-operated smoke alarms should be permitted provided that the facility demonstrates to the fire inspector that testing, maintenance, and battery replacement programs ensure reliability of power to the smoke alarms and signaling of a monitored alarm when the battery is low and that retrofitting the facility to connect the smoke alarms to the electrical system would be costly and difficult to achieve.

Facilities with smoke alarms that operate using power from the building electrical system should keep a supply of batteries and battery-operated detectors for use during power outages.

RATIONALE

Because of the large number of children at risk in a center, up-to-date smoke detection system technology is needed. Wireless smoke alarm systems that signal and set off a monitored alarm are acceptable. In large and small family child care homes, single-station smoke alarms are acceptable. However, for all new building installations where access to enable necessary wiring is available, smoke alarms should be used that receive their power from the building’s electrical system. These hard-wired detecting systems typically have a battery operated back-up system for times of power outage. The hard-wired and wireless smoke detectors should be interconnected so that occupants receive instantaneous alarms throughout the facility, not just in the room of origin. Single-station batteries are not reliable enough; single-station battery-operated smoke alarms should be accepted only where connecting smoke detectors to existing wiring would be too difficult and expensive as a retrofitted arrangement.

COMMENTS

Some state and local building codes specify the installation and maintenance of smoke detectors and fire alarm systems. For specific information, see the NFPA 101: Life Safety Code (1) and the NFPA 72: National Fire Alarm and Signaling Code from the National Fire Protection Association.

The Federal Emergency Management Agency (FEMA) has an online coloring book that can be printed and used to teach children about fire safety at https://www.usfa.dhs.gov/applications/publications/display.cfm?id=208/.

TYPE OF FACILITY

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

RELATED STANDARDS

5.1.1.3 Compliance with Fire Prevention Code

REFERENCES

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

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

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

RATIONALE

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

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

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

COMMENTS

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

Standard 5.2.7.6: Storage and Disposal of Infectious and Toxic Wastes

Infectious and toxic wastes should be stored separately from other wastes, and should be disposed of in a manner approved by the regulatory health authority.

RATIONALE

This practice provides for safe storage and disposal of infectious and toxic wastes.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.9.1 Use and Storage of Toxic Substances
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
5.2.9.4 Radon Concentrations
5.2.9.5 Carbon Monoxide Detectors
5.2.9.6 Preventing Exposure to Asbestos or Other Friable Materials
5.2.9.7 Proper Use of Art and Craft Materials
5.2.9.8 Use of Play Dough and Other Manipulative Art or Sensory Materials
5.2.9.9 Plastic Containers and Toys
5.2.9.10 Prohibition of Poisonous Plants
5.2.9.11 Chemicals Used to Control Odors
5.2.9.12 Treatment of CCA Pressure-Treated Wood
5.2.9.13 Testing for and Remediating Lead Hazards
5.2.9.14 Shoes in Infant Play Areas
5.2.9.15 Construction and Remodeling

Standard 5.2.8.1: Integrated Pest Management

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

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

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

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

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

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

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

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

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

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

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

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

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

RATIONALE

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

COMMENTS

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

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

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

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

TYPE OF FACILITY

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

REFERENCES

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

Standard 5.2.9.1: Use and Storage of Toxic Substances

Content in the STANDARD was modified on 1/12/2017 and 1/31/2023.

Programs should use the following items only in the way the manufacturer recommends, and store them away from children in the labeled, child-proof container they came in:^1–3

Cleaning materials

Detergents (in all forms, including pods)
Automatic dishwasher detergents (liquid or solid, including pods)
Aerosol cans
Paints, solvents, paint removers
Floor polish or stripper, furniture polish
Liquid soap, hand sanitizers, disinfectants
Pesticides
Health and beauty products
Lawn care chemicals

Medications/Substances

Medications (prescription and over-the-counter)
Marijuana –medical and recreational

all forms, including oils, liquids, and edible products and equipment

Liquid nicotine and tobacco products
Alcohol

Other toxic materials

Many of the chemicals and toxic substances listed above will not be found in child care centers. Many of these items may be present in small and large family child care homes. In states that allow recreational or medicinal marijuana, use extra care to store edible marijuana products securely¾and away from other foods and from the children’s medications¾to avoid accidentally giving them to children or children finding and ingesting them. State regulations usually require these products to be clearly labeled as an intoxicating substance and to be stored in the tamper-proof, child-resistant package they came in. In an early childhood program that takes place in a family home, keep all edible, adult medications, including nicotine, marijuana products and other substances, in a locked or child-resistant storage container. Accidentally eating these products can lead to serious adverse events, especially in children.⁴

Early care and education programs should store any potentially toxic substances behind doors/cabinets with child-resistant locks/latches. A locked cabinet or room that children cannot open or enter is best, but it must be locked all the time. Storing potentially toxic substances in child-resistant containers is another level of protection.

Safety data sheets (SDSs) must be available on site for each hazardous chemical that the program has. When you use chemicals, don’t let them contaminate play surfaces, food, or food preparation areas. Don’t use them in a way that is dangerous to children or staff. Chemicals for lawns must be safe for children if children use those areas of the lawn. When you are not using chemicals, keep them away from children by storing all chemicals in a locked room or cabinet with a child-resistant lock or latch. Store them separately from medications and food.

Medications can be toxic if taken by the wrong person or in the wrong dose. Store medications safely in child-resistant containers¾preferably in a locked cupboard or cabinet¾away from children nd discard them properly (see Standard 3.6.3.2).

Post the telephone number for the poison control center in a place where it is immediately available in emergencies. Poison control centers are open 24 hours a day, 7 days a week, and their number is 800-222-1222 (see Standard 5.2.9.2).

RATIONALE

Over 2 million human poisonings are reported to poison centers every year. Children under 6 make up more than half of those poisonings. The most common sources of childhood poisonings are health and beauty products, cleaning products, and medications.⁵A safety data sheet, or SDS, is a standardized document that has occupational safety and health information. The International Hazard Communication Standard (HCS) orders chemical manufacturers to inform the users of a chemical’s potential danger by giving the user an SDS. SDSs usually list chemical properties, health and environmental hazards, protective measures, and safety advice for storing, and handling of chemicals.⁶The SDS explains the risk of exposure to products so that users can be careful.

Many child-resistant locks or latches can be put on doors or cabinets to keep young children from getting to poisons. Many of these devices lock automatically when the door is closed, and they need an adult’s hand or skill to open the door.

Many adult medications, vitamins, marijuana, and other products now look like candy or gummies. Using separate, locked medication cabinets helps prevent child exposure and mistakes that early care and education program staff can make.

TYPE OF FACILITY

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

RELATED STANDARDS

3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs
3.6.3.1 Medication Administration
3.6.3.2 Labeling, Storage, and Disposal of Medications
5.2.8.1 Integrated Pest Management
5.2.9.3 Informing Staff Regarding Presence of Toxic Substances
9.2.3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks
5.2.9.2 Use of a Poison Center
Appendix J: Selection and Use of a Cleaning, Sanitizing or Disinfecting Product
Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting

REFERENCES

Jung L, Fan N-C, Yao T-C, et al. Clinical spectrum of acute poisoning in children admitted to the pediatric emergency department. Pediatrics & Neonatology. 2019;60(1):59-67
Davis MG, Casavant MJ, Spiller HA, Chounthirath T, Smith GA. Pediatric exposures to laundry and dishwasher detergents in the United States: 2013–2014. Pediatrics. 2016. doi: 10.1542/peds.2015-4529
http://pediatrics.aappublications.org/content/early/2016/04/21/peds.2015-4529
United States Environmental Protection Agency. Pesticides and their impact on children: key facts and talking points. 2015. https://www.epa.gov/sites/default/files/2015-12/documents/pest-impact-hsstaff.pdf. Accessed August 3, 2022
United States Food and Drug Administration. FDA warns consumers about the accidental ingestion by children of food products containing THC. June 16, 2022. https://www.fda.gov/food/alerts-advisories-safety-information/fda-warns-consumers-about-accidental-ingestion-children-food-products-containing-thc.Accessed August 3, 2022
American Association of Poison Control Centers’ National Poison Data System. Annual Reports. Poison center data snapshots (2012-2020). AAPCC.org Web site. https://www.aapcc.org/annual-reports. Accessed August 3, 2022
Chemical Safety. Safety Data Sheet Search. ChemicalSafety.com Web site. https://chemicalsafety.com/sds-search/. Accessed September 19, 2022

NOTES

Content in the STANDARD was modified on 1/12/2017 and 1/31/2023.

Standard 5.2.9.2: Use of a Poison Center

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

The Poison Control phone number, 1-800-222-1222, should be called for advice about any exposure to toxic substances or potential poisoning as soon as possible after exposure. Toxic substances could include medications, plants, berries or mushrooms, bites or stings, cleaning products, consumer products, and other chemicals. Exposure to toxic substances can happen if children swallow, inhale, or splash a product on their eyes or skin. Some common poisoning symptoms include dermatitis, dizziness, drowsiness, disorientation and/or sudden changes in behavior, nausea/vomiting, diarrhea, trouble breathing, pain, headaches, and feeling faint.^1,2If a child is unconscious, has a seizure, or is having trouble breathing, call 911 immediately.

Caregivers/teachers should feel comfortable calling Poison Control about medication dosing errors. The caregiver/teacher should not induce vomiting unless instructed by Poison Control.

The caregiver/teacher should be prepared for the call by having the following information for the Poison Control specialist:

The child’s age and sex
The substance involved
The estimated amount
The child’s condition
The time elapsed since ingestion or exposure

The national help line for Poison Control is 1-800-222-1222, and specialists will link the caregiver/teacher with their local poison center.³The national help line number should be posted in a visible location or be added to a phone/contact list. Poison centers provide free, confidential advice on how to handle the situation. The advice should be followed and documented in the early care and education program’s files.

Depending on the cause prompting a call to poison control there may be a need for updated education on the subject for caregivers/teachers and/or children as well as implementation of improved health and safety practices.

RATIONALE

Toxic substances, when ingested, inhaled, or in contact with skin, may react immediately or slowly, with serious symptoms occurring much later.³ It is important for the caregiver/teacher to call Poison Control immediately after the exposure and not “wait and see.”⁴Symptoms of poisoning vary with the type of substance involved.

Caregivers/teachers should be knowledgeable and intentional about keeping all potential poisonous or harmful substances out of reach of children so that poisonings or ingestion of harmful substances are not treated as possible maltreatment cases, resulting in false, inappropriate criminal and protective services investigations of the ECE program.⁵

COMMENTS

Caregivers/teachers can go to www.aapcc.org or https://www.poison.org for additional information on poisoning and poison safety. They can also access a variety of services that poison centers have, such as poison prevention; poison control; information about toxic substances, including lead and chemicals that may be found in consumer products; and assistance with disaster planning.

ADDITIONAL RESOURCES

Early care and education programs can also use the webPoisonControl online tool (www.poison.org or https://triage.webpoisoncontrol.org) for questions about a poison or to obtain poison prevention information.⁵

Poison Prevention & Treatment Tips
https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Poison-Prevention.aspx

TYPE OF FACILITY

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

RELATED STANDARDS

1.4.1.1 Pre-service Training
1.4.3.2 Topics Covered in Pediatric First Aid Training
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.10 Prohibition of Poisonous Plants
Appendix P: Situations that Require Medical Attention Right Away

REFERENCES

NorthShore University HealthSystem. NorthShore medical toxicology. Symptoms of poisoning, exposures & treatments. https://www.northshore.org/toxicology/symptoms-of-poisoning. Accessed May 18, 2020
KidsHealth. First aid: poisoning. https://kidshealth.org/en/parents/poisoning-sheet.html. Reviewed July 2018. Accessed May 18, 2020
Poison Control, National Capital Poison Center. Get help from Poison Control online or by phone. https://www.poison.org/18002221222. Accessed May 18, 2020
American Academy of Pediatrics. Poison prevention & treatment tips. HealthyChildren.org website. https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Poison-Prevention.aspx. Updated March 15, 2019. Accessed May 18, 2020
Hines, E. (2016). Child abuse by poisoning. Clinical Pediatric Emergency Medicine, 17(4), 296-301.

NOTES

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

Standard 5.2.9.3: Informing Staff Regarding Presence of Toxic Substances

Employers should provide staff with hazard information, including access to and review of the Safety Data Sheets (SDS) as required by the Occupational Safety and Health Administration (OSHA), about the presence of toxic substances such as formaldehyde, cleaning and sanitizing supplies, insecticides, herbicides, and other hazardous chemicals in use in the facility. Staff should always read the label prior to use to determine safety in use. For example, toxic products regulated by the Environmental Protection Agency (EPA) will have an EPA signal word of CAUTION, WARNING, or DANGER. Where nontoxic substitutes are available, these nontoxic substitutes should be used instead of toxic chemicals. If a nontoxic product is not available, caregivers/teachers should use the least toxic product for the job. A CAUTION label is safer than a WARNING label, which is safer than a DANGER label.

RATIONALE

These precautions are essential to the health and well-being of the staff and the children alike. Many cleaning products and art materials contain ingredients that may be toxic. Regulations require employers to make the complete identity of these materials known to users. Because nontoxic substitutes are available for virtually all necessary products, exchanging them for toxic products is required.

COMMENTS

The U.S. Department of Labor, which oversees OSHA, is responsible for protection of workers and is listed in the phone books of all large cities. Because standards change frequently, the facility should seek the latest standards from the EPA. Information on toxic substances in the environment is available from the EPA. For information on consumer products contact the U.S. Consumer Product Safety Commission (CPSC). For information on art and craft materials, contact the Art and Creative Materials Institute (ACMI). The local health jurisdiction can also be a resource for information on hazardous chemicals in child care.

The SDS explains the risk of exposure to products so that appropriate precautions may be taken.

TYPE OF FACILITY

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

RELATED STANDARDS

5.2.8.1 Integrated Pest Management
5.2.9.1 Use and Storage of Toxic Substances
5.2.9.7 Proper Use of Art and Craft Materials
6.3.2.3 Pool Equipment and Chemical Storage Rooms
6.3.4.2 Chlorine Pucks

REFERENCES

Wargo, J. 2004. The physical school environment: An essential component of a health-promoting school. WHO Information series on School Health, document 2. Geneva: WHO. http://www.who.int/school_youth_health/media/en/physical_sch_environment.pdf.
Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.

Standard 5.2.9.4: Radon Concentrations

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

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

RATIONALE

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

COMMENTS

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 5.2.9.5: Carbon Monoxide Detectors

Carbon monoxide detector(s) should be installed in child care settings if one of the following guidelines is met:

The child care program uses any sources of coal, wood, charcoal, oil, kerosene, propane, natural gas, or any other product that can produce carbon monoxide indoors or in an attached garage;
If detectors are required by state/local law or state licensing agency.

Facilities must meet state or local laws regarding carbon monoxide detectors. Detectors should be tested monthly. Batteries should be changed at least yearly. Detectors should be replaced at least every five years.

RATIONALE

Carbon monoxide (CO) is a deadly, colorless, odorless, poisonous gas. It is produced by the incomplete burning of various fuels, including coal, wood, charcoal, oil, kerosene, propane, and natural gas. Products and equipment powered by internal combustion engine-powered equipment such as portable generators, cars, lawn mowers, and power washers also produce carbon monoxide. Carbon monoxide detectors are the only way to detect this substance.

Carbon monoxide poisoning causes symptoms that mimic the flu; mild symptoms are typically headache, dizziness, fatigue, nausea, and diarrhea. Prolonged exposure can cause confusion, shortness of breath, unconsciousness, and even death.

On average, about 170 people in the United States die every year from carbon monoxide produced by non-automotive consumer products (1). These products include malfunctioning fuel-burning appliances such as furnaces, ranges, water heaters, and room heaters; engine-powered equipment such as portable generators; fireplaces; and charcoal that is burned in homes and other enclosed areas. In 2005 alone, the U.S. Consumer Product Safety Commission (CPSC) staff was aware of at least ninety-four generator-related carbon monoxide poisoning deaths (1). Still others die from carbon monoxide produced by non-consumer products, such as cars left running in attached garages. The Centers for Disease Control and Prevention (CDC) estimate that several thousand people go to hospital emergency rooms every year to be treated for carbon monoxide poisoning (1).

COMMENTS

Carbon monoxide detectors should be installed according to the manufacturer’s instructions. One carbon monoxide detector should be installed in the hallway outside the bedrooms in each separate sleeping area. Carbon monoxide detectors may be installed into a plug-in receptacle or high on the wall. Hard-wired or plug-in carbon monoxide detectors should have battery backup. Installing carbon monoxide detectors near heating vents, locations that can be covered by furniture or draperies, above fuel-burning appliances or in kitchens should be avoided (1).

There are a number of safety steps that child care programs can do to help prevent carbon monoxide exposure (1-3):

Make sure major appliances are professionally installed and inspected according to local building codes and have older appliances checked for malfunctions and leaks;
Choose vented appliances when possible;
Have heating systems inspected and cleaned by a qualified technician annually and make sure the chimney is clean and with a proper draft control to ensure a proper vent for flue gases;
Check the color of the flame in the burner and pilot light (a yellow-colored flame indicates the fuel is not burning efficiently and could be releasing more carbon monoxide) (4);
Never use a gas oven to heat your facility;
Do not burn charcoal indoors;
Never operate gasoline-powered engines or generators in confined areas in or near the building;
Never leave a vehicle running in a garage or closed area. Even if the garage door is open, normal circulation will not supply enough fresh air to prevent a buildup of CO gas;
If the CO alarm goes off or if you have symptoms of CO poisoning, exit the building and call 9-1-1.

For other questions on CO poisoning call the poison center.

TYPE OF FACILITY

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

REFERENCES

Safe Kids Worldwide. Home Safety Fact Sheet. http://www.safekids.org/fact-sheet/home-safety-fact-sheet-2015-pdf.
Cowling, T. 2007. Safety first: Carbon monoxide poisoning. Healthy Child Care 10(5): 6-7. http://www.safekids.org/safetytips/field_risks/carbon-monoxide.
U.S. Consumer Product Safety Commission (CPSC). 2008. Carbon monoxide questions and answers. Document #466. Bethesda, MD: CPSC. https://www.cpsc.gov/safety-education/safety-guides/home/asbestos-home.
Tremblay, K. R., Jr. 2006. Preventing carbon monoxide problems. Colorado State University Extension. http://www.ext.colostate.edu/pubs/consumer/09939.html.

Standard 5.2.9.13: Testing for and Remediating Lead Hazards

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

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

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

All ECE facilities built before 1978

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

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

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

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

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

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

RATIONALE

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

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

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

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

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

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

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

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

COMMENTS

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

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

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

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

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

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

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

ADDITIONAL RESOURCES

General Contacts

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

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

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

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

Lead in Paint Contacts

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

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

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

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

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

Lead in Soil Contacts

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

Lead in Water Contacts

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

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

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

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

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

Lead in Consumer Products Contacts

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

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

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

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

TYPE OF FACILITY

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

RELATED STANDARDS

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

REFERENCES

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

NOTES

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

Standard 5.3.1.1: Indoor and Outdoor Equipment, Materials, and Furnishing

Standard was last updated on September 13, 2022.

Early care and education programs should make sure that equipment, materials, and furnishings, accessible to children both indoors and outdoors, are sturdy, in good condition, safe to use, and used only as intended by the manufacturer. The equipment, materials, and furnishings in the program should meet the safety recommendations of the U.S. Consumer Product Safety Commission and ASTM International.

Program leadership and staff should:

Prevent children from accessing equipment, materials, and furnishings that are unsafe, such as items that
- Are known to be hazardous (e.g., infant walkers, inclined sleepers, trampolines)
- Are not developmentally appropriate for a child’s age or size (e.g., intended for older children)
- Are raised above the ground or floor (e.g., playground platforms, step stools) and have neither guardrails nor protective barriers
- Have sharp corners or points
- Have openings that could entrap a child’s body parts (e.g., head or fingers)
- Have small parts that may detach and be choking, breathing or swallowing hazards
- Can pinch, sheer, or crush body parts
Remove or make tip-over hazards secure, including
- Unstable furnishings or unsecured equipment (e.g., bookshelves, dressers, televisions, indoor climbing equipment)
- Playground equipment that is loosely anchored to the ground
Remove tripping hazards (e.g., rugs, electrical extension cords).
Remove strangulation hazards (e.g., cords, straps, strings), or make them secure or inaccessible to children.
Remove or repair equipment, materials, and furnishings that are worn, damaged, or in poor condition, such as items with
- Loose, rusty, or cracked parts
- Rotted or split wood or plastic pieces that can cause splinters or other injuries
- Protruding nails, bolts, or other components that could cause injury
- Missing or damaged protective caps or plugs
- Flaking paint or paint that may have lead or other hazardous materials
Prevent children from playing with or on
- Outdoor equipment, materials, and furnishings that are too hot or cold to use
- Equipment that is spaced too closely together for safety
- Climbing equipment or swings installed on surfaces that cannot absorb the impact of a fall
Inspect newly acquired equipment and furnishings carefully to decide if they meet this standard before allowing children to use the items.
Check that the U.S. Consumer Product Safety Commission (CPSC) for safety hazards has not recalled toys and equipment (see Standard 5.3.1.2: Product Recall Monitoring) by
- Reading the CPSC recall list regularly, and/or subscribing to an email notification list from the CPSC.

RATIONALE

Young children in early care and education programs are at risk for unintentional injuries indoors and outdoors. Awareness of potential hazards and proper choice, use, and maintenance of equipment, materials, and furnishings can help prevent injuries. The CPSC collaborates with ASTM International, an international organization that develops and communicates technical standards, in determining safety and testing standards for many products for children.¹ This standard lists hazards often associated with injury and death by CPSC.^2,3,4

Equipment and furnishings that are not sturdy, safe, or in good condition may cause falls, trap a child’s head or limbs, or contribute to other injuries.^2,3,4 Regardless of their condition, some types of equipment are simply dangerous to use in early care and education programs (e.g., baby walkers, trampolines, inclined sleepers).^5.6 Others are dangerous when used in ways the manufacturer did not intend or when directions are not followed (e.g., not buckling safety belts, using infant bouncers or car seats for napping).^7,8 Although emergency department visits due to tip-overs of televisions and furniture declined in recent years, tip-overs are still an important risk for injury of children younger than 6.⁹

Playground equipment and materials have many potential hazards.¹⁰More than a third of emergency visits for playground injuries involve pre-school children.¹¹ Falls from climbing structures cause the most serious injuries in early care and education programs.^11,12However, knowing the surface temperature of outdoor playground equipment (metal and plastic) is also important to make sure children are playing safely. Staff should also pay attention to the temperature of other materials or furnishings (e.g., slides, steps, railings, metal picnic tables). Metal and other surfaces exposed to sun can quickly reach high temperatures that can burn a child’s skin in seconds.³ (See Burn Safety Awareness on Playgrounds, a CPSC factsheet about preventing thermal burns.¹³)

Young children’s intake of lead dust and particles from artificial turf, playground surfaces, and lead-based paint on older playground equipment and furnishings is very hazardous to their health and development.¹⁴(See Standard 5.2.9.13: Testing for and Remediating Lead Hazards.. Directors and program staff need to pay attention to the safety and condition of new and existing equipment, materials, and furnishings to remove or fix potential hazards.

COMMENTS

For more information on specific requirements and safety considerations for many types of equipment, materials, and furnishings (e.g., infant equipment, playground surfaces, and inspections), see the Related Standards below. The CCHP Health and Safety Checklist,¹⁵a CFOC-based resource from the California Childcare Health program, has sections on indoor and outdoor equipment and furnishings that may help programs assess hazards in this standard and related standards. Child care health consultants or other appropriately trained staff can help find resources to review the safety of equipment, materials, and furnishings in programs.

The National Program for Playground Safety (NPPS) at the University of Northern Iowa offers the Playground Safety Report Card.¹⁰ The tool is useful to assess the safety of playground equipment and what to correct or improve.¹⁰

For more information on lead hazards, visit the Environmental Protection Agency (EPA) Web page, Protect Your Family from Sources of Lead.¹⁶Also see Standard 5.2.9.13: Testing for and Remediating Lead Hazards and Standard 5.2.9.15: Building Construction and Renovation Safety. Home-based early care and education programs may refer to The Lead-Safe Toolkit for Home-Based Child Care.¹⁷

TYPE OF FACILITY

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

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
3.4.6.1 Strangulation Hazards
5.1.5.4 Guards at Stairway Access Openings
5.1.6.6 Guardrails and Protective Barriers
5.2.9.13 Testing for and Remediating Lead Hazards
4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition
4.5.0.2 Tableware and Feeding Utensils
5.1.1.4 Accessibility of Facility
5.1.3.5 Finger-Pinch Protection Devices
5.1.5.1 Balusters
5.2.9.15 Construction and Remodeling
5.3.1.2 Product Recall Monitoring
5.3.1.3 Size of Furniture
5.3.1.5 Placement of Equipment and Furnishings
5.3.1.6 Floors, Walls, and Ceilings
5.3.1.8 High Chair Requirements
5.3.1.9 Carriage, Stroller, Gate, Enclosure, and Play Yard Requirements
5.3.1.10 Restrictive Infant Equipment Requirements
5.3.1.11 Exercise Equipment
5.3.1.12 Availability and Use of a Telephone or Wireless Communication Device
5.3.2.1 Therapeutic and Recreational Equipment
5.3.2.2 Special Adaptive Equipment
5.3.2.3 Storage for Adaptive Equipment
5.3.2.4 Orthotic and Prosthetic Devices
5.4.5.2 Cribs
5.4.5.3 Stackable Cribs
5.4.5.5 Bunk Beds
5.7.0.1 Maintenance of Exterior Surfaces
6.1.0.4 Elevated Play Areas
9.2.6.1 Policy on Use and Maintenance of Play Areas
6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

REFERENCES

Earls A. The CPSC and ASTM Collaboration: the consensus process plays a growing role in ensuring child-safe products. Standardization News. 2011;January/February. Accessed May 2, 2022. https://sn.astm.org/?q=features/cpsc-and-astm-collaboration-jf11.html
California Childcare Health Program. CCHP health and safety checklist. University of California San Francisco Web site. Updated July 2020. Accessed April 18, 2022. https://cchp.ucsf.edu/content/cchp-health-and-safety-checklist
Council on Environmental Health. Prevention of childhood lead toxicity. Pediatrics. 2016;138(1):e20161493. doi:10.1542/peds.2016-1493
Consumer Product Safety Commission. CPSC Fact Sheet: Burn Safety Awareness on Playgrounds. U.S. Consumer Product Safety Commission Publication 3200 042012. Published April 2012. Accessed May 2, 2022. https://www.cpsc.gov/s3fs-public/3200.pdf
Hashikawa AN, Newton MF, Cunningham RM, Stevens MW. Unintentional injuries in child care centers in the United States: a systematic review. J Child Health Care. 2015;19(1):93-105. doi:10.1177/1367493513501020
Nabavizadeh B, Hakam N, Holler JT, et al. Epidemiology of child playground equipment-related injuries in the USA: emergency department visits, 1995-2019. J Paediatr Child Health. 2022;58(1):69-76. doi:10.1111/jpc.15644
National Program for Playground Safety. Safety Report Card. National Program for Playground Safety Web site. Published 2004. Accessed April 18, 2022. https://playgroundsafety.org/sites/default/files/2020-08/blank-report-card.pdf
U.S. Environmental Protection Agency. Protect your family from sources of lead: soil, yards and playgrounds. U.S. Environmental Protection Agency Web site. Accessed April 18, 2022. https://www.epa.gov/lead/protect-your-family-sources-lead#soil
Lu C, Badeti J, Mehan TJ, Zhu M, Smith GA. Furniture and television tip-over injuries to children treated in United States emergency departments. Inj Epidemiol. 2021;8(1):53. Published 2021 Aug 27. doi:10.1186/s40621-021-00346-6
Liaw P, Moon RY, Han A, Colvin JD. Infant deaths in sitting devices. Pediatrics. 2019;144(1):e20182576. doi:10.1542/peds.2018-2576
Smith GA. Injuries to children in the United States related to trampolines, 1990-1995: a national epidemic. Pediatrics. 1998;101(3 Pt 1):406-412. doi:10.1542/peds.101.3.406
Sims A, Chounthirath T, Yang J, Hodges NL, Smith GA. Infant walker-related injuries in the United States. Pediatrics. 2018;142(4):e20174332. doi:10.1542/peds.2017-4332
O’Brien C. Injuries and investigated deaths associated with playground equipment, 2001–2008. U.S. Consumer Product Safety Commission. Published October 29, 2009. Accessed April 18, 2022. https://www.cpsc.gov/s3fs-public/pdfs/playground.pdf
U.S. Consumer Product Safety Commission. Public playground safety handbook. U.S. Consumer Product Safety Commission Web site. Published December 2015. Accessed April 18, 2022. https://www.cpsc.gov/s3fs-public/325.pdf
U.S. Consumer Product Safety Commission. Toys & children products: injury statistics. National Electronic Injury Surveillance System (NEISS). U.S. Consumer Product Safety Commission Web site. Published December 13, 2021. Accessed April 18. 2022. https://www.cpsc.gov/Research--Statistics/Toys-and-Childrens-Products
Chaudhary S, Figueroa J, Shaikh S, et al. Pediatric falls ages 0-4: understanding demographics, mechanisms, and injury severities. Inj Epidemiol. 2018;5(Suppl 1):7. Published 2018 Apr 10. doi:10.1186/s40621-018-0147-x
Children’s Environmental Health Network, National Center for Healthy Housing, and National Association for Family Child Care. Lead-safe toolkit for home-based child care. National Center for Health Housing Web site. Published 2019. Accessed April 18, 2022. https://nchh.org/tools-and-data/technical-assistance/protecting-children-from-lead-exposures-in-child-care/hbcc-toolkit/

NOTES

Standard was last updated on September 13, 2022.

Standard 5.3.1.12: Availability and Use of a Telephone or Wireless Communication Device

Content in the STANDARD was modified on 05/21/2019.

A wireless phone should be available to all caregivers/teachers in the event of an emergency or emergency evacuation away from the primary early care and education building. Early care and education programs should have access to at least one landline or one wireless communication device (cellular phone) for general and emergency use

On the premises of the child care facility
In each vehicle used when transporting children
On field trips

While operating a motor vehicle to transport children, drivers should not use wireless communication devices when the vehicle is in motion. Drivers should never send and receive text messages, use social media, or use other mobile applications (“apps”)—with the exception of the use of a navigational or global positioning system device—while transporting children.

RATIONALE

Using cellular devices while driving can divert attention away from the roadway, increasing the risk of motor vehicle crashes.¹ Wired or landline communication devices continue to be important in early care and education programs. Using a wireless device to call 911 can make locating the caller more complicated than when using a wired or landline device to call 911, as landline numbers are associated with a fixed address.²

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.4.3.1 Medical Emergency Procedures
5.6.0.1 First Aid and Emergency Supplies
9.2.4.3 Disaster Planning, Training, and Communication
6.5.1.1 Competence and Training of Transportation Staff
6.5.2.5 Distractions While Driving

REFERENCES

McDonald CC, Kennedy E, Fleisher L, Zonfrillo MR. Factors associated with cell phone use while driving: a survey of parents and caregivers of children ages 4-10 years. J Pediatr. 2018;201:208–214
US Federal Communications Commission. Emergency communications. https://www.fcc.gov/consumers/guides/emergency-communications. Updated March 28, 2018. Accessed December 20, 2018

NOTES

Content in the STANDARD was modified on 05/21/2019.

Standard 5.4.5.2: Cribs

Facilities should check each crib before its purchase and use to ensure that it is in compliance with the current U.S. Consumer Product Safety Commission (CPSC) and ASTM safety standards.

Recalled or “second-hand” cribs should not be used or stored in the facility. When it is determined that a crib is no longer safe for use in the facility, it should be dismantled and disposed of appropriately.

Staff should only use cribs for sleep purposes and should ensure that each crib is a safe sleep environment. No child of any age should be placed in a crib for a time-out or for disciplinary reasons. When an infant becomes large enough or mobile enough to reach crib latches or potentially climb out of a crib, they should be transitioned to a different sleeping environment (such as a cot or sleeping mat).

Each crib should be identified by brand, type, and/or product number and relevant product information should be kept on file (with the same identification information) as long as the crib is used or stored in the facility.

Staff should inspect each crib before each use to ensure that hardware is tightened and that there are not any safety hazards. If a screw or bolt cannot be tightened securely, or there are missing or broken screws, bolts, or mattress support hangers, the crib should not be used.

Safety standards document that cribs used in facilities should be made of wood, metal, or plastic. Crib slats should be spaced no more than two and three-eighths inches apart, with a firm mattress that is fitted so that no more than two fingers can fit between the mattress and the crib side in the lowest position. The minimum height from the top of the mattress to the top of the crib rail should be twenty inches in the highest position. Cribs with drop sides should not be used. The crib should not have corner post extensions (over one-sixteenth inch). The crib should have no cutout openings in the head board or footboard structure in which a child’s head could become entrapped. The mattress support system should not be easily dislodged from any point of the crib by an upward force from underneath the crib. All cribs should meet the ASTM F1169-10a Standard Consumer Safety Specification for Full-Size Baby Cribs, F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards, or the CPSC 16 CFR 1219, 1220, and 1500 – Safety Standards for Full-Size Baby Cribs and Non-Full-Size Baby Cribs; Final Rule.

Cribs should be placed away from window blinds or draperies.

As soon as a child can stand up, the mattress should be adjusted to its lowest position. Once a child can climb out of his/her crib, the child should be moved to a bed. Children should never be kept in their crib by placing, tying, or wedging various fabric, mesh, or other strong coverings over the top of the crib.

Cribs intended for evacuation purpose should be of a design and have wheels that are suitable for carrying up to five non-ambulatory children less than two years of age to a designated evacuation area. This crib should be used for evacuation in the event of fire or other emergency. The crib should be easily moveable and should be able to fit through the designated fire exit.

RATIONALE

Standards have been developed to define crib safety, and staff should make sure that cribs used in the facility meet these standards to protect children and prevent injuries or death (1-3). Significant changes to the ATSM and CPSC standards for cribs were published in December 2010. As of June 28, 2011 all cribs being manufactured, sold or leased must meet the new stringent requirements. Effective December 28, 2012 all cribs being used in early care and education facilities including family child care homes must also meet these standards. For the most current information about these new standards please go to http://www.cpsc.gov/info/cribs/index.html.

More infants die every year in incidents involving cribs than with any other nursery product (4). Children have become trapped or have strangled because their head or neck became caught in a gap between slats that was too wide or between the mattress and crib side.

An infant can suffocate if its head or body becomes wedged between the mattress and the crib sides (6).

Corner posts present a potential for clothing entanglement and strangulation (5). Asphyxial crib deaths from wedging the head or neck in parts of the crib and hanging by a necklace or clothing over a corner post have been well-documented (6).

Children who are thirty-five inches or taller in height have outgrown a crib and should not use a crib for sleeping (4). Turning a crib into a cage (covering over the crib) is not a safe solution for the problems caused by children climbing out. Children have died trying to escape their modified cribs by getting caught in the covering in various ways and firefighters trying to rescue children from burning homes have been slowed down by the crib covering (6).

CPSC has received numerous reports of strangulation deaths on window blind cords over the years (7).

COMMENTS

For more information on articles in cribs, see Standard 5.4.5.1: Sleeping Equipment and Supplies and Standard 6.4.1.3: Crib Toys.

A “safety-approved crib” is one that has been certified by the Juvenile Product Manufacturers Association (JPMA).

If portable cribs and those that are not full-size are substituted for regular full-sized cribs, they must be maintained in the condition that meets the ASTM F406-10b Standard Consumer Safety Specification for Non-Full-Size Baby Cribs/Play Yards. Portable cribs are designed so they may be folded or collapsed, with or without disassembly. Although portable cribs are not designed to withstand the wear and tear of normal full-sized cribs, they may provide more flexibility for programs that vary the number of infants in care from time to time.

Cribs designed to be used as evacuation cribs, can be used to evacuate infants, if rolling is possible on the evacuation route(s).

To keep window blind cords out of the reach of children, staff can use tie-down devices or take the cord loop and cut it in half to make two separate cords. Consumers can call 1-800-506-4636begin_of_the_skype_highlighting 1-800-506-4636 end_of_the_skype_highlighting or visit the Window Covering Safety Council Website at http://windowcoverings.org to receive a free repair kit for each set of blinds.

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction
5.4.5.1 Sleeping Equipment and Supplies
5.4.5.3 Stackable Cribs
6.4.1.3 Crib Toys

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe?http://www.cpsc.gov/cpscpub/pubs/5009a.pdf.
Juvenile Products Manufacturers Association. 2007. Safe and sound for baby: A guide to juvenile product safety, use, and selection. 9th ed. Moorestown, NJ: JPMA. http://www.jpma.org/content/retailers/safe-and-sound/.
U.S. Consumer Product Safety Commission (CPSC). 1996. CPSC warns parents about infant strangulations caused by failure of crib hardware. http://www.ridgevfd.org/content/prevent/sleepwear.pdf
U.S. Consumer Product Safety Commission (CPSC). 1997. The safe nursery. Washington, DC: CPSC.http://www.cpsc.gov/cpscpub/pubs/202.pdf.
U.S. Consumer Product Safety Commission (CPSC). 2010. Safety standards for full-size baby cribs and non-full-size baby cribs; final rule. 16 CFR 1219, 1220, and 1500.http://www.cpsc.gov/businfo/frnotices/fr11/cribfinal.pdf.
ASTM International. 2010. ASTM F406-10b: Standard consumer safety specification for non-full-size baby cribs/play yards. West Conshohocken, PA: ASTM.
ASTM International. 2010. ASTM F1169-10a: Standard consumer safety specification for full-size baby cribs. West Conshohocken, PA: ASTM.

Standard 5.5.0.6: Inaccessibility to Matches, Candles, and Lighters

Matches, candles, and lighters should not be accessible to children.

RATIONALE

The U.S. Consumer Product Safety Commission (CPSC) estimates that 150 deaths occur each year from fires started by children playing with lighters. Children under five-years-old account for most of these fatalities (1). A child playing with candles or near candles is one of the biggest contributors to candle fires (2). Matches have also been the source of some fire-related deaths. Children may hide in a closet or under a bed when faced with fire, leading to fatalities (2).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Miller, D., R. Chowdhury, M. Greene. 2009. 2004-2006 residential fire loss estimates. Washington, DC: U.S. Consumer Product Safety Commission (CPSC). http://www.cpsc.gov/LIBRARY/fire06.pdf.
U.S. Consumer Product Safety Commission (CPSC). Child-resistant lighters protect young children. Document #5021. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/
5021.html.

Standard 5.5.0.7: Storage of Plastic Bags

Plastic bags, whether intended for storage, trash, diaper disposal, or any other purpose, should be stored out of reach of children.

RATIONALE

Plastic bags have been recognized for many years as a cause of suffocation. Warnings regarding this risk are printed on diaper-pail bags, dry-cleaning bags, and so forth. The U.S. Consumer Product Safety Commission (CPSC) has received average annual reports of twenty-five deaths per year to children due to suffocation from plastic bags. Nearly 90% of the reported deaths were to children under the age of one (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

U.S. Consumer Safety Commission (CPSC). Children still suffocating with plastic bags. Document #5604. Bethesda, MD: CPSC. http://nurse.png.woodcrest.schoolfusion.us/modules/locker/files/get_group_file.phtml?fid=2333676&gid=572924&sessionid=e71cb1192f18078f5dbd2fbf4f1f63bb

Standard 5.5.0.8: Firearms

Centers should not have any firearms, pellet or BB guns (loaded or unloaded), darts, bows and arrows, cap pistols, stun guns, paint ball guns, or objects manufactured for play as toy guns within the premises at any time. If present in a small or large family child care home, these items must be unloaded, equipped with child protective devices, and kept under lock and key with the ammunition locked separately in areas inaccessible to the children. Parents/guardians should be informed about this policy.

RATIONALE

The potential for injury to and death of young children due to firearms is apparent (1-5). These items should not be accessible to children in a facility (2,3).

COMMENTS

Compliance is monitored via inspection.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Hemenway, D., D. Weil. 1990. Phasers on stun: The case for less lethal weapons. J Policy Analysis Management 9:94-98.
Katcher, M. L., A. N. Meister., C. A. Sorkness, A. G. Staresinic, S. E. Pierce, B. M. Goodman, N. M. Peterson, P. M. Hatfield, J. A. Schirmer. 2006. Use of the modified Delphi technique to identify and rate home injury hazard risks and prevention methods for young children. Injury Prev 12:189-94.
Grossman, D. C., B. A. Mueller, C. Riedy, et al. 2005. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA 296:707-14.
DiScala, C., R. Sege. 2004. Outcomes in children and young adults who are hospitalized for firearms-related injuries. Pediatrics 113:1306-12.
American Academy of Pediatrics, Committee on Injury and Poison Prevention. 2004. Policy statement: Firearm-related injuries affecting the pediatric population. Pediatrics 114:1126.

Standard 5.6.0.1: First Aid and Emergency Supplies

Content in the STANDARD was modified on 01/23/2020.

Early care and education programs should maintain fully equipped first aid kits in each classroom in case of an injury. The first aid kit should be kept in a container, cabinet, or drawer that is labeled and stored in a location that is known and accessible to staff at all times and out of reach of children. First aid kits in vehicles and classroom kits taken out for recess or a walk should be stored safely in a place that is out of reach of children. When children leave the facility for recess or a walk or to be transported, a designated staff member should bring a first aid kit in a portable device (eg, backpack) or otherwise ensure that a first aid kit is readily available.

Early care and education staff should inventory or check first aid supplies once a month and replace any used or expired items.¹ An itemized list of supplies and a written log should be kept that documents

The date that each inventory was conducted
Verification that expiration dates of supplies were checked
Location of supplies (eg, in the facility supply, transportable first aid kit[s])
The legal name/signature of the staff member who completed the inventory

Early care and education program directors should have plans/methods for verifying that these steps are taken as planned.

First Aid Items

The following first aid supplies should be in all classroom first aid kits ^{1(p463-464)-4:}

Adhesive bandages (assorted sizes) and tape
Antiseptic solution (hydrogen peroxide) or antiseptic wipes
Cold pack
Cotton-tipped swabs
Disposable powder-free, latex-free gloves
Eye patch
Fever-reducing medications (eg, acetaminophen/ibuprofen) to be used ONLY for children with an order from a primary health care provider and signed parental consent
Flexible roller gauze
Liquid hand soap and/or handwashing gels
Mouthpiece for giving cardiopulmonary resuscitation (CPR) (available from your local Red Cross)
Pen/pencil and note pad
Plastic bags (for disposing of blood and other body fluids)
Safety pins
Sanitary pads, individually wrapped (to contain bleeding of injuries)
Small scissors
Sterile eyewash
Sterile gauze pads (various sizes)
Thermometer—digital or tympanic (ear)—should not contain glass/mercury
Triangular bandages
Tweezers
Water (2 L of sterile water for cleaning wounds or eyes)

When children are on a walk or are transported to another location, the transportable first aid kit should include ALL items listed previously AND the following emergency information/items:

A roster of all children present
Contact information and list of approved family/guardians authorized for pickup
List of emergency phone numbers (eg, poison control, hospital/emergency facilities)
Special health care plans/emergency medications for both children and caregivers
Special health care documents
Signed emergency release forms for each child
First aid/choking/CPR chart (American Academy of Pediatrics or equivalent)
Up-to-date first aid manual
Written transportation policy and contingency plan (up-to-date and easily accessible)
Maps
Cell phone
Radio
Whistle
Flashlight

RATIONALE

Facilities must place emphasis on safeguarding each child and ensuring that staff members are prepared and able to handle emergencies.³ Well-stocked first aid and disaster/emergency supplies help ensure staff are prepared and able to handle possible emergencies and injuries.

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
1.4.3.2 Topics Covered in Pediatric First Aid Training
3.4.3.1 Medical Emergency Procedures
3.2.2.5 Hand Sanitizers
3.6.1.3 Guidelines for Taking Children’s Temperatures
4.9.0.8 Supply of Food and Water for Disasters
9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.2.5.1 Transportation Policy for Centers and Large Family Homes
Appendix NN: First Aid and Emergency Supply Lists

REFERENCES

American Academy of Pediatrics. PedFACTs: Pediatric First Aid for Caregivers and Teachers. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2014
KidsHealth. First-aid kit. https://kidshealth.org/en/parents/firstaid-kit.html. Reviewed August 2018. Accessed August 20, 2019
eXtension. First aid in child care. https://articles.extension.org/pages/25746/first-aid-in-child-care. Published September 14, 2015. Accessed August 20, 2019
Federal Emergency Management Agency. Emergency supply list. https://www.fema.gov/media-library-data/1390846764394-dc08e309debe561d866b05ac84daf1ee/checklist_2014.pdf. Accessed August 20, 2019

NOTES

Content in the STANDARD was modified on 01/23/2020.

Standard 5.7.0.4: Inaccessibility of Hazardous Equipment

Any hazardous equipment should be made inaccessible to children by barriers, or removed until rendered safe or replaced. The barriers should not pose any hazard.

RATIONALE

Limiting access to hazardous equipment can prevent injuries to children and staff in child care.

COMMENTS

Examples of barriers to equipment that pose a safety hazard are structures (including fences) that children can climb, prickly bushes, and standing bodies of water. Barriers such as plastic orange construction site fencing could be used to block access. While not child proof, it is conspicuous and sends a message that it is there to prevent access to the equipment it surrounds.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

Chapter 6 - Play Areas/Playgrounds and Transportation

Standard 6.1.0.6: Location of Play Areas Near Bodies of Water

Outside play areas should be free from the following bodies of water:

Unfenced swimming and wading pools;
Ditches;
Quarries;
Canals;
Excavations;
Fish ponds;
Water retention or detention basins;
Other bodies of water.

RATIONALE

Drowning is one of the leading causes of unintentional death in children one to fourteen years of age (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Centers for Disease Control and Prevention. 2008. Water-related injuries. http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/.

Standard 6.1.0.8: Enclosures for Outdoor Play Areas

The outdoor play area should be enclosed with a fence or natural barriers. Fences and barriers should not prevent the observation of children by caregivers/teachers. If a fence is used, it should conform to applicable local building codes in height and construction. Fence posts should be outside the fence where allowed by local building codes. These areas should have at least two exits, with at least one being remote from the buildings.

Gates should be equipped with self-closing and positive self-latching closure mechanisms. The latch or securing device should be high enough or of a type such that children cannot open it. The openings in the fence and gates should be no larger than three and one-half inches. The fence and gates should be constructed to discourage climbing. Play areas should be secured against inappropriate use when the facility is closed.

Wooden fences and playground structures created out of wood should be tested for chromated copper arsenate (CCA). Wooden fences and playground structures created out of wood that is found to contain CCA should be sealed with an oil-based outdoor sealant annually.

RATIONALE

This standard helps to ensure proper supervision and protection, prevention of injuries, and control of the area (3). An effective fence is one that prevents a child from getting over, under, or through it and keeps children from leaving the fenced outdoor play area, except when supervising adults are present. Although fences are not childproof, they provide a layer of protection for children who stray from supervision. Small openings in the fence (no larger than three and one-half inches) prevent entrapment and discourage climbing (1,2). Fence posts should be on the outside of the fence to prevent injuries from children running into the posts or climbing on horizontal supports (2).

Fences that prevent the child from obtaining a proper toe hold will discourage climbing. Chain link fences allow for climbing when the links are large enough for a foothold. Children are known to scale fences with diamonds or links that are two inches wide. One-inch diamonds are less of a problem.

CCA is a wood preservative and insecticide that is made up of 22% arsenic, a known carcinogen. In 2004, CCA was phased-out for residential uses; however, older, treated wood is a still a health concern, particularly for children. For more information on CCA-treated wood products, see Standard 5.2.9.12.

COMMENTS

Picket fences with V spaces at the top of the fencing are a potential entrapment hazard.

Some fence designs have horizontal supports on the side of the fence that is outside the play area which may allow intruders to climb over the fence. Facilities should consider selecting a fence design that prevents the ability to climb on either side of the fence.

For additional information on fencing, consult the ASTM International “Standard F2049-09b: Standard Guide for Fences/Barriers for Public, Commercial, and Multi-family Residential use Outdoor Play Areas” (2).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.2.9.12 Treatment of CCA Pressure-Treated Wood

REFERENCES

ASTM International (ASTM). 2009. Standard guide for fences/barriers for public, commercial, and multi-family residential use outdoor play areas. ASTM F2049-09b. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
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 6.2.1.9: Entrapment Hazards of Play Equipment

All openings in pieces of play equipment should be designed too large for a child’s head to get stuck in or too small for a child’s body to fit into, in order to prevent entrapment and strangulation. Openings in exercise rings (overhead hanging rings such as those used in a ring trek or ring ladder) should be smaller than three and one-half inches or larger than nine inches in diameter. Rings on long chains are prohibited. A play structure should have no openings with a dimension between three and one-half inches and nine inches. In particular, side railings, stairs, and other locations where a child might slip or try to climb through should be checked for appropriate dimensions.

Protrusions such as pipes, wood ends, or long bolts that may catch a child’s clothing are prohibited. Distances between two vertical objects that are positioned near each other should be less than three and one-half inches to prevent entrapment of a child’s head. No opening should have a vertical angle of less than fifty-five degrees. To prevent entrapment of fingers, openings should not be larger than three-eighths inch or smaller than one inch. A Certified Playground Safety Inspector (CPSI) is specially trained to find and measure various play equipment hazards.

RATIONALE

Any equipment opening between three and one-half inches and nine inches in diameter presents the potential for head entrapment. Similarly, openings between three-eighths inch and one inch can cause entrapment of the child’s fingers (1-2).

COMMENTS

To locate a CPSI, check the National Park and Recreation Association (NPRA) registry at https://ipv
.nrpa.org/CPSI_registry/.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/basic-report/13-indicators-quality-child-care.
U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.

Standard 6.2.3.1: Prohibited Surfaces for Placing Climbing Equipment

Equipment used for climbing should not be placed over, or immediately next to, hard surfaces such as asphalt, concrete, dirt, grass, or flooring covered by carpet or gym mats not intended for use as surfacing for climbing equipment.

All pieces of playground equipment should be placed over and surrounded by a shock-absorbing surface. This material may be either the unitary or the loose-fill type, as defined by the U.S. Consumer Product Safety Commission (CPSC) guidelines and ASTM International (ASTM) standards, extending at least six feet beyond the perimeter of the stationary equipment (1,2). These shock-absorbing surfaces must conform to the standard stating that the impact of falling from the height of the structure will be less than or equal to peak deceleration of 200G and a Head Injury Criterion (HIC) of 1000 and should be maintained at all times (3). Organic materials that support colonization of molds and bacteria should not be used. All loose fill materials must be raked to retain their proper distribution, shock-absorbing properties and to remove foreign material. This standard applies whether the equipment is installed outdoors or indoors.

RATIONALE

Head-impact injuries present a significant danger to children. Falls into a shock-absorbing surface are less likely to cause serious injury because the surface is yielding, so peak deceleration and force are reduced (1). The critical issue of surfaces, both under equipment and in general, should receive the most careful attention (1).

COMMENTS

Children should not dig in sand used under swings. It is not safe and the sand could be contaminated. If sand is provided in a play area for the purpose of digging, it should be in a covered box. Sand used as surfacing does not need to be covered. Staff should realize that sand used as surfacing may be used as a litter box for animals. Also, sand compacts and becomes less shock-absorbing when wet and it can become very hard when temperatures drop below freezing. Two scales are used for measuring the potential severity of falls. One is known as the G-max, and the other is known as the HIC. G-max measures the peak force at the time of impact; HIC measures total force during impact. Levels of 200 G-max or 1000 HIC have been accepted as thresholds for risk of life-threatening injuries. G-max and HIC levels of playground surfaces can be tested in various ways. The easiest one to use is the instrumented hemispherical triaxial headform. The individual conducting the test should use a process that conforms to the ASTM standard “F1292-09: Standard Specification for Impact Attenuation of Surfacing Materials within the Use Zone of Playground Equipment” (2).

For guidelines on play equipment and surfacing, contact the CPSC or a Certified Playground Safety Inspector (CPSI).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

6.2.4.1 Sandboxes
Appendix Z: Depth Required for Shock-Absorbing Surfacing Materials for Use Under Play Equipment

REFERENCES

Sushinsky, G. F. 2005. Surfacing materials for indoor play areas: Impact attenuation test report. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/LIBRARY/FOIA/foia06/os/surfacing.pdf.
ASTM International (ASTM). 2009. Standard specification for impact attenuation of surfacing materials within the use zone of playground equipment. ASTM F1292-09. West Conshohocken, PA: ASTM.
U.S. Consumer Product Safety Commission (CPSC). 2010. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/PageFiles/122149/325.pdf.

Standard 6.2.4.4: Trampolines

Trampolines, both full and mini-size, should be prohibited from being used as part of the child care program activities both on-site and during field trips.

RATIONALE

Both the American Academy of Pediatrics (AAP) and American Academy of Orthopedic Surgeons (AAOS) Policy Statements recommend the prohibition of trampolines for children younger than six years of age (1,2). The U.S. Consumer Product Safety Commission (CPSC) also supports this position (3). The numbers of injuries incurred on trampolines is large and growing (4-8). Even if one accepts that the rates of injury are uncertain due to increasing sales as well as injuries, the severity of injury incurred (number of injuries requiring admission for surgery, small but documented number of deaths) all have supported those recommendations. Given the risk reflected in the recommendations of national health and safety groups, there are documented cases where insurance companies have refused to issue or to continue insurance to the home or child care center in which a trampoline was found.

COMMENTS

The AAP recommends: “Despite all currently available measures to prevent injury, the potential for serious injury while using a trampoline remains. The need for supervision and trained personnel at all times makes home use extremely unwise” (1). The trampoline should not be used at home, inside or outside. During anticipatory guidance, health care professionals should advise parents/guardians never to purchase a home trampoline or allow children to use home trampolines (2). The trampoline should not be part of routine physical education classes in schools (3). The trampoline has no place in outdoor playgrounds and should never be regarded as play equipment (1).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Bond, A. 2008. Trampolines unsafe for children at any age. AAP News 29:29.
Smith, G. A. 1998. Injuries to children in the United States related to trampolines, 1990-1995: A national epidemic. Pediatrics 101:406-12.
Levine, D. 2006. All-terrain vehicle, trampoline, and scooter injuries and their prevention in children. Current Ops Pediatrics 18:260-65.
Linakis, J. G., M. J. Mello, J. Machan, S. Amanullah, L. M. Palmisciano. 2007. Emergency department visits for pediatric trampoline-related injuries: An update. Academic Emergency Med 14:539-44.
Shields, B. J., S. A. Fernandez, G. A. Smith. 2005. Comparison of mini-trampoline and full-sized trampoline injuries in the United States. Pediatrics 116:96-103.
U.S. Consumer Product Safety Commission (CPSC). Consumer product safety alert: Trampoline safety alert. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/085.pdf.
American Academy of Orthopedic Surgeons (AAOS). 2005. Trampolines and trampoline safety. Position Statement no. 1135. Rosemont, IL: AAOS.
American Academy of Pediatrics, Committee on Injury and Poison Prevention, and Committee on Sports Medicine and Fitness. 2006. Policy statement: Trampolines at home, school, and recreational centers. Pediatrics 117:1846-47.

Standard 6.2.5.1: Inspection of Indoor and Outdoor Play Areas and Equipment

The indoor and outdoor play areas and equipment should be inspected daily for the following:

Missing or broken parts;
Protrusion of nuts and bolts;
Rust and chipping or peeling paint;
Sharp edges, splinters, and rough surfaces;
Stability of handholds;
Visible cracks;
Stability of non-anchored large play equipment (e.g., playhouses);
Wear and deterioration.

Observations should be documented and filed, and the problems corrected.

Facilities should conduct a monthly inspection as outlined in Appendix EE, America’s Playgrounds Safety Report Card.

RATIONALE

Regular outdoor inspections are critical to prevent deterioration of equipment and accumulation of hazardous materials within the play site, and to ensure that appropriate repairs are made as soon as possible (1,2). Pools of water may cause children to slip and fall.

A monthly safety check of all the equipment within the facility as a focused task provides an opportunity to notice wear and tear that requires maintenance.

COMMENTS

Regularity of inspections can be assured by assigning a staff member to check all play equipment to make certain that it is safe for children. Observations should be made while the children are playing, too, to spot any maintenance problems and correct them as soon as possible.

If an off-site play area is used, a safety check for hazardous materials within the play area should be done upon arrival to the off-site playground. Hazardous materials may have been left in the play area by other people before the arrival of children from the child care facility.

If the playground is not safe, then alternate gross motor activities should be offered rather than allowing children to use equipment that is not safe for them because of hazards.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

5.2.8.1 Integrated Pest Management
6.2.3.1 Prohibited Surfaces for Placing Climbing Equipment
9.2.6.1 Policy on Use and Maintenance of Play Areas
9.2.6.2 Reports of Annual Audits/Monthly Maintenance Checks of Play Areas and Equipment
9.2.6.3 Records of Proper Installation and Maintenance of Facility Equipment
Appendix EE: America’s Playgrounds Safety Report Card

REFERENCES

U.S. Consumer Product Safety Commission (CPSC). 2008. Public playground safety handbook. Bethesda, MD: CPSC. http://www.cpsc.gov/cpscpub/pubs/325.pdf.
U.S. Consumer Product Safety Commission (CPSC). For kids’ sake: Think toy safety. Washington, DC: CPSC. http://www.cpsc.gov/cpscpub/pubs/281.pdf.

Standard 6.3.1.1: Enclosure of Bodies of Water

Content in the STANDARD was modified on 02/27/2020.

All water hazards, such as pools, swimming pools, stationary wading pools, ditches, fish ponds, and water retention or detention basins, should be enclosed with a permanent fence, wall, building wall, or combination thereof that is 4 to 6 feet in height or higher. The barrier must measure a distance of 3 feet horizontally from the swimming pool or body of water.¹ The maximum vertical clearance (or gapping) allowed between the ground and the fence shall be 2 inches from surfaces that are not solid, such as grass or gravel, and measured on the side of the barrier that faces away from the vessel.^1(p25)

Openings in the fence should be no greater than 3.5 inches.¹ The fence should be constructed to discourage children and unwanted visitors from climbing and be kept in good repair. A house exterior wall can constitute one side of a fence if the wall has no openings capable of providing direct access to the pool (eg, doors, windows).

If the fence is made of horizontal and vertical members (like a typical wooden fence) and the distance between the tops of the horizontal parts of the fence is less than 45 inches, the horizontal parts should be on the swimming pool side of the fence.^1(p26) The spacing of the vertical members and/or all mesh barriers should not exceed 1.75 inches.^1(p26)

Exit and entrance points should have self-closing, positive latching gates with locking devices a minimum of 54 inches from the ground.^1(p26–27)

If the facility has a water play area, the following requirements should be met:

Water play areas should conform to all state and local health regulations.
Water play areas should not include hidden or enclosed spaces.
Spray areas and water-collecting areas should have a nonslip surface, such as asphalt.
Water play areas, particularly those that have standing water, should not have sudden changes in depth of water.
Drains, streams, waterspouts, and hydrants should not create strong suction effects or water-jet forces.
All toys and other equipment used in and around the water play area should be made of sturdy plastic or metal (no glass should be permitted).
Water play areas in which standing water is maintained for more than 24 hours should be treated according to Standard 6.3.4.1: Pool Water Quality and inspected for glass, trash, animal excrement, and other foreign material.

All areas must be visible to allow caregivers/teachers adequate active supervision of all children.²

RATIONALE

Fenced enclosures around swimming pools and spas provide an adequate barrier to prevent unwanted and unsupervised access.³ Drownings can occur in fresh water, often in home swimming pools within a few feet of safety and in the presence of a supervising adult.⁴ An effective fence is one that prevents a child from getting over, under, or through it and keeps the child from gaining access to the pool or body of water except when supervising adults are present. Fences are not childproof, but they provide a layer of protection for a child who strays from supervision. Fence heights are a matter of local ordinances with minimum heights being 5 feet.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

6.2.5.1 Inspection of Indoor and Outdoor Play Areas and Equipment
6.2.5.2 Inspection of Play Area Surfacing
6.3.1.2 Accessibility to Above-Ground Pools
6.3.1.3 Sensors or Remote Monitors
6.3.1.7 Pool Safety Rules
6.3.4.1 Pool Water Quality

REFERENCES

International Code Council, The Association of Pool & Spa Professionals. 2012 International Swimming Pool and Spa Code. Country Club Hills, IL: International Code Council; 2011. https://www.waterparks.org/docs/ISPSC-PV1.pdf. Accessed August 21, 2019
US Department of Health and Human Services, Administration for Children and Families, Head Start Early Childhood Learning and Knowledge Center. Safety practices. Active supervision. https://eclkc.ohs.acf.hhs.gov/safety-practices/article/active-supervision. Updated January 29, 2019. Accessed August 21, 2019
American Red Cross. Swimming and Water Safety. https://www.redcross.org/store/swimming-and-water-safety-manual-rev-04-14/651327.html?cgid=sp-lifeguarding-and-learn-to-swim. Accessed August 21, 2019
Leavy JE, Crawford G, Leaversuch F, Nimmo L, McCausland K, Jancey J. A review of drowning prevention interventions for children and young people in high, low and middle income countries. J Community Health. 2016;41(2):424–441

NOTES

Content in the STANDARD was modified on 02/27/2020.

Standard 6.3.1.4: Safety Covers for Swimming Pools

When not in use, in-ground and above-ground swimming pools should be covered with a safety cover that meets or exceeds the ASTM International (ASTM) standard “F1346-03: Standard performance specification for safety covers and labeling requirements for all covers for swimming pools, spas, and hot tubs” (2).

RATIONALE

Fatal injuries have occurred when water has collected on top of a secured pool cover. The depression caused by the water, coupled with the smoothness of the cover material, has proved to be a deadly trap for some children (1). The ASTM standard now defines a safety cover “as a barrier (intended to be completely removed before water use) for swimming pools, spas, hot tubs, or wading pools, attendant appurtenances and/or anchoring mechanisms which reduces--when properly labeled, installed, used and maintained in accordance with the manufacturer’s published instructions--the risk of drowning of children under five years of age, by inhibiting their access to the contained body of water, and by providing for the removal of any substantially hazardous level of collected surface water” (2).

In addition to home swimming and wading pools, young children drown in bathtubs and pails (4). Bathtub drownings are equally distributed in both sexes. Any body of water, including hot tubs, pails, and toilets, presents a drowning risk to young children (1,2,4,5).

From 2003-2005, eleven children under the age of five died from drowning in buckets or containers that were being used for cleaning (4). Of all buckets, the five-gallon size presents the greatest hazard to young children because of its tall straight sides and its weight with even just a small amount of liquid. It is nearly impossible for top-heavy infants and toddlers to free themselves when they fall into a five-gallon bucket head first (3).

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Rivera, F. P. 1999. Pediatric injury control in 1999: Where do we go from here? Pediatrics 103:883-88.
U.S. Consumer Safety Commission (CPSC). How to plan for the unexpected: Preventing child drownings. Document #359. https://www.cpsc.gov/s3fs-public/359.pdf.
U.S. Consumer Products Safety Commission (CPSC). In home danger: CPSC warns of children drowning in bathtubs, bath seats and buckets more than 400 deaths estimated over a five-year. period. 2012. https://www.cpsc.gov/Newsroom/News-Releases/2012/In-Home-Danger-CPSC-Warns-of-Children-Drowning-in-Bathtubs-Bath-Seats-and-Buckets-More-than-400-deaths-estimated-over-a-five-year-period/.
U.S. Consumer Products Safety Commission (CPSC). Submersions related to non-pool and non-spa products, 2009 report. 2010. https://www.cpsc.gov/s3fs-public/pdfs/nonpoolsub2009.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of drowning. Pediatrics 126:178-85.

Standard 6.4.1.2: Inaccessibility of Toys or Objects to Children Under Three Years of Age

Small objects, toys, and toy parts available to children under the age of three years should meet the federal small parts standards for toys. The following toys or objects should not be accessible to children under three years of age:

Toys or objects with removable parts with a diameter less than one and one-quarter inches and a length between one inch and two and one-quarter inches;
Balls and toys with spherical, ovoid (egg shaped), or elliptical parts that are smaller than one and three-quarters inches in diameter;
Toys with sharp points and edges;
Plastic bags;
Styrofoam objects;
Coins;
Rubber or latex balloons;
Safety pins;
Marbles;
Magnets;
Foam blocks, books, or objects;
Other small objects;
Latex gloves;
Bulletin board tacks;
Glitter.

RATIONALE

Injury and fatality from aspiration of small parts is well-documented (1,2). Eliminating small parts from children’s environment will greatly reduce the risk (2). Objects should not be small enough to fit entirely into a child’s mouth.

According to the federal government’s small parts standard on a safe-size toy for children under three years of age, a small part should be at least one and one-quarter inches in diameter and between one inch and two and one-quarter inches long; any part smaller than this has a potential choking hazard.

Magnets generally are small enough to pass through the digestive tract, however, they can attach to each other across intestinal walls, causing obstructions and perforations within the gastrointestinal tract (5).

Glitter, inadvertently rubbed in eyes, has been known to scratch the surface of the eye and is especially hazardous in children under three years of age (3).

Toys can also contain many chemicals of concern such as lead, phthalates found in many polyvinylchloride (PVC) plastics, cadmium, chlorine, arsenic, bromine, and mercury. When children put toys in their mouths, they may be exposed to these chemicals.

COMMENTS

Toys or games intended for use by children three to five years of age and that contain small parts should be labeled “CHOKING HAZARD--Small Parts. Not for children under three.” Because choking on small parts occurs throughout the preschool years, small parts should be kept away from children at least up to three years of age. Also, children occasionally have choked on toys or toy parts that meet federal standards, so caregivers/teachers must constantly be vigilant (2).

The federal standard that applies is Code of Federal Regulations, Title 16, Part 1501 – “Method for Identifying Toys and Other Articles Intended for Use by Children Under 3 Years of Age Which Present Choking, Aspiration, or Ingestion Hazards Because of Small Parts” – which defines the method for identifying toys and other articles intended for use by children under three years of age that present choking, aspiration, or ingestion hazards because of small parts. To obtain this publication, contact the Superintendent of Documents of the U.S. Government Printing Office or access online at http://www.access.gpo.gov/nara/cfr/waisidx_04/16cfr1501_04.html. This information also is described in the U.S. Consumer Product Safety Commission (CPSC) document, “Small Parts Regulations: Toys and Products Intended for Use by Children Under 3 Years Old,” available online at http://www.cpsc.gov/businfo/
regsumsmallparts.pdf. Also note the ASTM International (ASTM) standard “F963-08: Standard Consumer Safety Specification on Toy Safety.” To obtain this publication, contact the ASTM at http://www.astm.org.

CPSC has produced several useful resources regarding safety and toys based on age group, see: “Which Toy for Which Child Ages Birth to Five” at http://www.cpsc.gov/cpscpub/pubs/285.pdf and “Which Toy for Which Child Ages Six through Twelve” at http://www.cpsc.gov/cpscpub/pubs/286.pdf.

New technologies have become smaller and smaller. Caregivers/teachers should be aware of items such as small computer components, batteries in talking books, mobile phones, portable music players, etc. that fall under item a) in the list of prohibited items.

HealthyToys.org is a good resource for information on chemical contents in toys (4).

TYPE OF FACILITY

Center, Early Head Start, Large Family Child Care Home, Small Family Child Care Home

REFERENCES

Centers for Disease Control and Prevention. 2006. Gastrointestinal injuries from magnet ingestion in children — United States, 2003-2006. MMWR 55:1296-1300.
HealthyStuff.org. Chemicals of concern: Introduction. http://www.healthystuff.org/departments/toys/chemicals.introduction.php.
Southern Daily Echo. 2009. Dr. John Heyworth from Southampton General Hospital warns about festive injuries. http://www.dailyecho.co.uk/news/4814667.City_doctor_warns_about_bizarre_Christmas_injuries/.
Chowdhury, R. T., U.S. Consumer Product Safety Commission. 2008. Toy-related deaths and injuries, calendar year 2007. Washington, DC: CPSC. http://www.cpsc.gov/LIBRARY/toymemo07.pdf.
American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.

Standard 6.4.1.5: Balloons

Infants, toddlers, and preschool children should not be permitted to inflate balloons, suck on or put balloons in their mouths nor have access to uninflated or underinflated balloons. Children under eight should not have access to latex balloons or inflated latex objects that are treated as balloons and these objects should not be permitted in the child care facility.

RATIONALE

Balloons are an aspiration hazard (1). The U.S. Consumer Product Safety Commission (CPSC) reported eight deaths from balloon aspiration with choking between 2006 and 2008 (1). Aspiration injuries occur from latex balloons or other latex objects treated as balloons, such as inflated latex gloves. Latex gloves are commonly used in child care facilities for diaper changing, but they should not be inflated (2). When children bite inflated latex balloons or gloves, these objects may break suddenly and blow an obstructing piece of latex into the child’s airway. Exposure to latex balloons could trigger an allergic reaction in children with latex allergies.

Underinflated or uninflated balloons of all types could be chewed or sucked and pieces potentially aspirated.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

6.4.1.2 Inaccessibility of Toys or Objects to Children Under Three Years of Age

REFERENCES

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. 2010. Policy statement: Prevention of choking among children. Pediatrics 125:601-7.
Garland, S. 2009. Toy-related deaths and injuries, calendar year 2008. Bethesda, MD: U.S. Consumer Product Safety Commission. http://www.cpsc.gov/library/toymemo08.pdf.

Standard 6.4.2.2: Helmets

Content in the STANDARD was modified on 3/31/2017.

All children one year of age and over should wear properly fitted and approved helmets while riding toys with wheels (tricycles, bicycles, etc.) or using any wheeled equipment (rollerblades, skateboards, etc.). Helmets should be removed as soon as children stop riding the wheeled toys or using wheeled equipment. Approved helmets should meet the standards of the U.S. Consumer Product Safety Commission (CPSC) (1). The standards sticker should be located on the bike helmet. Bike helmets should be replaced if they have been involved in a crash, the helmet is cracked, when straps are broken, the helmet can no longer be worn properly, or according to recommendations by the manufacturer (usually after three years).
It is not recommended that infants (children under the age of one year) wear helmets or ride as a passenger on wheeled equipment (2).

RATIONALE

Injuries occur when riding tricycles, bicycles, and other riding toys or wheeled equipment. Helmet use is associated with a reduction in the risk of any head injury by 69%, brain injury by 65%, and severe brain injuries by 74%, and recommended for all children one year of age and over (2-4).

Helmets can be a potential strangulation hazard if they are worn for activities other than when using riding toys or wheeled equipment and/or when worn incorrectly.

Infants are just learning to sit unsupported at about nine months of age. Until this age, infants have not developed sufficient bone mass and muscle tone to enable them to sit unsupported with their backs straight. Pediatricians advise against having infants sitting in a slumped or curled position for prolonged periods due to the underdevelopment of their neck muscles (5). This situation may even be exacerbated by the added weight of a bicycle helmet on the infant’s head.

COMMENTS

The CPSC helmet standard was published in March 1998 (6). Bike helmets manufactured or imported for sale in the U.S. after January 1999 must meet the CPSC standard. Helmets made before this date will not have a CPSC approval label. However, helmets made before this date should have an ASTM International (ASTM) approval label. The American National Standard Institute (ANSI) standard for helmet approval has been withdrawn, and ANSI approval labels will no longer appear on helmets. The Snell Memorial Foundation also no longer certifies bike helmets.

Concern regarding the spreading of head lice when sharing helmets should not override the practice of using helmets. The prevention of a potential brain injury heavily outweighs a possible case of head lice. While it is best practice for each child to have his/her own helmet, this may not be possible. If helmets need to be shared, it is recommended to clean the helmet between users. Helmets should be cleaned according to manufacturer's instructions.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

6.4.2.1 Riding Toys with Wheels and Wheeled Equipment

REFERENCES

ADDITIONAL REFERENCE:

Centers for Disease Control and Prevention. 2015. Head injuries and bicycle safety. http://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/headinjuries.html.
U.S. Consumer Product Safety Commission (CPSC). 2017. CPSC’s Bicycle Helmet Standard. http://www.helmets.org/cpscstd.htm.
Bicycle Helmet Safety Institute. 2016. Should you take your baby along? http://www.helmets.org/little1s.htm.
Head Start. An Office of the Administration of Children and Families Early Childhood Learning & Knowledge Center (ECLKC). 2014. Play it safe: Walking and biking safely. https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family/for-families/safety/safety-prevention/PlayitSafeWal.htm.
Thompson, D. C., F. P. Rivara, R. S. Thompson. 1996. Effectiveness of bicycle safety helmets in preventing head injuries: A case-control study. JAMA 276:1968-73.
U.S. Consumer Product Safety Commission. 2016. CPSC guidelines for age-related activities. Bicycle Helmet Safety Institute. http://www.helmets.org/ageguide.htm.
U.S. Consumer Product Safety Commission (CPSC). 1998. Safety standard for bicycle helmets. http://www.bhsi.org/cpscstd.pdf.

NOTES

Content in the STANDARD was modified on 3/31/2017.

Standard 6.5.1.1: Competence and Training of Transportation Staff

At least one adult who accompanies or drives children for field trips and out-of-facility activities should receive training by a professional knowledgeable about child development and procedures, to ensure the safety of all children. The caregiver should hold a valid pediatric first aid certificate, including rescue breathing and management of blocked airways, as specified in First Aid and CPR Standards 1.4.3.1-1.4.3.3. Any emergency medications that a child might require, such as self-injecting epinephrine for life-threatening allergy, should also be available at all times as well as a mobile phone to call for medical assistance. Child:staff ratios should be maintained on field trips and during transport, as specified in Standards 1.1.1.1-1.1.1.5; the driver should not be included in these ratios. No child should ever be left alone in the vehicle.

All drivers, passenger monitors, chaperones, and assistants should receive instructions in safety precautions. Transportation procedures should include:

Use of developmentally appropriate safety restraints;
Proper placement of the child in the motor vehicle in accordance with state and federal child restraint laws and regulations and recognized best practice;
Training in handling of emergency medical situations. If a child has a chronic medical condition or special health care needs that could result in an emergency (such as asthma, diabetes, or seizures), the driver or chaperone should have written instructions including parent/guardian emergency contacts, child summary health information, special needs and treatment plans, and should:
1. Recognize the signs of a medical emergency;
2. Know emergency procedures to follow (3);
3. Have on hand any emergency supplies or medications necessary, properly stored out of reach of children;
4. Know specific medication administration (ex. a child who requires EpiPen or diazepam);
5. Know about water safety when field trip is to a location with a body of water.
Knowledge of appropriate routes to emergency facility;
Defensive driving;
Child s

Special Collection

Stepping Stones to Caring for Our Children (SS)

Table of Contents

Chapter 1 - Staffing

Chapter 2 - Program Activities for Healthy Development

Chapter 3 - Health Promotion and Protection

Chapter 4 - Nutrition and Food Service

Chapter 5 - Facilities, Supplies, Equipment, and Environmental Health

Chapter 6 - Play Areas/Playgrounds and Transportation

Chapter 7 - Infectious Disease

Chapter 9 - Policies

Chapter 10 - Licensing and Community Action

Appendices

Chapter 1 - Staffing

Standard 1.1.1.1: Ratios for Small Family Child Care Homes

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.1.1.2: Ratios for Large Family Child Care Homes and Centers

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.1.1.3: Ratios for Facilities Serving Children with Special Health Care Needs and Disabilities

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.1.1.4: Ratios and Supervision During Transportation

RATIONALE

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.1.1.5: Ratios and Supervision for Swimming, Wading, and Water Play

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.2.0.2: Background Screening

RATIONALE

COMMENTS

TYPE OF FACILITY

REFERENCES

NOTES

Standard 1.3.1.1: General Qualifications of Directors

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.3.2.2: Qualifications of Lead Teachers and Teachers

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.3.3.1: General Qualifications of Family Child Care Caregivers/Teachers to Operate a Family Child Care Home

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.4.1.1: Pre-service Training

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.4.2.2: Orientation for Care of Children with Special Health Care Needs

RATIONALE

COMMENTS

TYPE OF FACILITY

RELATED STANDARDS

REFERENCES

Standard 1.4.2.3: Orientation Topics