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1 National Health and Safety Performance Standards • Guidelines for Early Care and Education Programs, 4th Edition Caring for Our Children Caring for Our Children Caring for Our National Health and Safety Performance Standards Guidelines for Early Care and Education Programs, 4th Edition A Joint Collaborative Project of American Academy of Pediatrics American Public Health Association Children National Resource Center for Health and Safety in Child Care and Early Education National Health and Safety Performance Standards These national standards represent the best evidence, Every day millions of children attend early care and Guidelines for Early Care and Education Programs expertise, and experience in the country on quality education programs. It is critical that they have the health and safety practices and policies that should opportunity to grow and learn in healthy and safe FOURTH EDITION be followed in today’s early care and education environments with caring and professional settings. caregivers/teachers. Substantially revised and updated, the fourth edition The American Academy of Pediatrics, the American features 10 chapters of more than 650 standards and Public Health Association, and the National Resource dozens of appendixes with valuable supplemental Center for Health and Safety in Child Care and Early information, forms, and tools. Education are pleased to release the fourth edition of Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care Key Features and Education Programs . ä More than 100 updated standards ä Updated appendixes, including Signs and Symptoms Chart, recommended immunization Topics Include schedules, and “Recommendations for Preventive Staffing ä Pediatric Health Care” Program Activities for Healthy Development ä ä Many revisions and updates in environmental health, infectious diseases, and nutrition ä Health Promotion and Protection Nutrition and Food Service ä ä Facilities, Supplies, Equipment, and Environmental Health Play Areas/Playgrounds and Transportation ä ä Infectious Diseases ä Children with Special Health Care Needs and Disabilities ä Administration Licensing and Community Action ä And more... AAP CFOC COVER SPREAD - 2018.indd All Pages 11/29/18 4:10 PM

2 Caring for Our Children National Health and Safety Performance Standards Guidelines for Early Care and Education Programs FOURTH EDITION A Joint Collaborative Project of American Academy of Pediatrics 345 Park Boulevard Itasca, IL 60143 American Public Health Association 800 I Street NW Washington, DC 20001-3710 National Resource Center for Health and Safety in Child Care and Early Education University of Colorado, College of Nursing 13120 19th Avenue Aurora, CO 80045 Support for this project was provided by the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services (Cooperative Agreement #U44MC30806).

3 The National Standards are for reference purposes only and shall not be used as a substitute for medical or legal consultation, nor be used to authorize actions beyond a person’s licensing, training, or ability. Listing of resources does not imply an endorsement by the copyright holders. The copyright holders are not responsible for the content of external resources. Information was current at the time of publication. Brand names are furnished for identification purposes only. No endorsement of the manufacturers or products mentioned is implied. The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. Special discounts are available for bulk purchases of this publication. E-mail Special Sales at [email protected] for more information. © 2019 American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care and Early Education All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher (locate title at http://ebooks.aappublications.org and click on © Get permissions; you may also fax the permissions editor at 847/434-8780 or e-mail [email protected]). The photographs in this publication were taken using funds from cooperative agreement #U44MC30806 for the US Department of Health and Human Services, Administration for Children and Families, Office of Head Start, Office of Child Care, and Health Resources and Services Administration, Maternal and Child Health Bureau, by the National Center on Early Childhood Health and Wellness. The photographs may be duplicated for noncommercial uses without permission. The photographs are in the public domain, and no copyright can be claimed by persons or organizations. Suggested Citation: American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care and Early Education. Caring for Our Children: National Health and Safety Performance Standards; Guidelines for Early Care and Education Programs. 4th ed. Itasca, IL: American Academy of Pediatrics; 2019 Printed in the United States of America 1 2 3 4 5 6 7 8 9 10 MA0908 ISBN: 978-1-61002-297-2 eBook: 978-1-61002-298-9 Cover and publication design by Linda Diamond Library of Congress Control Number: 2018947984

4 iii Contents ... Acknowledgments ix xvii Introduction ... xix Guiding Principles ... Advice to the User ... xx History of Standard Language Changes Caring for Our Children ... Since the 3rd Edition (Through July 2018) xxiii 1 Staffing Chapter ... ➊ 3 1.1 Child:Staff Ratio, Group Size, and Minimum Age ... 3 Child:Staff Ratio and Group Size 1.1.1 ... 7 1.1.2 Minimum Age ... 9 Recruitment and Background Screening 1.2 ... 11 ... 1.3 Pre-service Qualifications ... 1.3.1 Director’s Qualifications 11 Caregiver’s/Teacher’s and Other Staff Qualifications 12 1.3.2 ... ... 1.3.3 19 Family Child Care Home Caregiver/Teacher Qualifications 21 1.4 Professional Development/Training ... 21 Pre-service Training 1.4.1 ... 23 ... 1.4.2 Orientation Training ... 1.4.3 First Aid and CPR Training 26 Continuing Education/Professional Development 28 1.4.4 ... ... Specialized Training/Education 31 1.4.5 ... 33 1.4.6 Educational Leave/Compensation 34 ... 1.5 Substitutes 1.6 Consultants 36 ... 1.7 ... 42 Staff Health Human Resource Management 46 1.8 ... ... 1.8.1 46 Benefits 47 Evaluation 1.8.2 ... Chapter ... 49 Program Activities for Healthy Development ➋ ... 51 2.1 Program of Developmental Activities 2.1.1 51 General Program Activities ... Program Activities for Infants and Toddlers from 2.1.2 59 Three Months to Less Than Thirty-Six Months ... ... 64 Program Activities for Three- to Five-Year-Olds 2.1.3 Program Activities for School-Age Children ... 2.1.4 66 2.2 ... 68 Supervision and Discipline Parent/Guardian Relationships 80 2.3 ... ... 80 General 2.3.1 Regular Communication ... 82 2.3.2 Health Information Sharing ... 84 2.3.3 Health Education 2.4 85 ... Health Education for Children 85 2.4.1 ... Health Education for Staff 2.4.2 88 ... 2.4.3 Health Education for Parents/Guardians ... 90

5 iv Contents ... 93 Health Promotion and Protection Chapter ➌ ... 3.1 Health Promotion in Child Care 95 95 ... 3.1.1 Daily Health Check ... 96 3.1.2 Routine Health Supervision 97 ... Physical Activity and Limiting Screen Time 3.1.3 ... 102 3.1.4 Safe Sleep ... Oral Health 3.1.5 108 ... Hygiene 111 3.2 3.2.1 Diapering and Changing Soiled Clothing ... 111 3.2.2 118 Hand Hygiene ... Exposure to Body Fluids ... 122 3.2.3 Cleaning, Sanitizing, and Disinfecting 3.3 125 ... 3.4 ... 127 Health Protection in Child Care Tobacco and Drug Use ... 3.4.1 127 ... Animals 128 3.4.2 ... 131 3.4.3 Emergency Procedures ... 132 Child Abuse and Neglect 3.4.4 Sun Safety and Insect Repellent ... 135 3.4.5 Strangulation 3.4.6 138 ... Care Plans and Adaptations 139 3.5 ... Management of Illness ... 141 3.6 3.6.1 ... 141 Inclusion/Exclusion Due to Illness 3.6.2 Caring for Children Who Are Ill ... 147 3.6.3 Medications ... 153 3.6.4 Reporting Illness and Death 155 ... ... 159 Nutrition and Food Service Chapter  ... Introduction 161 4.1 ... 162 4.2 General Requirements ... 174 Requirements for Special Groups or Ages of Children 4.3 Nutrition for Infants ... 174 4.3.1 4.3.2 Nutrition for Toddlers and Preschoolers 184 ... Nutrition for School-Age Children 186 4.3.3 ... 4.4 Staffing ... 187 Meal Service, Seating, and Supervision 4.5 188 ... 4.6 Food Brought From Home ... 193 4.7 Nutrition Learning Experiences for Children and Nutrition Education for Parents/Guardians ... 194 4.8 Kitchen and Equipment 197 ... Food Safety 200 4.9 ... 4.10 Meals from Outside Vendors or Central Kitchens ... 206 Chapter Facilities, Supplies, Equipment, and Environmental Health ... 209 ➎ 5.1 Overall Requirements ... 211 5.1.1 General Location, Layout, and Construction of the Facility ... 211 5.1.2 ... 215 Space per Child 5.1.3 Openings ... 217 5.1.4 Exits ... 219 5.1.5 Steps and Stairs ... 221 5.1.6 Exterior Areas ... 222

6 v Contents Quality of the Outdoor and Indoor Environment ... 5.2 224 ... 5.2.1 224 Ventilation, Heating, Cooling, and Hot Water 230 5.2.2 Lighting ... Noise ... 232 5.2.3 233 5.2.4 Electrical Fixtures and Outlets ... ... 234 Fire Warning Systems 5.2.5 5.2.6 ... 235 Water Supply and Plumbing Sewage and Garbage 239 5.2.7 ... ... Integrated Pest Management 241 5.2.8 ... 5.2.9 Prevention and Management of Toxic Substances 243 General Furnishings and Equipment ... 253 5.3 General Furnishings and Equipment Requirements ... 5.3.1 253 5.3.2 Additional Equipment Requirements for Facilities Serving Children with Special Health Care Needs ... 260 ... Space and Equipment in Designated Areas 5.4 261 ... 261 5.4.1 Toilet and Handwashing Areas Diaper Changing Areas 265 5.4.2 ... 5.4.3 Bathtubs and Showers ... 267 Laundry Area 5.4.4 268 ... 5.4.5 ... 268 Sleep and Rest Areas Space for Children Who Are Ill, Injured, 5.4.6 or Need Special Therapies ... 272 5.5 ... 273 Storage Areas 5.6 Supplies ... 274 5.7 Maintenance ... 277 Play Areas/Playgrounds and Transportation ... 281 Chapter ➏ Play Area/Playground Size and Location ... 6.1 283 287 Play Area/Playground Equipment ... 6.2 6.2.1 ... 287 General Requirements Use Zones and Clearance Requirements ... 291 6.2.2 Play Area and Playground Surfacing 6.2.3 292 ... Specific Play Equipment ... 293 6.2.4 Inspection of Play Areas/Playgrounds and Equipment 6.2.5 296 ... 6.3 Water Play Areas (Pools, Etc.) ... 297 6.3.1 Access to and Safety Around Bodies of Water ... 297 6.3.2 Pool Equipment 300 ... Pool Maintenance 300 6.3.3 ... 6.3.4 Water Quality of Pools ... 302 Other Water Play Areas 6.3.5 302 ... 6.4 Toys ... 303 6.4.1 Selected Toys ... 303 6.4.2 Riding Toys and Helmets ... 305 6.5 ... 307 Transportation 6.5.1 Transportation Staff ... 307 6.5.2 Transportation Safety ... 309 6.5.3 Vehicles ... 313

7 vi Contents ... 315 Infectious Diseases Chapter ➐ ... 7.1 317 How Infections Spread 317 7.2 Immunizations ... 320 Respiratory Tract Infections 7.3 ... 320 ... 7.3.1 Group A Streptococcal (GAS) Infections Type B (Hib) 7.3.2 321 Haemophilus Influenzae ... Influenza 323 7.3.3 ... ... 324 Mumps 7.3.4 Neisseria Meningitidis (Meningococcus) ... 325 7.3.5 Parvovirus B19 7.3.6 326 ... 7.3.7 ... 326 Pertussis Respiratory Syncytial Virus (RSV) ... 7.3.8 328 ... 329 Streptococcus Pneumoniae 7.3.9 7.3.10 Tuberculosis ... 330 Unspecified Respiratory Tract Infection ... 331 7.3.11 7.4 ... 332 Enteric (Diarrheal) Infections and Hepatitis A Virus (HAV) Skin and Mucous Membrane Infections 336 7.5 ... Conjunctivitis ... 7.5.1 336 7.5.2 Enteroviruses ... 337 7.5.3 Human Papillomaviruses (Warts) ... 338 7.5.4 Impetigo 338 ... Lymphadenitis ... 7.5.5 339 ... Measles 340 7.5.6 ... 340 7.5.7 Molluscum Contagiosum ... 341 Pediculosis Capitis (Head Lice) 7.5.8 Tinea Capitis and Tinea Cruris (Ringworm) ... 7.5.9 342 7.5.10 Skin Infections Including MRSA ... 342 Staphylococcus Aureus Scabies 343 7.5.11 ... Thrush ... 7.5.12 344 7.6 Bloodborne Infections ... 344 7.6.1 Hepatitis B Virus (HBV) ... 344 7.6.2 Hepatitis C Virus (HCV) ... 346 Human Immunodeficiency Virus (HIV) 347 7.6.3 ... Herpes Viruses ... 7.7 349 7.7.1 Cytomegalovirus (CMV) ... 349 7.7.2 Herpes Simplex ... 350 7.7.3 ... 351 Herpes Virus 6 and 7 (Roseola) 7.7.4 Varicella-Zoster (Chickenpox) Virus ... 351 7.8 Interaction with State or Local Health Departments ... 353 7.9 Note to Reader on Judicious Use of Antibiotics ... 353

8 vii Contents 355 Children with Special Health Care Needs and Disabilities ... Chapter ➑ 357 ... 8.1 Guiding Principles for This Chapter and Introduction Inclusion of Children with Special Needs in the Child Care Setting ... 359 8.2 360 8.3 Process Prior to Enrolling at a Facility ... Developing a Service Plan for a Child with a Disability 8.4 or a Child with Special Health Care Needs ... 361 ... 365 8.5 Coordination and Documentation ... 365 Periodic Reevaluation 8.6 8.7 Assessment of Facilities for Children with Special Needs ... 366 8.8 Additional Standards for Providers Caring for Children ... 367 with Special Health Care Needs Administration ... 369 Chapter ➒ 9.1 ... 371 Governance Policies ... 9.2 372 ... 372 Overview 9.2.1 Transitions ... 377 9.2.2 Health Policies ... 379 9.2.3 Emergency/Security Policies and Plans ... 393 9.2.4 Transportation Policies ... 402 9.2.5 Play Area Policies ... 9.2.6 403 9.3 Human Resource Management ... 405 9.4 Records ... 407 9.4.1 Facility Records/Reports ... 407 Child Records ... 9.4.2 418 ... 9.4.3 424 Staff Records Licensing and Community Action ... 427 Chapter ➓ 10.1 Introduction ... 429 Regulatory Policy ... 10.2 429 10.3 ... 430 Licensing Agency The Regulation Setting Process 430 10.3.1 ... Advisory Groups ... 431 10.3.2 Licensing Role with Staff Credentials, 10.3.3 Child Abuse Prevention, and ADA Compliance ... 433 10.3.4 Technical Assistance from the Licensing Agency ... 435 10.3.5 Licensing Staff Training 439 ... Facility Licensing 440 10.4 ... Initial Considerations for Licensing ... 440 10.4.1 Facility Inspections and Monitoring ... 442 10.4.2 10.4.3 Procedures for Complaints, Reporting, and Data Collecting ... 443 10.5 ... 444 Health Department Responsibilities and Role 10.6 Caregiver/Teacher Support ... 448 10.6.1 Caregiver/Teacher Training ... 448 10.6.2 Caregiver/Teacher Networking and Collaboration ... 449 10.7 Public Policy Issues and Resource Development ... 450

9 viii Contents ... 451 Appendixes ... Signs and Symptoms Chart 453 Appendix A: 458 ... Appendix B: Major Occupational Health Hazards Appendix C: Nutrition Specialist, Registered Dietitian, Licensed Nutritionist, Consultant, and Food Service Staff Qualifications ... 459 460 ... Gloving Appendix D: ... Appendix E: Child Care Staff Health Assessment 461 Enrollment/Attendance/Symptom Record 467 Appendix F: ... Recommended Immunization Schedule for Children and Appendix G: Adolescents Aged 18 Years or Younger 468 ... Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older ... 476 Appendix I: ... 482 Recommendations for Preventive Pediatric Health Care Appendix J: ... 484 Selecting an Appropriate Sanitizer or Disinfectant Routine Schedule for Cleaning, Sanitizing, and Disinfecting ... Appendix K: 491 ... 493 Cleaning Up Body Fluids Appendix L: Appendix M: Recognizing Child Abuse and Neglect: Signs and Symptoms ... 494 Protective Factors Regarding Child Abuse and Neglect ... 498 Appendix N: Care Plan for Children With Special Health Needs Appendix O: 500 ... Situations that Require Medical Attention Right Away 506 Appendix P: ... Getting Started with MyPlate ... 507 Appendix Q: Appendix R: Choose MyPlate: 10 Tips to a Great Plate ... 508 Appendix S: Physical Activity: How Much Is Needed? ... 509 Appendix T: Helping Children in Foster Care Make Successful ... 510 Transitions Into Child Care ... Recommended Safe Minimum Internal Cooking Temperatures 512 Appendix U: ... 513 Appendix V: Food Storage Chart Sample Food Service Cleaning Schedule ... 515 Appendix W: Adaptive Equipment for Children with Special Health Care Needs Appendix X: 516 ... Appendix Y: ... 518 Even Plants Can Be Poisonous Depth Required for Shock-Absorbing Surfacing Materials Appendix Z: ... 520 for Use Under Play Equipment Medication Administration Packet ... Appendix AA: 522 Appendix BB: Emergency Information Form for Children With Special Needs ... 527 Appendix CC: Incident Report Form ... 529 Appendix DD: Child Injury Report Form for Indoor and Outdoor Injuries 530 ... America’s Playgrounds Safety Report Card 532 Appendix EE: ... Child Health Assessment ... 535 Appendix FF: Appendix GG: ... 536 Licensing and Public Regulation of Early Childhood Programs Appendix HH: Use Zones and Clearance Dimensions for Single- and Multi-Axis Swings ... 544 Appendix II: Bike and Multi-sport Helmets: Quick-Fit Check ... 547 Appendix JJ: ... 549 Our Child Care Center Supports Breastfeeding Appendix KK: Authorization for Emergency Medical/Dental Care ... 550 Acronyms/Abbreviations ... 551 Glossary ... 557 Index ... 575

10 ix Acknowledgments - The following individuals and organizations are acknowl Dr. Susan Aronson, MD, FAAP; Dr. Albert Chang, MD, MPH, FAAP; and Dr. George Sterne, MD, FAAP. edged for their contributions as subject matter experts or Caring for Our Children, Third Edition . field reviewers for Their leadership and dedication in setting the bar high Some of those listed also served as subject matter experts for for quality health and safety standards in early care and revised standards included in Caring for Our Children, education ensured that children experienced healthier and , which did not undergo additional field Fourth Edition safer lives and environments in child care and provided a testing. valuable and nationally recognized resource for all in the The National Resource Center for Health and Safety in field. We are pleased to build upon their foundational work Child Care would like to acknowledge the outstanding in this Third Edition with new science and research. contributions of all persons and organizations involved in the revision of Caring for Our Children: National Health and Technical Panel Chairs and Members Safety Performance Standards: Guidelines for Out-of-Home Child Abuse . The collaboration of Child Care Programs, Third Edition Anne B. Keith, DrPH, RN, C-PNP, Chair; the American Academy of Pediatrics, the American Public New Gloucester, ME Health Association, and the Maternal and Child Health Melissa Brodowski, MSW, MPH; Washington, DC Bureau provided a wide scope of technical expertise from Gilbert Handal, MD, FAAP; El Paso, TX their constituents in the creation of this project. The subject- specific Technical Panels as listed provided the majority Carole Jenny, MD, MBA, FAAP; Providence, RI of the content and resources. Over 180 organizations and Salwa Khan, MD, MHS; Baltimore, MD individuals were asked to review and validate the accuracy Ashley Lucas, MD, FAAP; Baton Rouge, LA of the content and contribute additional expertise where Hannah Pressler, MHS, PNP-BC; Portland, ME applicable. The individuals representing these organizations Sara E. Schuh, MD, FAAP; Charleston, SC Stakeholder Reviewers/Additional Contributors are listed in (see below). This broad collaboration and review from the Child Development best minds in the field has led to a more comprehensive Angela Crowley, PhD, APRN, CS, PNP-BC, Chair; and useful tool. New Haven, CT In a project of such scope, many individuals provide valuable George J. Cohen, MD, FAAP; Rockville, MD input to the end product. We would like to acknowledge Christine Garvey, PhD, RN; Chicago, IL those individuals whose names may have been omitted. Walter S. Gilliam, PhD; New Haven, CT Peter A. Gorski, MD, MPA; Tampa, FL Steering Committee Mary Louise Hemmeter, PhD; Nashville, TN Danette Swanson Glassy, MD, FAAP Michael Kaplan, MD; New Haven, CT Co-Chair, American Academy of Pediatrics; Mercer Island, WA Cynthia Olson, MS; New Haven, CT Deborah F. Perry, PhD; Baltimore, MD Jonathan B. Kotch, MD, MPH, FAAP June Solnit Sale, MSW; Los Angeles, CA Co-Chair, American Public Health Association; Chapel Hill, NC Children with Special Health Care Needs Herbert J. Cohen, MD, FAAP, Chair; Bronx, NY Barbara U. Hamilton, MA Project Officer, U.S. Department of Health and Human Elaine Donoghue, MD, FAAP; Neptune, NJ Services, Health Resources and Services Administration, Lillian Kornhaber, PT, MPH; Bronx, NY Maternal and Child Health Bureau; Rockville, MD Jack M. Levine, MD, FAAP; New Hyde Park, NY Marilyn J. Krajicek, EdD, RN, FAAN Cordelia Robinson Rosenberg, PhD, RN; Aurora, CO Director, National Resource Center for Health and Sarah Schoen, PhD, OTR; Greenwood Village, CO Safety in Child Care and Early Education; Aurora, CO Nancy Tarshis, MA, CCC/SP; Bronx, NY Phyllis Stubbs-Wynn, MD, MPH Melanie Tyner-Wilson, MS; Lexington, KY Former Project Officer, U.S. Department of Health and Environmental Quality Human Services, Health Resources and Services Steven B. Eng, MPH, CIPHI(C), Chair; Port Moody, BC Administration, Maternal and Child Health Bureau; Darlene Dinkins; Washington, DC Rockville, MD Hester Dooley, MS; Portland, OR Bettina Fletcher; The Caring for Our Children, 3rd Ed. Steering Washington, DC Committee would like to express special gratitude to C. Eve J. Kimball, MD, FAAP; West Reading, PA Kathy the Co-Chairs of the First and/or Second Editions: Seikel, MBA; Washington, DC

11 x Acknowledgments Richard Snaman, REHS/RS; Arlington, VA Brooke Organization and Administration Stebbins, BSN; Concord, NH Christopher A. Kus, MD, MPH, Chair; Albany, NY Nsedu Obot Witherspoon, MPH; Washington, DC Christine Ross–Baze; Topeka, KS Janet Carter; Dover, DE General Health Sally Clausen, ARNP, BSN; Des Moines, IA CAPT. Timothy R. Shope, MD, MPH, FAAP, Chair; Portsmouth, VA Judy Collins; Norman, OK Abbey Alkon, RN, PNP, PhD; San Francisco, CA Pauline Koch; Newark, DE Paul Casamassimo, DDS, MS; Columbus, OH Jackie Quirk; Raleigh, NC Sandra Cianciolo, MPH, RN; Chapel Hill, NC Staff Health Beth A. DelConte, MD, FAAP; Broomall, PA Amy C. Cory, PhD, RN, CPNP, PCNS, BC, Chair; Karen Leamer, MD, FAAP; Denver, CO Valparaiso, IN Judy Romano, MD, FAAP; Martins Ferry, OHLinda Patricia S. Cole; Indianapolis, IN Satkowiak, ND, RN, CNS; Denver, CO Susan Eckelt, CDA; Tulsa, OK Karen Sokal-Gutierrez, MD, MPH, FAAP; Berkeley, CA Bethany Geldmaker, PNP, PhD; Richmond, VA Infectious Diseases Stephanie Olmore, MA; Washington, DC Larry Pickering, MD, FAAP, Chair; Atlanta, GA Barbara Sawyer; Arvada, CO Ralph L. Cordell, PhD; Atlanta, GA Lead Organizations’ Reviewers Dennis L. Murray, MD; Augusta, GA American Academy of Pediatrics Thomas J. Sandora, MD, MPH; Boston, MA Sandra G. Hassink, MD, MPH, FAAP Andi L. Shane, MD, MPH; Atlanta, GA Jeanne VanOrsdal, MEd Injury Prevention American Public Health Association Seth Scholer, MD, MPH, Chair; Elizabeth L. M. Miller, BSN, RN, BC; Newtown Square, PA Nashville, TN Barbara Schwartz, PhD; New York, NY Laura Aird, MS; Elk Grove Village, IL U.S. Department of Health and Human Services, Health Sally Fogerty, BSN, Med; Newton, MA Resources and Services Administration, Maternal and Paula Deaun Jackson, MSN, CRNP, LNC; Philadelphia, PA Child Health Bureau Rhonda Laird; Nashville, TN R. Lorraine Brown, RN, BS, CPHP; Rockville, MD Sarah L. Myers, RN; Moorhead, MN CAPT. Stephanie Bryn, MPH; Rockville, MD Denise Sofka, MPH, RD; Rockville, MD Susan H. Pollack, MD, FAAP; Lexington, KY Ellen R. Schmidt, MS, OTR; Washington, DC National Resource Center for Health and Safety in Alexander W. (Sandy) Sinclair; Washington, DC Child Care and Early Education Project Team Donna Thompson, PhD; Cedar Falls, IA Marilyn J. Krajicek, EdD, RN, FAAN; Director Jean M. Cimino, MPH; Professional Research Assistant Nutrition Betty Geer, MSN, RN, CPNP; Research Assistant Catherine Cowell, PhD, Chair; New York, NY Barbara U. Hamilton, MA; Former Assistant Director Sara Benjamin Neelon, PhD, MPH, RD; Durham, NC Susan Paige Lehtola, BBA, BS; Research Assistant Donna Blum-Kemelor, MS, RD, LD; Alexandria, VA David Merten, BS; Former Research Assistant Robin Brocato, MHS; Washington, DC Garrett T. Risley, MBA-HA; Research Assistant Kristen Copeland, MD, FAAP; Cincinnati, OH Linda Satkowiak, ND, RN, CNS; Nurse Consultant Suzanne Haydu, MPH, RD; Sacramento, CA Gerri Steinke, PhD; Evaluator Janet Hill, MS, RD, IBCLC; Sacramento, CA Ginny Torrey, BA; Program Specialist Susan L. Johnson, PhD; Aurora, CO Ruby Natale, PhD, PsyD; Miami, FL Jeanette Panchula, BSW, RN, PHN, IBCLC Shana Patterson, RD; Denver, CO Barbara Polhamus, PhD, MPH, RD; Atlanta, GA Susan Schlosser, MS, RD; Chappaqua, NY Denise Sofka, MPH, RD; Rockville, MD Jamie Stang, PhD, MPH, RD; Minneapolis, MN

12 xi Acknowledgments Kathie Boe Stakeholder Reviewers/Additional Contributors Knowledge Learning Corporation, OR Kenneth C. Akwuole, PhD U.S. Administration for Children and Families, Kathie Boling Office of Child Care, DC Zero to Three, DC Duane Alexander, MD, FAAP Suzanne Boulter, MD, FAAP National Institute of Child Health and Human American Academy of Pediatrics, Section on Pediatric Development, MD Dentistry and Oral Health, IL Abbey Alkon, RN, PNP, MPH, PhD Laurel Branen, PhD, RD, LD American Academy of Pediatrics, Section on Early University of Idaho, School of Family and Consumer Education and Child Care, IL Sciences, ID University of California San Francisco, California Marsha R. Brookins Childcare Health Program, CA U.S. Administration for Children and Families, DC Krista Allison, RN, BSN Mary Jane Brown Parent, CO Centers for Disease Control and Prevention, Environment Division, GA Jamie Anderson, RNC, IBCLC New Jersey Department of Health and Senior Services, Oscar Brown, MD, FAAP Division of Family Health Services, NJ American Academy of Pediatrics, Committee on Practice in Ambulatory Medicine and Immunizations, IL Kristie Applegren, MD American Academy of Pediatrics, Council on Heather Brumberg, MD, MPH, FAAP Communication and Media, IL American Academy of Pediatrics, Committee on Environmental Health, IL Lois D. W. Arnold, PhD, MPH National Commission on Donor Milk Banking, American Barbara Cameron, MA, MSW Breastfeeding Institute, MA University of North Carolina, Carolina Breastfeeding Institute, NC Susan Aronson, MD, FAAP Healthy Child Care America Pennsylvania, Pennsylvania Charles Cappetta, MD, FAAP Chapter of the American Academy of Pediatrics, PA American Academy of Pediatrics, Council on Sports Medicine and Fitness, IL Robert Baker, MD, PhD, FAAP Gastroenterology, Hepatology, and Therapeutics, NY Anne Carmody, BS Wisconsin Department of Children and Families, Polly T. Barey, RN, MS Bureau of Early Care Regulation, WI Connecticut Nurses Association, CT Anna Carter Molly Bauer, ARNP, CPNP, RN North Carolina Division of Child Development, NC University of Iowa Health Care, IA Susan Case Kristen Becker Oklahoma Department of Human Services, OK P a r e n t , WA Dimitri Christakis, MD, FAAP Debbie Beirne American Academy of Pediatrics, Council on Virginia Department of Social Services and Division of Communication and Media, IL Licensing, VA Tom Clark, MD, FAAP Nancy P. Bernard, MPH Task Force of the Youth Futures Authority, GA Washington State Department of Health, Indoor Air Quality/ School Environmental Health and Safety, WA Sally Clausen, ARNP, BSN Healthy Child Care America, IA Wendy Bickford, MA Buell Early Childhood Leadership Program, CO Abby J. Cohen, JD National Child Care Information and Technical Julia D. Block, MD, MPH, FAAP Assistance Center, CA American Academy of Pediatrics, NY

13 xii Acknowledgments Herbert J. Cohen, MD, FAAP Jose Esquibel Council on Children with Disabilities, MD Colorado Department of Public Health and Albert Einstein College of Medicine, Department Environment, CO of Pediatrics, NY Karen Farley, RD, IBCLC California WIC Association, CA Teresa Cooper, RN Rick Fiene, PhD Washington Early Childhood Comprehensive Systems, Penn State University, Capital Area Early Childhood State Department of Health, WA Training Institute, PA Kristen A. Copeland, MD, FAAP Margaret Fisher, MD, FAAP Cincinnati Children’s Hospital Medical Center, OH American Academy of Pediatrics, Disaster Preparedness Ron Coté, PE Advisory Council, IL National Fire Protection Association, MA American Academy of Pediatrics, Section on Infectious William Cotton, MD, FAAP Diseases, IL American Academy of Pediatrics, Council on Thomas Fleisher, MD, FAAP Community Pediatrics, IL American Academy of Pediatrics, Section on Allergy and Melissa Courts Immunology, IL Ohio Early Childhood Comprehensive Systems, Janice Fletcher, EdD Healthy Child Care America, OH University of Idaho, School of Family and Consumer Debby Cryer, PhD Sciences, ID University of North Carolina-Chapel Hill, FPG Carroll Forsch Child Development Institute, NC South Dakota Department of Social Services, Division of Edward Curry, MD, FAAP Child Care Services, SD American Academy of Pediatrics, Committee on Practice Daniel Frattarelli, MD, FAAP in Ambulatory Medicine and Immunizations, IL American Academy of Pediatrics, Section on Clinical Nancy M. Curtis Pharmacology and Therapeutics/Committee on Drugs, IL Maryland Health and Human Services, Montgomery Doris Fredericks, MEd, RD, FADA C ou nt y, M D Child Development, Inc., Choices for Children, CA Cynthia Devore, MD, FAAP Gilbert Fuld, MD, FAAP American Academy of Pediatrics, Council on American Academy of Pediatrics, Council on School Health, IL Communication and Media, IL Ann Ditty, MA Jill Fussell, MD, FAAP National Association for Regulatory Administration, KY American Academy of Pediatrics, Committee on Early Steven M. Donn, MD, FAAP Childhood, Adoption, and Dependent Care, Section American Academy of Pediatrics, Committee on Medical on Developmental and Behavioral Pediatrics, IL Liability and Risk Management, IL Carol Gage Elaine Donoghue, MD, FAAP U.S. Administration for Children and Families, American Academy of Pediatrics, Committee on Early Office of Child Care, DC Childhood, Adoption, and Dependent Care, IL Robert Gilchick, MD, MPH American Academy of Pediatrics, Section on Early Los Angeles County Department of Public Health, Child Education and Child Care, IL and Adolescent Health Program and Policy, CA Adrienne Dorf, MPH, RD, CD Frances Page Glascoe, PhD Public Health - Seattle and King County, WA American Academy of Pediatrics, Section on Developmental and Behavioral Pediatrics, IL Jacqueline Douge, MD, FAAP American Academy of Pediatrics, Council on Mary P. Glode, MD, FAAP Communication and Media, IL American Academy of Pediatrics, Committee on Infectious Diseases, IL Benard Dreyer, MD, FAAP American Academy of Pediatrics, Council on Communication and Media, IL

14 xiii Acknowledgments Chanda Nicole Holsey, DrPH, MPH, AE-C Eloisa Gonzalez, MD, MPH San Diego State University, Graduate School of Public Los Angeles County Department of Public Health, Health, CA Physical Activity and Cardiovascular Health Program, CA Sarah Hoover, MEd University of Colorado School of Medicine, Rosario Gonzalez, MD, FAAP JFK Partners, CO American Academy of Pediatrics, Council on Communication and Media, IL Gail Houle, PhD U.S. Department of Education, Early Childhood David Gremse, MD, FAAP Programs Office of Special Education, DC Gastroenterology, Hepatology, and Therapeutics, AL Bob Howard Joseph Hagan, MD, FAAP Division of Child Day Care Licensing and Regulatory American Academy of Pediatrics, Bright Futures, IL Services, SC Michelle Hahn, RN, PHN, BSN Julian Hsin-Cheng Wan, MD, FAAP Healthy Child Care Minnesota, MN American Academy of Pediatrics, Section on Urology, IL Cheryl Hall, RN, BSN, CCHC Moniquin Huggins Maryland State Department of Education, U.S. U.S. Administration for Children and Families, Administration for Children and Families, Office Office of Child Care, DC of Child Care, MD Anne Hulick, RN, MS, JD Lawrence D. Hammer, MD, FAAP Connecticut Nurses Association, CT American Academy of Pediatrics, Committee on Practice in Ambulatory Medicine and Immunizations, IL Ta m my Hu rle y American Academy of Pediatrics, Section on Child Abuse Gil Handal, MD, FAAP and Neglect, IL American Academy of Pediatrics, Council on Community Pediatrics, IL Mary Anne Jackson, MD, FAAP American Academy of Pediatrics, Committee on Infectious Patty Hannah Diseases, IL KinderCare Learning Centers, OH Paula Deaun Jackson, MSN, CPNP, CCHC Pediatric Nurse Jodi Hardin, MPH Practitioner and Child Care Health Consultant, PA Early Childhood Systems, CO Paula James Thelma Harms, PhD Contra Costa Child Care Council, Child Health and University of North Carolina-Chapel Hill, NC Nutrition Program, CA Sandra Hassink, MD, FAAP Laura Jana, MD, FAAP American Academy of Pediatrics, Obesity Initiatives, IL American Academy of Pediatrics, Section on Early Leo Heitlinger, MD, FAAP Education and Child Care, IL Gastroenterology, Hepatology, and Therapeutics, PA Renee Jarrett, MPH James Henry American Academy of Pediatrics, Section on Early U.S. Administration for Children and Families, Education and Child Care, IL Office of Child Care, DC Paula Jaudes, MD, FAAP Mary Ann Heryer, MA American Academy of Pediatrics, Committee on Early Childhood, Adoption, and Dependent Care, IL University of Missouri at Kansas City, Institute of Human Development, MO Lowest Jefferson, REHS/RS, MS, PHA Department of Health, WA Karen Heying National Infant and Toddler Child Care Initiative, Zero to Mark Jenkerson Three, DC Missouri Department of Health and Senior Services, MO Pam High, MD, MS, FAAP Lynn Jezyk American Academy of Pediatrics, Committee on Early U.S. Administration for Children and Families, Office of Childhood Adoption and Dependent Care, IL Child Care Licensing, DC

15 xiv Acknowledgments Veronnie Faye Jones, MD, FAAP Linda L. Lindeke, PhD, RN, CNP American Academy of Pediatrics, Committee on Early American Academy of Pediatrics, Medical Home Childhood, Adoption, and Dependent Care, IL Initiatives, IL Mark Kastenbaum Michelle Macias, MD, FAAP Department of Early Learning, WA American Academy of Pediatrics, Section on Developmental and Behavioral Pediatrics, IL Harry L. Keyserling, MD, FAAP American Academy of Pediatrics, Committee on Karin A. Mack, PhD Infectious Diseases, IL Centers for Disease Control and Prevention, GA Matthew Edward Knight, MD, FAAP Maxine M. Maloney American Academy of Pediatrics, Section on Clinical U.S. Administration for Children and Families, Pharmacology and Therapeutics/Committee on Drugs, IL Office of Child Care, DC Pauline Koch Barry Marx, MD, FAAP National Association for Regulatory Administration, DE U.S. Office of Head Start, DC Bonnie Kozial Bryce McClamroch American Academy of Pediatrics, Section/Committee on Massachusetts Early Childhood Comprehensive Systems, Injury, Violence, and Poison Prevention, IL State Department of Public Health, MA Steven Krug, MD, FAAP Janet R. McGinnis American Academy of Pediatrics, Disaster Preparedness North Carolina Department of Public Instruction, Advisory Council, IL Office of Early Learning, NC Mae Kyono, MD, FAAP Ellen McGuffey, CPNP American Academy of Pediatrics, Section on Early National Association of Pediatric Nurse Practitioners , NJ Education and Child Care, IL Kandi Mell Miriam Labbok, MD, MPH, FACPM, FABM, IBCLC Juvenile Products Manufacturers Association, NJ University of North Carolina, Carolina Breastfeeding Shelly Meyer, RN, BSN, PHN, CCHC Institute, NC Missoula City-County Health Department, Child Care Mary LaCasse, MS, EdD Resources, MT Department of Mental Health and Hygiene, MD Joan Younger Meek, MD, MS, RD, IBCLC James Laughlin, MD, FAAP Orlando Health, Arnold Palmer Hospital for Children, American Academy of Pediatrics, Committee on Practice Florida State University College of Medicine, FL in Ambulatory Medicine and Immunizations, IL Angela Mickalide, PhD, CHES Sharis LeMay Home Safety Council, DC Alabama Department of Public Health, Healthy Child Care Jonathan D. Midgett, PhD Alabama, AL U.S. Consumer Product Safety Commission, MD Vickie Leonard, RN, FNP, PhD Mark Minier, MD, FAAP University of California San Francisco, California American Academy of Pediatrics, Council on School Childcare Health Program, CA Health, IL Herschel Lessin, MD, FAAP Mary Beth Miotto, MD, FAAP American Academy of Pediatrics, Committee on Practice American Academy of Pediatrics, Council on in Ambulatory Medicine and Immunizations, IL Communication and Media, IL Michael Leu, MD, MS, MHS, FAAP Antoinette Montgomery, BA American Academy of Pediatrics, Council on P a r e n t , VA Communication and Media, IL Rachel Moon, MD, FAAP Katy Levenhagen, MS, RD American Academy of Pediatrics, Task Force on Infant Snohomish Health District, WA Positioning and SIDS, IL

16 xv Acknowledgments Dawn Ramsburg, PhD Len Morrissey U.S. Administration for Children and Families, Office of ASTM International, PA Child Care, DC Jane Morton, MD, FAAP Chadwick Rodgers, MD, FAAP American Academy of Pediatrics, Section on American Academy of Pediatrics, Committee on Practice Breastfeeding, IL in Ambulatory Medicine and Immunizations, IL Robert D. Murray, MD, FAAP Judy Romano, MD, FAAP American Academy of Pediatrics, Council on School American Academy of Pediatrics, Section on Early Health, IL Education and Child Care, IL Scott Needle, MD, FAAP Kate Roper, EdM American Academy of Pediatrics, Disaster Preparedness Massachusetts Early Childhood Comprehensive Systems, Advisory Council, IL State Department of Public Health, MA Sara Benjamin Neelon, PhD, MPH, RD Bobbie Rose, RN Duke University Medical Center, Duke Global Health University of California San Francisco, California Institute, NC Childcare Health Program, CA Jeffrey Okamoto, MD, FAAP, FAACPDM Lori Saltzman American Academy of Pediatrics, Council on School U.S. Consumer Products Safety Commission, MD Health, IL Teresa Sakraida, PhD, MS, MSEd, BSN Isaac Okehie University of Colorado, College of Nursing, CO U.S. Administration for Children and Families, Office of Child Care, DC Kim Sandor, RN, MSN, FNP Connecticut Nurses Association, CT Stephanie Olmore National Association for the Education of Karen Savoie, RDH, BS Young Children, DC Colorado Area Health Education Center System, Cavity Free at Three, CO John Pascoe, MD, MPH, FAAP American Academy of Pediatrics, Committee on Barbara Sawyer Psychosocial Aspects of Child and Family Health, IL National Association for Family Child Care, CO Shana Patterson, RD Beverly Schmalzried Colorado Physical Activity and Nutrition Program, CO National Association of Child Care Resource and Referral Agencies, VA Jerome A. Paulson, MD, FAAP American Academy of Pediatrics, Committee on David J. Schonfeld, MD, FAAP Environmental Health, IL American Academy of Pediatrics, Disaster Preparedness Advisory Council, IL Kathy Penfold, MSN, RN Department of Health and Human Services, MO Gordon E. Schutze, MD, FAAP American Academy of Pediatrics, Committee on Infectious Leatha Perez-Chun, MS Diseases, IL U.S. Administration for Children and Families, Office of Child Care, DC Lynne Shulster, PhD Centers for Disease Control and Prevention, GA Christine Perreault, RN, MHA The Children’s Hospital, CO Steve Shuman Consultant, CA Lauren Pfeiffer Juvenile Products Manufacturers Association, NJ Benjamin S. Siegel, MD, FAAP American Academy of Pediatrics, Committee on Lisa Albers Prock, MD, MPH Psychosocial Aspects of Child and Family Health, IL American Academy of Pediatrics, Section on Adoption and Foster Care, IL Geoffrey Simon, MD, FAAP American Academy of Pediatrics, Committee on Practice Susan K. Purcell, BS, MA in Ambulatory Medicine and Immunizations, IL Grandparent, CO

17 xvi Acknowledgments Heather Smith Grace Whitney, PhD, MPA Parent, MO Connecticut Head Start Collaboration Office, CT Linda J. Smith, BSE, FACCE, IBCLC, FILCA Karen Cachevki Williams, PhD Bright Future Lactation Resource Centre, OH University of Wyoming, Department of Family and Consumer Sciences, WY Karen Sokal-Gutierrez, MD, MPH, FAAP UCB-UCSF Joint Medical Program, CA David Willis, MD, FAAP American Academy of Pediatrics, Section on Early Robin Stanton, MA, RD, LD Education and Child Care, IL Oregon Public Health Division, Adolescent Health Section, OR Cindy Young, MPH, RD, CLE County of Los Angeles Department of Public Health, CA Brooke Stebbins Healthy Child Care New Hampshire, Department of Public Health Services, NH Kathleen M. Stiles, MA Colorado Office of Professional Development, CO Justine Strickland Georgia Department of Early Care and Learning, Child Care Policy, GA Jeanine Swenson, MD, FAAP American Academy of Pediatrics, Council on Communication and Media, IL Barbara Thompson U.S. Department of Defense, Office of Family Policy/ Children and Youth, VA Lynne E. Torpy, RD Colorado Department of Public Health and Environment, Colorado Child and Adult Care Food Program, CO Michael Trautman, MD, FAAP American Academy of Pediatrics, Section on Transport Medicine, IL Patricia A. Treadwell, MD, FAAP American Academy of Pediatrics, Section on Dermatology, IL Mari Uehara, MD University of Hawaii at Manoa, John A. Burns School of Medicine, Department of Pediatrics, HI Ta a r a Ve d v i k Parent, CO Darlene Watford U.S. Environmental Protection Agency, Office of Pollution Prevention and Toxics, DC Holly E. Wells American Association of Poison Control Centers, VA Lani Wheeler, MD, FAAP American Academy of Pediatrics, Council on School Health, IL

18 xvii Introduction - Every day millions of children attend early care and educa Standards; Guidelines for Early Care and Education tion programs. It is critical that they have the opportunity to Programs. 4th ed. Itasca, IL: American Academy of grow and learn in healthy and safe environments with Pediatrics; 2019 caring and professional caregivers/teachers. Following History health and safety best practices is an important way to In 1992, the American Public Health Association (APHA) provide quality early care and education for young children. and the American Academy of Pediatrics (AAP) jointly The American Academy of Pediatrics (AAP), the American Caring for Our Children: National Health and published Public Health Association (APHA), and the National Safety Performance Standards; Guidelines for Out-of-Home Resource Center for Health and Safety in Child Care and (1). The publication was the product of Child Care Programs Early Education (NRC) are pleased to release the fourth a five year national project funded by the U.S. Department edition of Caring for Our Children: National Health and of Health and Human Services, Health Resources and Safety Performance Standards; Guidelines for Early Care and Services Administration, Maternal and Child Health . These national standards represent the Education Programs Bureau (MCHB). This comprehensive set of health and best evidence, expertise, and experience in the country on safety standards was a response to many years of effort by quality health and safety practices and policies that should advocates for quality child care. In 1976, Aronson and be followed in today’s early care and education settings. Pizzo recommended development and use of national is an innovative, continually Caring for Our Children health and safety standards as part of a report to Congress updated set of standards for early care and education Federal Interagency Day Care in association with the programs. The most up-to-date version of the standards Appropriateness Study Requirements (2). In the (FIDCR) may be accessed at www.nrckids.org/CFOC. years that followed, experts repeatedly reaffirmed the need for these standards. For example, while the work to prepare The third print edition, the 2011 publication, was the result was underway, the National Caring for Our Children of an extensive process that benefited from the contribu - Who Cares for America’s Research Council’s report, tions of 86 technical experts in the field of health and safety Children? Child Care Policy for the 1990s , called for uniform in early care and education. (The history of past revisions national child care standards (3). Subsequently a second appears in the following section.) Since the publication of Caring for Our Children was published in 2002 edition of the third edition, the standards are continually reviewed by addressing new knowledge generated by increasing research - the AAP, APHA, and NRC, with new and updated stan into health and safety in early care and education dards posted online as they become available, year-round. - programs. The increased use of the standards both in prac Many users of the Caring for Our Children standards like to tical onsite applications and in research documents the have a print reference on-hand, and because the third value of the standards and validates the importance of edition preceded the online updates, the AAP, APHA, and keeping the standards up-to-date (4). Caring for Our NRC are publishing new print editions that reflect updated has been a yardstick for measuring what has been Children standards. The fourth print edition of Caring for Our done and what still needs to be done, as well as a technical Children builds upon the foundation of the first three manual on how to do it. editions and includes online updates since 2011. Third Edition Review Process The online Important note about edition terminology: - The Maternal and Child Health Bureau’s continuing fund version of Caring for Our Children no longer will be labeled ing since 1995 of a National Resource Center for Health and with “edition” terminology. It is the latest version, updated Safety in Child Care and Early Education (NRC) at the as new or revised standards are posted. The suggested cita - University of Colorado, College of Nursing supported the tion for the online standards at www.nrckids.org/CFOC is work to coordinate the development of the second and as follows: third editions. American Academy of Pediatrics, American Public Health Caring for Our The standards in the third edition of Association, National Resource Center for Health and were revised by eighty-six technical experts. Children Safety in Child Care and Early Education. Caring for Our Critical reviews and recommendations were then provided Children: National Health and Safety Performance by 184 stakeholder individuals - those representing Standards; Guidelines for Early Care and Education - consumers of the information and organizations represent http://cfoc.nrckids.org. Updated . Programs. ing major constituents of the early care and education Accessed community. Caregivers/teachers, parents/guardians, fami - Print publications will be labeled by edition numbers to lies, health care professionals, safety specialists, early child - identify the latest print edition for readers, programs, book - hood educators, early care and education advocates, stores, and libraries. The suggested citation for this fourth regulators, and federal, military, and state agencies all print edition is as follows: brought their expertise and experience to the revision process. A complete listing of the Steering Committee, Lead American Academy of Pediatrics, American Public Health Organizations’ reviewers, Technical Panel members, and Association, National Resource Center for Health and Stakeholder contributors appears on the Acknowledgment Caring for Our Safety in Child Care and Early Education. pages. Children: National Health and Safety Performance

19 xviii Introduction The process of revising the standards and the consensus 2. The NRC proposes revisions to individual standards building was organized in stages: based on current research-based evidence. 3. The NRC conducts the following steps to revise stan - 1. Technical panel chairs recruited members to their dards identified above: panels and reviewed the standards from the second • Develops timeline for review edition. Using the best evidence available (peer reviewed Identifies and invites potential subject matter experts • scientific studies, published reports, and best practice (SMEs) based on content area to serve as reviewers of information) they removed standards that were no the proposed changes longer applicable or out-of-date, identified those that • Assigns SMEs to revision subgroups based on were still applicable (in their original or in a revised specific area of expertise form), and formulated many new standards that were Facilitates communication with the SMEs through - • deemed appropriate and necessary. out the revision process - 2. Telephone conference calls were convened among tech Assesses the quality of SME feedback based on • nical panel chairs to bring consensus on standards that current research/best practice bridge several technical areas. Submits final SME-approved revisions to the NRC • 3. A draft of these revised standards was sent to a national Expert Advisory Group (EAG) and state constituency of stakeholders for their Incorporates EAG feedback and prepares the revised • comments and suggestions. standards for copyediting by the AAP. 4. This feedback was subsequently reviewed and consid - Sends the copyedited version of standards to the • ered by the technical panels and a decision was made to NCECHW Steering Committee for final review further revise or not to revise a standard. It should be Incorporates final revisions into the searchable • noted that the national review called attention to many CFOC database - important points of view and new information for addi Communicates with the NCECHW and the AAP to • tional discussion and debate. disseminate information on revised standards 5. The edited standards were then sent to review teams of the AAP, the APHA and the MCHB. Final copy was Requirements of Other Organizations approved by the Steering Committee representing the We recognize that many organizations have requirements four organizations (AAP, APHA, NRC and MCHB). and recommendations that apply to out-of home early care In projects of this scope and magnitude, the end product is and education. For example, the National Association for only as good as the persons who participate in the effort. It the Education of Young Children (NAEYC) publishes is hard to enumerate in this introduction the countless requirements for developmentally appropriate practice and hours of dedication and effort from contributors and accreditation of child care centers; Head Start follows reviewers. The project owes each of them a huge debt of Performance Standards; the AAP has many standards gratitude. Their reward will come when high-quality early related to child health; the U.S. Department of Defense has care and education services become available to all children standards for military child care; the Office of Child Care and their families! (OCC) produces health and safety standards for tribal child care; the National Fire Protection Association has stan - CFOC Standard Revision Process dards for fire safety in child care settings. The Office of In collaboration with the National Center for Early Child Care administers the Child Care and Development Childhood Health and Wellness (NCECHW), the NRC Fund (CCDF) which provides funds to states, territories, CFOC Standards using the following process: updates and tribes to assist low-income families, families receiving 1. The NRC continually monitors and prioritizes stan - temporary public assistance, and those transitioning from dards for revision based on the following criteria: public assistance in obtaining child care so that they can • Impact on child and/or staff morbidity/mortality work or attend training/education. Caregivers/teachers Publication of new/updated science-based evidence • serving children funded by CCDF must meet basic health or best practices that necessitate a standard change and safety requirements set by states and tribes. All of these Assessment of new/updated publications, require • - - are valuable resources, as are many excellent state publica ments, or applicable policy statements that are related tions. By addressing health and safety as an integrated Red Book, to CFOC standards (eg, the AAP component of early care and education, contributors to Managing Infectious Diseases in Child Care and Caring for Our Children have made every effort to ensure Schools, Child and Adult Care Food Programs) that these standards are consistent with and complement Analysis of relationship to the Child Care • other child care requirements and recommendations. Development Block Grant health and safety priority Continuing Improvement areas Standards are never static. Each year the knowledge base • Receipt and analysis of nominations from subject increases, and new scientific findings become available. matter experts and other stakeholders New areas of concern and interest arise. These standards Contact from stakeholders via direct communication • will assist individuals and organizations who are involved with the NRC or via the NCECHW Info line in the continuing work of standards improvement at every • Inclusion in CFOC Basics level: in early care and education practice, in regulatory

20 xix Introduction administration, in research in early childhood systems together should be encouraged. Daily communication, building, in academic curricula, and in the professional combined with at least yearly conferences between performance of the relevant disciplines. families and the principal caregiver/teacher, should occur. Communication with families should take Each of these areas affects the others in the ongoing process place through a variety of means and ensure all of improving the way we meet the needs of children. families, regardless of language, literacy level, or Possibly the most important use of these standards will be special needs, receive all of the communication. to raise the level of understanding about what those needs 5. The nurturing of a child’s development is based on are, and to contribute to a greater willingness to commit knowledge of the child’s general health, growth and more resources to achieve quality early care and education development, learning style, and unique characteristics. where children can grow and develop in a healthy and safe This nurturing enhances the enjoyment of both child environment. and parent/guardian as maturation and adaptation take place. As shown by studies of early brain development, References 1. American Public Health Association, American Academy of Pediatrics. trustworthy relationships with a small number of adults 1992. Caring for our children. National health and safety performance and an environment conducive to bonding and learning standards: Guidelines for out-of-home child care programs. Washington, DC: are essential to the healthy development of children. APHA. 2. USDHEW, Office of the Assistant Secretary for Planning and Evaluation. Staff selection, training, and support should be directed Policy issues in day care: Summaries of 21 papers, 109-15. 19 7 7. to the following goals: Who 3. National Research Council, National Academy of Sciences. 1990. Promoting continuity of affective relationships; a. Washington, Cares for America’s Children? Child Care Policy in the 1990s. DC: National Academy Press. b. Encouraging staff capacity for identification with Crowley, A. A., J. Kulikowich. 2009. Impact of training on child care health 4. and empathy for the child; Ped Nurs 35:93- 100. consultant knowledge and practice. c. Emphasizing an attitude of involvement as an adult in the children’s play without dominating the Guiding Principles activity; d. Being sensitive to cultural differences; and The following are the guiding principles used in writing e. Being sensitive to stressors in the home these standards: environment. 1. The health and safety of all children in early care and Children with special health care needs encompass 6. education settings is essential. The child care setting those who have or are at increased risk for a chronic offers many opportunities for incorporating health and physical, developmental, behavioral, or emotional safety education and life skills into everyday activities. condition and who also require health and related Health education for children is an investment in a services of a type or amount beyond that generally lifetime of good health practices and contributes to a required by children. This includes children who have healthier childhood and adult life. Modeling of good intermittent and continuous needs in all aspects of - health habits, such as healthy eating and physical activ health. No child with special health care needs should ity, by all staff in indoor and outdoor learning/play envi - - be denied access to child care because of his/her disabil ronments, is the most effective method of health ity(ies), unless one of the four reasons for denying care education for young children. exists: level of care required; physical limitations of the Child care for infants, young children, and school-age 2. site; limited resources in the community, or unavailabil - children is anchored in a respect for the developmental ity of specialized, trained staff. Whenever possible, chil - needs, characteristics, and cultures of the children and dren with special health care needs should be cared for their families; it recognizes the unique qualities of each and provided services in settings including children individual and the importance of early brain develop - without special health care needs. ment in young children and in particular children birth 7. Developmental programs and care should be based on a to three years of age. child’s functional status, and the child’s needs should be 3. To the extent possible, indoor and outdoor learning/play described in behavioral or functional terms. Children activities should be geared to the needs of all children. with special needs should have a comprehensive inter - The relationship between parent/guardian/family and 4. disciplinary or multidisciplinary evaluation if deter - child is of utmost importance for the child’s current mined necessary. and future development and should be supported by 8. Written policies and procedures should identify facility caregivers/teachers. Those who care for children on a requirements and persons and/or entities responsible for - daily basis have abundant, rich observational informa implementing such requirements including clear guid - tion to share, as well as offer instruction and best prac - ance as to when the policy does or does not apply. tices to parents/guardians. Parents/guardians should 9. Whenever possible, written information about facility share with caregivers/teachers the unique behavioral, policies and procedures should be provided in the native medical and developmental aspects of their children. language of parents/guardians, in a form appropriate for Ideally, parents/guardians can benefit from time spent parents/guardians who are visually impaired, and also in the child’s caregiving environment and time for in an appropriate literacy/readability level for parents/ the child, parent/guardian and caregiver/teacher to be

21 xx Introduction guardians who may have difficulty with reading. How- and information about physical and mental health ever, processes should never become more important problems in the children for whom the staff care. If than the care and education of children. staff turnover is high, training on health and safety Confidentiality of records and shared verbal informa - 10. related subjects should be repeated frequently. tion must be maintained to protect the child, family, Maintaining a healthy, toxic-free physical environment 18. and staff. The information obtained at early care and positively impacts the health and well-being of the chil - education programs should be used to plan for a child’s dren and staff served. Environmental responsibility is safe and appropriate participation. Parents/guardians an important concept to teach and practice daily. must be assured of the vigilance of the staff in protect - ing such information. When sharing information, such Advice to the User as referrals to services that would benefit the child, The intended users of the standards include all who care for attainment of parental consent to share information young children in early care and education settings and must be obtained in writing. It is also important to who work toward the goal of ensuring that all children document key communication (verbal and written) from day one have the opportunity to grow and develop between staff and parents/guardians. appropriately, to thrive in healthy and safe environments, 11. The facility’s nutrition activities complement and sup- and to develop healthy and safe behaviors that will last a plement those of home and community. Food provided lifetime. in a child care setting should help to meet the child’s daily nutritional needs while reflecting individual, All of the standards are attainable. Some may have al- ready cultural, religious, and philosophical differences and been attained in individual settings; others can be imple - providing an opportunity for learning. Facilities can mented over time. For example, any organization that contribute to overall child development goals by helping funds early care and education should, in our opinion, the child and family understand the relationship of adopt these standards as funding requirements and should nutrition to health, the importance of positive child set a payment rate that covers the cost of meeting them. feeding practices, the factors that influence food prac - Recommended Use tices, and the variety of ways to meet nutritional needs. • Caregivers/Teachers can use the standards to develop All children should engage in daily physical activity - and implement sound practices, policies, and staff train in a safe environment that promotes developmentally ing to ensure that their program is healthy, safe, age- appropriate movement skills and a healthy lifestyle. appropriate for all children in their care. The expression of, and exposure to, cultural and ethnic 12. • Early Childhood Systems can build integrated health and diversity enriches the experience of all children, fami - safety components into their systems that promote lies, and staff. Planning for cultural diversity through healthy lifestyles for all children. the provision of books, toys, activities and pictures and • Families have sound information from the standards to working with language differences should be select quality programs and/or evaluate their child’s cur- encouraged. rent early care and education program. They can work in - Community resources should be identified and infor 13. partnership with caregivers/teachers in promoting mation about their services, eligibility requirements, healthy and safe behavior and practice for their child and - and hours of operation should be available to the fami family. Families may also want to incorporate many of lies and utilized as much as possible to provide consulta - these healthy and safe practices at home. tion and related services as needed. can assist families and consult • Health Care Professionals 14. Programs should continuously strive for improvement - with caregivers/teachers by using the standards as guid in health and safety processes and policies for the ance on what makes a healthy and safe and age ap- improvement of the overall quality of care to children. propriate environment that encourages children’s An emergency or disaster can happen at any time. 15. development of healthy and safe habits. Consultants may Programs should be prepared for and equipped to use the standards to develop guidance materials to share respond to any type of emergency or disaster in order to with both caregivers/teachers and parents/guardians. ensure the safety and well-being of staff and children, can use the • Licensing Professionals/Regulators and communicate effectively with parents/guardians. evidence-based rationale to develop or improve regula - Young children should receive optimal medical care 16. tions that require a healthy and safe learning environment in a family-centered medical home. Cooperation and at a critical time in a child’s life and develop lifelong collaboration between the medical home and caregivers/ healthy behaviors in children. teachers lead to more successful outcomes. • National Private Organizations - that will update stan Education is an ongoing, lifelong process and child care 17. dards for accreditation or guidance purposes for a special staff need continuous education about health and safety discipline can draw on the new work and rationales of the related subject matter. Staff members who are current third edition just as Caring for Our Children’s expert - on health related topics are better able to prevent, recog contributors drew upon the expertise of these organiza - nize, and correct health and safety problems. Subjects to tions in developing the new standards. be covered include the rationale for health promotion

22 xxi Introduction • Policy-Makers are equipped with sound science to meet required to enter an early care and education program. The emerging challenges to children’s development of lifelong components of the regulation will vary by topic addressed healthy behaviors and lifestyles. as well as by area of jurisdiction (e.g., municipality or state). • State Departments of Education (DOEs) and local Because a regulation prescribes a practice that every agency can use the standards to guide school administrations or program must comply with, it usually is the minimum or the writing of standards for school operated child care the floor below which no agency or program should and preschool facilities, and this guidance will help prin - operate. - cipals to implement good practice in early care and educa Types of Facilities tion programs. Child care offers developmentally appropriate care and • States and localities who fund subsidized care and education for young children who receive care in out-of- services for income-eligible families - can use the stan - home settings (not their own home). Several types of facili dards to determine the level and quality of service to be ties are covered by the general definition of child care and expected. - education. Although there are generally understood defini • University/College Faculty of early childhood education tions for child care facilities, states vary greatly in their legal programs can instill healthy practices in their students to definitions, and some overlap and confusion of terms still model and use with young children upon entering the exists in defining child care facilities. Although the needs of early childhood workplace and transfer the latest research children do not differ from one setting to another, the into their education. declared intent of different types of facilities may differ. Definitions Facilities that operate part-day, in the evening, during the We have defined many terms in the Glossary. Some of these traditional work day and work week, or during a specific are so important to the user that we are emphasizing them part of the year may call themselves by different names. here as well. These standards recognize that while children’s needs do not differ in any of these settings, the way children’s needs Types of Requirements are met may differ by whether the facility is in a residence A is a statement that defines a goal of practice. It standard or a non-residence and whether the child is expected to differs from a recommendation or a guideline in that it have a longer or only a very short-term arrangement for carries greater incentive for universal compliance. It differs care. from a regulation in that compliance is not necessarily A provides care and Small family child care home - required for legal operation. It usually is legitimized or vali , including the care - education of one to six children dated based on scientific or epidemiological data, or when giver’s/teacher’s own children in the home of the care - this evidence is lacking, it represents the widely agreed giver/teacher. Family members or other helpers may be upon, state-of-the-art, high-quality level of practice. involved in assisting the caregiver/teacher, but often, The agency, program, or health practitioner that does not there is only one caregiver/teacher present at any one meet the standard may incur disapproval or sanction from time. within or without the organization. Thus, a standard is the Large family child care home A provides care and strongest criterion for practice set by a health organization education of seven to twelve children , including the or association. For example, many manufacturers advertise caregiver’s/teacher’s own children in the home of the that their products meet ASTM standards as evidence to caregiver/teacher, with one or more qualified adult the consumer of safety, while those products that cannot assistants to meet child: staff ratio requirements. meet the standards are sold without such labeling to undis - cerning purchasers. Center A is a facility that provides care and education , of any number of children in a nonresidential setting is a statement of advice or instruction pertain - A guideline - or thirteen or more children in any setting if the facil ing to practice. It originates in an organization with ity is open on a regular basis. acknowledged professional standing. Although it may be unsolicited, a guideline often is developed in response to a For definitions of other special types of child care – - stated request or perceived need for such advice or instruc drop-in, school-age, for the mildly ill – see Standard tion. For example, the American Academy of Pediatrics 10.4.1.1: Uniform Categories and Definitions. (AAP) has a guideline for the elements necessary to make The standards are to guide all the types of programs listed the diagnosis of Attention-Deficit/Hyperactivity Disorder. above. regulation A takes a previous standard or guideline and makes it a requirement for legal operation. A regulation Age Groups originates in an agency with either governmental or official Although we recognize that designated age groups and authority and has the power of law. Such authority is developmental levels must be used flexibly to meet the usually accompanied by an enforcement activity. Examples needs of individual children, many of the standards are of regulations are: State regulations pertaining to child:staff applicable to specific age and developmental categories. The ratios in a licensed child care center, and immunizations following categories are used in Caring for Our Children .

23 xxii Introduction • Parents/guardians—for those adults legally responsible Functional Definition for a child’s welfare; (By Developmental Level) Age • Primary care provider—for the licensed health profes - Birth-12 Infant Birth to ambulation sional, to name a few: pediatrician, pediatric nurse months practitioner, family physician, who has responsibility Ambulation to accomplishment of Toddler 13-35 for the health supervision of an individual child; self-care routines such as use of the toilet months for all forms of child • Child abuse and neglect From achievement of self-care routines to Pre-schooler 36-59 maltreatment; entry into regular school months • Children with special health care needs—to encompass children with special needs, children with disabilities, Entry into regular school, including 5-12 School-Age Child years kindergarten through 6th grade children with chronic illnesses, etc. Relationship of the Standards to Laws, Ordinances, Format and Language Each standard unit has at least three components: the and Regulations Ty p e o f , and the applicable itself, the Rationale Standard The members of the technical panels could not annotate section, a . Most standards also have a Facility Comment the standards to address local laws, ordinances, and regula - References section. The Related Standards section and a tions. Many of these legal requirements have a different - reader will find the scientific reference and/or epidemiolog intent from that addressed by the standards. Users of this ical evidence for the standard in the rationale section of document should check legal requirements that may apply each standard. The Rationale explains the intent of and the to facilities in particular locales. need for the standard. Where no scientific evidence for a In general, child care is regulated by at least three different standard is available, the standard is based on the best legal entities or jurisdictions. The first is the building code available professional consensus. If such a professional jurisdiction. Building inspectors enforce building codes to consensus has been published, that reference is cited. The protect life and property in all buildings, not just child care Rationale both justifies the standard and serves as an facilities. Some of the standards should be written into state educational tool. The Comments section includes other or local building codes, rather than into the licensing explanatory information relevant to the standard, such as requirements. applicability of the standard and, in some cases, suggested The second major legal entity that regulates child care is the ways to measure compliance with the standard. Although health system. A number of different codes are intended to this document reflects the best information available at the prevent the spread of disease in restaurants, hospitals, and time of publication, as was the case with the first and other institutions where hazards and risky practices might second editions, this third edition will need updating from exist. Many of these health codes are not specific to child time to time to reflect changes in knowledge affecting early care; however, specific provisions for child care might be care and education. found in a health code. Some of the provisions in the Caring for Our Children standards and appendixes are standards might be appropriate for incorporation into a available at no cost online at http://nrckids.org. It is also health code. available in print format for a fee from the American The third legal jurisdiction applied to child care is child Academy of Pediatrics (AAP) and the American Public care licensing. Usually, before a child care operator receives Health Association (APHA). a license, the operator must obtain approvals from health Standards have been written to be measurable and enforce- and building safety authorities. Sometimes a standard is able. Measurability is important for performance standards not included as a child care licensing requirement because in a contractual relationship between a provider of service it is covered in another code. Sometimes, however, it is not and a funding source. Concrete and specific language helps covered in any code. Since children need full protection, caregivers/teachers and facilities put the standards into the issues addressed in this document should be addressed practice. Where a standard is difficult to measure, we have in some aspect of public policy, and consistently addressed provided guidance to make the requirement as specific as within a community. In an effective regulatory system, - possible. Some standards required more technical terminol different inspectors do not try to regulate the same thing. ogy (e.g., certain infectious diseases, plumbing and heating Advocates should decide which codes to review in making terminology). We encourage readers to seek interpretation sure that these standards are addressed appropriately in by appropriate specialists when needed. Where feasible, we their regulatory systems. Although the licensing require - have written the standards to be understood by readers ments are most usually affected, it may be more appropriate from a wide variety of backgrounds. to revise the health or building codes to include certain The Steering Committee agreed to consistent use of the standards, and it may be necessary to negotiate conflicts terms below to convey broader concepts instead of using among applicable codes. a multitude of different terms. The National Standards are for reference purposes only • Caregiver/teacher—for the early care and education/ and should not be used as a substitute for medical or legal child care professional that provides care and learning consultation, nor be used to authorize actions beyond a opportunities to children—instead of child care provider, person’s licensing, training, or ability. just caregiver or just teacher;

24 xxiii History of Caring for Our Children Standard Language Changes Since the 3rd Edition (Through July 2018) (CFOC) standards listed in The Caring for Our Children revisions, with the exception of those pending below, this document have had revisions made to the Standard appear in this fourth print edition. The pending standard language since the 2011 publication of the third print revisions and any future revisions may be found in the edition. Revisions are based on new or updated research/ CFOC online database (http://nrckids.org/CFOC) and are evidence, policy statements, and/or best practices. These designated by the Notes icon. Standard Number and Title Date of Change (Listed Numerically) 1.2.0.1 Staff Recruitment Pending at time of publication 1.2.0.2 Background Screening 5/2018 5/2018 1.4.5.2 Child Abuse and Neglect Education 1.5.0.2 Orientation of Substitutes 5/2018 1.6.0.2 Frequency of Child Care Health Consultant Visits 8/2013 5/2018 2.1.1.1 Written Daily Activity Program and Statement of Principles 5/2018 2.1.1.2 Health, Nutrition, Physical Activity, and Safety Awareness 5/2018 Personal Caregiver/Teacher Relationships for Infants and Toddlers 2.1.2.1 Methods of Supervision of Children Pending at time of publication 2.2.0.1 2.2.0.3 Screen Time/Digital Media Use 3/2012, 10/2017 Prohibited Caregiver/Teacher Behaviors 5/2018 2.2.0.9 2.3.1.2 Parent/Guardian Visits Pending at time of publication Health and Safety Education Topics for Children 1/2017, 5/2018 2.4.1.1 2.4.1.2 Staff Modeling of Healthy and Safe Behavior and Health and Safety Education Activities 1/2017 2.4.2.1 Health and Safety Education Topics for Staff 1/2017 Parent/Guardian Education Plan 1/2017 2.4.3.2 3.1.3.1 Active Opportunities for Physical Activity 5/2018 Playing Outdoors 8/2013, 5/2018 3.1.3.2 8/2016 Protection from Air Pollution While Children Are Outside 3.1.3.3 Caregivers’/Teachers’ Encouragement of Physical Activity 5/2018 3.1.3.4 3.1.4.1 Safe Sleep Practices and Sudden Unexpected Infant Death (SUID)/SIDS Risk Reduction 12/2011, 12/2016 Scheduled Rest Periods and Sleep Arrangements 5/2018 3.1.4.4 3/2016 3.1.5.1 Routine Oral Hygiene Activities 2/2013, 4/2013, 3/2016 3.1.5.2 Toothbrushes and Toothpaste 8/2017 3.2.1.1 Type of Diapers Worn 3.2.1.4 Diaper Changing Procedure 1/2012, 7/2012, 5/2013, 8/2016 3.2.1.5 Procedure for Changing Children’s Soiled Underwear/Pull-Ups and Clothing 1/2012, 7/2012, 11/2013, 8/2016 Situations that Require Hand Hygiene 3.2.2.1 8/2016, 8/2017 3.2.2.2 8/2017 Handwashing Procedure Hand Sanitizers 4/2016, 4/2017 3.2.2.5 1/2017 3.4.1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and Drugs 3.4.4.1 Recognizing and Reporting Suspected Child Abuse, Neglect and Exploitation 5/2018 3.4.4.2 Immunity for Reporters of Child Abuse and Neglect Pending at time of publication Preventing and Identifying Shaken Baby Syndrome/Abusive Head Trauma 3.4.4.3 5/2018 3.4.4.4 3/2013; Pending at time of publication Care of Children Who Have Been Abused/Neglected Facility Layout to Reduce Risk of Child Abuse and Neglect Pending at time of publication 3.4.4.5 Sun Safety Including Sunscreen 8/2013 3.4.5.1 3.4.5.2 Insect Repellent and Protection from Vector-Borne Diseases 4/2017

25 xxiv History of Standard Language Changes Since the 3rd Edition (Through July 2018) Caring for Our Children (Listed Numerically) Date of Change Standard Number and Title 4/2015, 8/2015, 4/2017 Inclusion/Exclusion/Dismissal of Children 3.6.1.1 Staff Exclusion for Illness 4/2017 3.6.1.2 3.6.2.2 Space Requirements for Care of Children Who Are Ill 8/2017 Inclusion and Exclusion of Children from Facilities That Serve Children Who Are Ill 8/2017 3.6.2.10 11/2017 4.2.0.1 Written Nutrition Plan 11/2017 4.2.0.2 Assessment and Planning of Nutrition for Individual Children 11/2017 4.2.0.3 Use of US Department of Agriculture Child and Adult Care Food Program Guidelines 4.2.0.4 Categories of Foods 2/2012, 11/2017 4.2.0.5 Meal and Snack Patterns 11/2017 Availability of Drinking Water 11/2017 4.2.0.6 4.2.0.7 100% Fruit Juice 11/2017 Feeding Plans and Dietary Modifications 11/2017 4.2.0.8 11/2017 4.2.0.9 Written Menus and Introduction of New Foods 4.2.0.10 Care for Children with Food Allergies 11/2017 4.2.0.11 Ingestion of Substances that Do Not Provide Nutrition 8/2016, 11/2017 Vegetarian/Vegan Diets 11/2017 4.2.0.12 4.3.1.1 General Plan for Feeding Infants 5/2018 Feeding Infants on Cue by a Consistent Caregiver/Teacher 4.3.1.2 5/2018 Preparing, Feeding, and Storing Human Milk 8/2016 4.3.1.3 4.3.1.4 8/2017 Feeding Human Milk to Another Mother’s Child 4.3.1.5 Preparing, Feeding, and Storing Infant Formula 11/2013, 8/2016 4.3.1.6 Use of Soy-Based Formula and Soy Milk 5/2018 4.3.1.7 Feeding Cow’s Milk 5/2018 Warming Bottles and Infant Foods 11/2013, 8/2016, 5/2018 4.3.1.9 5/2018 4.3.1.10 Cleaning and Sanitizing Equipment Used for Bottle Feeding Introduction of Age-Appropriate Solid Foods to Infants 5/2018 4.3.1.11 4.3.1.12 Feeding Age-Appropriate Solid Foods to Infants 5/2018 Meal and Snack Patterns for Toddlers and Preschoolers 5/2018 4.3.2.1 Serving Size for Toddlers and Preschoolers 4.3.2.2 5/2018 4.3.2.3 5/2018 Encouraging Self-Feeding by Older Infants and Toddlers Meal and Snack Patterns for School-Age Children 4.3.3.1 5/2018 Activities that Are Incompatible with Eating 8/2016 4.5.0.3 4.7.0.2 5/2018 Nutrition Education for Parents/Guardians 4.9.0.13 Methods for Washing Dishes by Hand 8/2013 5.1.1.5 Environmental Audit of Site Location 8/2016 5.2.1.1 Ensuring Access to Fresh Air Indoors 8/2016 Ventilation to Control Odors 5.2.1.6 8/2016 Water Supply 5/2016 5.2.6.1 5.2.7.4 8/2017 Containment of Soiled Diapers 5.2.9.1 Use and Storage of Toxic Substances 1/2017 5.2.9.4 Radon Concentrations 5/2016 5.2.9.11 8/2016 Chemicals Used to Control Odors 5.2.9.12 Treatment of CCA Pressure-Treated Wood 8/2016 5.2.9.13 Testing for Lead 8/2015 5.2.9.15 Construction and Remodeling 5/2016 5.4.1.10 Handwashing Sinks 8/2017

26 xxv Standard Language Changes Since the 3rd Edition (Through July 2018) History of Caring for Our Children Date of Change (Listed Numerically) Standard Number and Title 3/2017 Sleeping Equipment and Supplies 5.4.5.1 Storage of Flammable Materials 8/2011 5.5.0.5 Helmets 6.4.2.2 3/2017 6.5.1.2 Qualifications for Drivers 1/2017 Drop-Off and Pick-Up 5/2016 6.5.2.1 8/2017 7.3.1.1 Exclusion for Group A Streptococcal (GAS) Infections 7.3.2.1 Immunization for 8/2017 Type B (Hib) Haemophilus Influenzae 7.3.2.2 8/2017 Type B (Hib) Exposure Haemophilus Influenzae Informing Parents/Guardians of 8/2017 Attendance of Children with Unspecified Respiratory Tract Infection 7.3.11.1 4/2017 Control of Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections 7.4.0.1 4/2017 Staff Education and Policies on Enteric (Diarrheal) and Hepatitis A Virus (HAV) Infections 7.4.0.2 3/2017 Conjunctivitis (Pinkeye) 7.5.1.1 8/2017 Enterovirus Infections 7.5.2.1 7.5.8.1 8/2016 Attendance of Children with Head Lice 8/2017 7.5.11.1 Attendance of Children with Scabies 7.6.3.1 3/2017 Attendance of Children with HIV Staff Education and Policies on Cytomegalovirus (CMV) 3/2017 7.7.1.1 8/2016, 5/2018 Policies and Practices that Promote Physical Activity 9.2.3.1 1/2017 Policies Prohibiting Smoking, Tobacco, Alcohol, Illegal Drugs, and Toxic Substances 9.2.3.15 9.4.1.11 Pending at time of publication Review and Accessibility of Injury and Illness Reports 10.3.3.2 5/2018 Background Screening Pending at time of publication Licensing Agency Role in Communicating the Importance of Reporting Suspected Child Abuse 10.3.3.3 Pending at time of publication Licensing Agency Provision of Child Abuse Prevention Materials 10.3.3.4 Pending at time of publication Training of Licensing Agency Personnel about Child Abuse 10.3.5.3 10.4.3.3 Collection of Data on Illness or Harm to Children in Facilities Pending at time of publication Date of Change Appendixes (Listed Alphabetically) Appendix A: Signs and Symptoms Chart 1/2017 7/2018 Appendix E: Child Care Staff Health Assessment Appendix G: Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger Updated Annually Last Update: 4/2018 Appendix H: Recommended Immunization Schedule for Adults Aged 19 Years or Older Updated Annually Last Update: 4/2018 7/2018 Appendix I: Recommendations for Preventive Pediatric Health Care Appendix J: Selecting an Appropriate Sanitizer or Disinfectant 8/2011, 3/2013 Appendix II: Bike and Multi-sport Helmets: Quick-Fit Check 7/2018

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28 CHAPTER 1 Staffing

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30 3 Chapter 1: Staffing programs, this may be difficult in practice because the 1.1 caregiver/teacher is typically alone, and all of the children CHILD:STAFF RATIO, GROUP SIZE, most likely will not sleep at the same time. In order to pro- vide constant supervision during sleep, caregivers/teachers AND MINIMUM AGE could consider discontinuing the practice of placing infant(s) 1.1.1 in a separate room for sleep, but instead placing the infant’s CHILD:STAFF RATIO AND GROUP SIZE crib in the area used by the other children so the caregiver/ teacher is able to supervise the sleeping infant(s) while caring 1.1.1.1 for the other children. Care must be taken so that placement Ratios for Small Family Child Care Homes of cribs in an area used by other children does not encroach upon the minimum usable floor space requirements. Infants The small family child care home caregiver/teacher do not require a dark and quiet place for sleep. Once they child:staff ratios should conform to the following table: become accustomed, infants are able to sleep without prob - If the small family child care home then the small family child care lems in environments with light and noise. By placing infants caregiver/teacher has no children home caregiver/teacher may (as well as all children in care) on the main (ground) level of under two years of age in care, have one to six children over the home for sleep and remaining on the same level as the two years of age in care children, the caregiver/teacher is more likely able to evacuate If the small family child care home then the small family child care the children in less time; thus, increasing the odds of a suc- caregiver/teacher has one child home caregiver/teacher may cessful evacuation in the event of a fire or another emergency. under two years of age in care, have one to three children over two years of age in care - Caregivers/teachers must also continually monitor other chil dren in this area so they are not climbing on or into the cribs. If the small family child care home then the small family child care If the caregiver/teacher cannot remain in the same room as caregiver/teacher has two children home caregiver/teacher may under two years of age in care, have no children over two years the infant(s) when the infant is sleeping, it is recommended of age in care that the caregiver/teacher should do visual checks every ten to fifteen minutes to make sure the infant’s head is uncovered, The small family child care home caregiver’s/teacher’s own and assess the infant’s breathing, color, etc. Supervision is children as well as any other children in the home tempo - recommended for toddlers and preschoolers to ensure safety rarily requiring supervision should be included in the and prevent behaviors such as inappropriate touching or child:staff ratio. During nap time, at least one adult should hurting other sleeping children from taking place. These be physically present in the same room as the children. behaviors may go undetected if a caregiver/teacher is not RATIONALE present. If caregiver/teacher is not able to remain in the same Low child:staff ratios are most critical for infants and room as the children, frequent visual checks are also recom - toddlers (birth to thirty-six months) (1). Infant and child mended for toddlers and preschoolers when they are sleeping. development and caregiving quality improves when group Each state has its own set of regulations that specify child: size and child:staff ratios are smaller (2). Improved verbal staff ratios. To view a particular state’s regulations, go to the interactions are correlated with lower child:staff ratios (3). National Resource Center for Health and Safety in Child Care - Small ratios are very important for young children’s devel . and Early Education’s (NRC) Website: http://nrckids.org opment (7). The recommended group size and child:staff Some states are setting limits on the number of school-age ratio allow three- to five-year-old children to have continu - children that are allowed to be cared for in small family child - ing adult support and guidance while encouraging inde care homes, e.g., two school-age children in addition to the pendent, self-initiated play and other activities (4). maximum number allowed for infants/preschool children. The National Fire Protection Association (NFPA) requires No data are available to support using a different ratio where in the NFPA 101: Life Safety Code that small family child school-age children are in family child care homes. Since care homes serve no more than two clients incapable of school-age children require focused caregiver/teacher time self-preservation (5). and attention for supervision and adult-child interaction, this standard applies the same ratio to all children three-years-old Direct, warm social interaction between adults and chil - and over. The family child care caregiver/teacher must be able dren is more common and more likely with lower child: to have a positive relationship and provide guidance for each staff ratios. Caregivers/teachers must be recognized as per- child in care. This standard is consistent with ratio require - forming a job for groups of children that parents/guardians ments for toddlers in centers as described in Standard 1.1.1.2. of twins, triplets, or quadruplets would rarely be left to han- dle alone. In child care, these children do not come from Unscheduled inspections encourage compliance with this the same family and must learn a set of common rules that standard. may differ from expectations in their own homes (6,8). RELATED STANDARDS COMMENTS 1.1.1. 3 Ratios for Facilities Serving Children with Special It is best practice for the caregiver/teacher to remain in the Health Care Needs and Disabilities same room as the infants when they are sleeping to provide 1.1. 2 .1 Minimum Age to Enter Child Care small family child care constant supervision. However in

31 4 Caring for Our Children: National Health and Safety Performance Standards During nap time for children ages thirty-one months and References 1. Zero to Three. 2007. The infant-toddler set-aside of the Child Care and older, at least one adult should be physically present in the Development Block Grant: Improving quality child care for infants and same room as the children and maximum group size must http://main .zerotothree.org/site/ toddlers. Washington, DC: Zero to Three. be maintained. Children over thirty-one months of age can DocServer/Jan_07_Child_Care_Fact _Sheet.pdf. National Institute of Child Health and Human Development (NICHD). 2. usually be organized to nap on a schedule, but infants and 2006. The NICHD study of early child care and youth development: toddlers as individuals are more likely to nap on different Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. schedules. In the event even one child is not sleeping the http://www.nichd.nih.gov/publications/pubs/upload/seccyd_051206.pdf. 3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and develop- child should be moved to another activity where appropriate ment of babies in child care: What does the research say? Washington, DC: supervision is provided. ht tp://main . Center for Law and Social Policy (CLASP); Zero to Three. zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf. If there is an emergency during nap time other adults should De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of 4. be on the same floor and should immediately assist the staff child-caregiver ratio on the interactions between caregivers and children in 77:861-74 . child-care centers: An experimental study. Child Devel. supervising sleeping children. The caregiver/teacher who 5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety is in the same room with the children should be able to code. 2009 ed. Quincy, MA: NFPA. summon these adults without leaving the children. Fiene, R. 2002. 13 indicators of quality child care: Research update. 6. Washington, DC: U.S. Department of Health and Human Services, Office When there are mixed age groups in the same room, the of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ child:staff ratio and group size should be consistent with the basic-report/13-indicators-qualitychild-care. 7. Zigler, E., W. S. Gilliam, S. M. Jones. 2006. A vision for universal preschool age of most of the children. When infants or toddlers are in education, 107-29. New York: Cambridge University Press. the mixed age group, the child:staff ratio and group size for Stebbins, H. 2007. State policies to improve the odds for the healthy develop- 8. infants and toddlers should be maintained. In large family ment and school readiness of infants and toddlers. Washington, DC: Zero to http://main.zerotothree.org/site/DocServer/NCCP_article_for_BM_ Three. child care homes with two or more caregivers/teachers car- final.pdf. ing for no more than twelve children, no more than three children younger than two years of age should be in care. 1.1.1. 2 Children with special health care needs or who require more Ratios for Large Family Child Care attention due to certain disabilities may require additional Homes and Centers staff on-site, depending on their special needs and the Child:staff ratios in large family child care homes and extent of their disabilities (1). See Standard 1.1.1.3. centers should be maintained as follows during all hours At least one adult who has satisfactorily completed a course of operation, including in vehicles during transport. in pediatric first aid, including CPR skills within the past Large Family Child Care Homes three years, should be part of the ratio at all times. Maximum Maximum RATIONALE Group Size Child:Staff Ratio Age These child:staff ratios are within the range of recommen- 6 ≤ 12 months 2:1 dations for each age group that the National Association 8 13-23 months 2:1 for the Education of Young Children (NAEYC) uses in its accreditation program (5). The NAEYC recommends a 24-35 months 3:1 12 range that assumes the director and staff members are 7:1 3-year-olds 12 highly trained and, by virtue of the accreditation process, 4- to 5-year-olds 8:1 12 have formed a staffing pattern that enables effective staff 6- to 8-year-olds 10:1 12 functioning. The standard for child:staff ratios in this docu - ment uses a single desired ratio, rather than a range, for each 9- to 12-year-olds 12 12:1 age group. These ratios are more likely than less stringent During nap time for children birth through thirty months ratios to support quality experiences for young children. of age, the child:staff ratio must be maintained at all times - Low child:staff ratios for non-ambulatory children are essen regardless of how many infants are sleeping. They must also tial for fire safety. The National Fire Protection Association be maintained even during the adult’s break time so that (NFPA), in its NFPA 101: Life Safety Code, recommends that ratios are not relaxed. no more than three children younger than two years of age Child Care Centers be cared for in large family child care homes where two staff Maximum Maximum members are caring for up to twelve children (6). Age Child:Staff Ratio Group Size Children benefit from social interactions with peers. How- ≤ 12 months 3:1 6 ever, larger groups are generally associated with less positive 13-35 months 8 4:1 interactions and developmental outcomes. Group size and ratio of children to adults are limited to allow for one to one 3-year-olds 7:1 14 interaction, intimate knowledge of individual children, and 8:1 16 4-year-olds consistent caregiving (7). 16 5-year-olds 8:1 Studies have found that children (particularly infants and 6- to 8-year-olds 20 10:1 toddlers) in groups that comply with the recommended 12:1 9- to 12-year-olds 24

32 5 Chapter 1: Staffing ratio receive more sensitive and appropriate caregiving and COMMENTS score higher on developmental assessments, particularly The child:staff ratio indicates the maximum number of chil- vo c a bu l a r y (1,9). dren permitted per caregiver/teacher (8). These ratios assume that caregivers/teachers do not have time-consuming book- As is true in small family child care homes, Standard 1.1.1.1, keeping and housekeeping duties, so they are free to provide child:staff ratios alone do not predict the quality of care. direct care for children. The ratios do not include other Direct, warm social interaction between adults and chil - personnel (such as bus drivers) necessary for specialized dren is more common and more likely with lower child:staff functions (such as driving a vehicle). ratios. Caregivers/teachers must be recognized as perform - ing a job for groups of children that parents/guardians of Group size is the number of children assigned to a caregiver/ twins, triplets, or quadruplets would rarely be left to handle teacher or team of caregivers/teachers occupying an individ - alone. In child care, these children do not come from the ual classroom or well-defined space within a larger room (8). same family and must learn a set of common rules that The “group” in child care represents the “home room” for school- may differ from expectations in their own homes (10). age children. It is the psychological base with which the school-aged child identifies and from which the child gains Similarly, low child:staff ratios are most critical for infants continual guidance and support in various activities. This and young toddlers (birth to twenty-four months) (1). Infant standard does not prohibit larger numbers of school-aged development and caregiving quality improves when group children from joining in occasional collective activities as size and child:staff ratios are smaller (2). Improved verbal long as child:staff ratios and the concept of “home room” interactions are correlated with lower ratios (3). For three- are maintained. and four-year-old children, the size of the group is even more important than ratios. The recommended group size Unscheduled inspections encourage compliance with and child:staff ratio allow three- to five-year-old children to this standard. have continuing adult support and guidance while encour - These standards are based on what children need for quality aging independent, self-initiated play and other activities (4). nurturing care. Those who question whether these ratios are In addition, the children’s physical safety and sanitation affordable must consider that efforts to limit costs can result routines require a staff that is not fragmented by excessive in overlooking the basic needs of children and creating a demands. Child:staff ratios in child care settings should be highly stressful work environment for caregivers/teachers. sufficiently low to keep staff stress below levels that might Community resources, in addition to parent/guardian fees result in anger with children. Caring for too many young and a greater public investment in child care, can make criti - children, in particular, increases the possibility of stress cal contributions to the achievement of the child:staff ratios to the caregiver/teacher, and may result in loss of the and group sizes specified in this standard. Each state has its caregiver’s/teacher’s self-control (11). own set of regulations that specify child: staff ratios. To view a particular state’s regulations, go to the National Resource Although observation of sleeping children does not require Center for Health and Safety in Child Care and Early the physical presence of more than one caregiver/teacher Education’s (NRC) Website: http://nrckids.org . for sleeping children thirty-one months and older, the staff needed for an emergency response or evacuation of the TYPE OF FACILITY children must remain available on site for this purpose. Center, Large Family Child Care Home Ratios are required to be maintained for children thirty RELATED STANDARDS months and younger during nap time due to the need for 1.1.1. 3 Ratios for Facilities Serving Children with Special closer observation and the frequent need to interact with Health Care Needs and Disabilities younger children during periods while they are resting. Ratios and Supervision During Transportation 1.1.1.4 Close proximity of staff to these younger groups enables more rapid response to situations where young children Ratios and Supervision for Swimming, Wading, 1.1.1.5 - require more assistance than older children, e.g., for evacu and Water Play ation. The requirement that a caregiver/teacher should First Aid and CPR Training for Staff 1. 4 . 3.1 remain in the sleeping area of children thirty-one months Topics Covered in First Aid Training 1.4. 3. 2 and older is not only to ensure safety, but also to prevent CPR Training for Swimming and Water Play 1.4.3.3 inappropriate behavior from taking place that may go un- detected if a caregiver/teacher is not present. While nap References 1. Zero to Three. 2007. The infant-toddler set-aside of the Child Care and time may be the best option for regular staff conferences, Development Block Grant: Improving quality child care for infants and staff lunch breaks, and staff training, one staff person should http://main .zerotothree.org/site/ toddlers. Washington, DC: Zero to Three. stay in the nap room, and the above staff activities should DocServer/Jan_07_Child_Care_Fact _Sheet.pdf. 2. National Institute of Child Health and Human Development (NICHD). 2006. take place in an area next to the nap room so other staff can The NICHD study of early child care and youth development: Findings for assist if emergency evacuation becomes necessary. If a child children up to age 4 1/2 years. Rockville, MD: NICHD. http://www.nichd.nih. with a potentially life- threatening special health care need gov/ publications/pubs/upload/seccyd_051206.pdf. 3. Goldstein, A., K. Hamm, R. Schumacher. Supporting growth and develop- is present, a staffmember trained in CPR and pediatric first ment of babies in child care: What does the research say? Washington, DC: aid and one trained in administration of any potentially Center for Law and Social Policy (CLASP); Zero to Three. ht tp://main . required medication should be available at all times. zerotothree.org/site/DocServer/ChildCareResearchBrief.pdf.

33 6 Caring for Our Children: National Health and Safety Performance Standards 4. De Schipper, E. J., J. M. Riksen-Walraven, S. A. E. Geurts. 2006. Effects of Reference child-caregiver ratio on the interactions between caregivers and children 1. University of North Carolina at Chapel Hill, FPG Child Development in child-care centers: An experimental study. Child Devel 77:861-74. Institute. The national early childhood technical assistance center. ht tp:// 5. National Association for the Education of Young Children (NAEYC). www.nectac.org 2007. Early childhood program standards and accreditation criteria. Washington, DC: NAEYC. National Fire Protection Association (NFPA). 2009. NFPA 101: Life 6. 1.1.1.4 safety code. 2009 ed. Quincy, MA: NFPA. Ratios and Supervision During Transportation 7. Bradley, R. H., D. L. Vandell. 2007. Child care and the well-being of children. Arch Ped Adolescent Med 161:669-76. Child:staff ratios established for out-of-home child care 8. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A should be maintained on all transportation the facility manual for health professionals. 4th ed. Elk Grove Village, IL: American provides or arranges. Drivers should not be included in the Academy of Pediatrics. 9. Vandell, D. L., B. Wolfe. 2000. Child care quality: Does it matter and ratio. No child of any age should be left unattended in or does it need to be improved? Washington, DC: U.S. Department of around a vehicle, when children are in a car, or when they http://aspe.hhs.gov/hsp/ccquality00/. Health and Human Services. are in a car seat. A face-to-name count of children should be 10. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, conducted prior to leaving for a destination, when the desti - ht tp:// Office of the Assistant Secretary for Planning and Evaluation. nation is reached, before departing for return to the facility aspe.hhs.gov/basic-report/13-indicators-quality-child-care. and upon return. Caregivers/teachers should also remember Wrigley, J., J. Derby. 2005. Fatalities and the organization of child care in 11. the United States. Am Socio Rev 70:729-57. to take into account in this head count if any children were picked up or dropped off while being transported away from the facility. 1.1.1. 3 Ratios for Facilities Serving Children with RATIONALE Special Health Care Needs and Disabilities Children must receive direct supervision when they are being Facilities enrolling children with special health care needs transported, in loading zones, and when they get in and out and disabilities should determine, by an individual assess- of vehicles. Drivers must be able to focus entirely on driving ment of each child’s needs, whether the facility requires tasks, leaving the supervision of children to other adults. This a lower child:staff ratio. is especially important with young children who will be sit- ting in close proximity to one another in the vehicle and may RATIONALE need care during the trip. In any vehicle making multiple The child:staff ratio must allow the needs of the children stops to pick up or drop off children, this also permits one enrolled to be met. The facility should have sufficient direct adult to get one child out and take that child to a home, while care professional staff to provide the required programs and the other adult supervises the children remaining in the services. Integrated facilities with fewer resources may be vehicle, who would otherwise be unattended for that time (1). able to serve children who need fewer services, and the staff - Children require supervision at all times, even when buckled ing levels may vary accordingly. Adjustment of the ratio in seat restraints. A head count is essential to ensure that allows for the flexibility needed to meet each child’s type no child is inadvertently left behind in or out of the vehicle. and degree of special need and encourage each child to Child deaths in child care have occurred when children were participate comfortably in program activities. Adjustment of mistakenly left in vehicles, thinking the vehicle was empty. the ratio produces flexibility without resulting in a need for TYPE OF FACILITY care that is greater than the staff can provide without compromising the health and safety of other children. The Center, Large Family Child Care Home facility should seek consultation with parents/guardians, a RELATED STANDARD child care health consultant (CCHC), and other profession - 5. 6 . 0.1 First Aid and Emergency Supplies als, regarding the appropriate child:staff ratio. The facility Reference may wish to increase the number of staff members if the 1. Aird, L. D. 2007. Moving kids safely in child care: A refresher course. Child child requires significant special assistance (1). Care Exchange (January/February): 25-28. http://www.childcareexchange. com/library/5017325.pdf. COMMENTS These ratios do not include personnel who have other 1.1.1. 5 duties that might preclude their involvement in needed supervision while they are performing those duties, such Ratios and Supervision for Swimming, as therapists, cooks, maintenance workers, or bus drivers. Wading, and Water Play The following child:staff ratios should apply while children TYPE OF FACILITY are swimming, wading, or engaged in water play: Center, Large Family Child Care Home RELATED STANDARDS Developmental Levels Child:Staff Ratio 1.1.1.1 Ratios for Small Family Child Care Homes Infants 1:1 1.1.1. 2 Ratios for Large Family Child Care Homes and Toddlers 1:1 Centers Preschoolers 4:1 School-age Children 6:1

34 7 Chapter 1: Staffing Constant and active supervision should be maintained 6 . 3.1. 4 Safety Covers for Swimming Pools - when any child is in or around water (4). During any swim Pool Safety Rules 6 . 3.1.7 ming/wading/water play activities where either an infant Lifesaving Equipment 6 . 3. 2 .1 or a toddler is present, the ratio should always be one adult Lifeline in Pool 6.3.2.2 to one infant/toddler. The required ratio of adults to older 6.3.5.2 Water in Containers children should be met without including the adults who 6.3.5.3 Portable Wading Pools are required for supervision of infants and/or toddlers. An adult should remain in direct physical contact with References an infant at all times during swimming or water play (4). 1. U.S. Consumer Product Safety Commission (CPSC). Pool and spa safety: http://www.poolsafely. The Virginia Graeme Baker pool and spa safety act. Whenever children thirteen months and up to five years of gov/wp-content/uploads/VGBA.pdf. age are in or around water, the supervising adult should be 2. Consumer Product Safety Commission. Steps for safety around the pool: within an arm’s length providing “touch supervision” (6). http://www.poolsafely.gov/ The pool and spa safety act. Pool Safely. wp-content/uploads/360.pdf. The attention of an adult who is supervising children of any 3. Gipson, K. 2008. Pool and spa submersion: Estimated injuries and reported age should be focused on the child, and the adult should fatalities, 2008 report. Bethesda, MD: U.S. Consumer Product Safety never be engaged in other distracting activities (4), such as http://www.cpsc.gov/LIBRARY/poolsub2008.pdf. Commission. Gipson, K. 2009. Submersions related to non-pool and non-spa products, 4. talking on the telephone, socializing, or tending to chores. 2008 report. Washington, DC: CPSC. http://www.cpsc.gov/library/FOIA/ FOIA09/OS/nonpoolsub2008.pdf. A lifeguard should not be counted in the child:staff ratio. 5. U.S. Consumer Product Safety Commission (CPSC). 2009. CPSC warns of RATIONALE in-home drowning dangers with bathtubs, bath seats, buckets. Release http://www.cpsc.gov/cpscpub/prerel/prhtml10/10008.html. #10 - 0 08. The circumstances surrounding drownings and water- American Academy of Pediatrics Committee on Injury, Violence, and 6. related injuries of young children suggest that staffing Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. Pediatrics 126: e253-62. requirements and environmental modifications may reduce 7. American Academy of Pediatrics Committee on Injury, Violence, and the risk of this type of injury. Essential elements are close Poison Prevention, J. Weiss. 2010. Technical report: Prevention of drowning. continuous supervision (1,4), four-sided fencing and self- Pediatrics 126: e253-62. 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 1.1. 2 play (4). Water play using small (one quart) plastic pitchers MINIMUM AGE and plastic containers for pouring water and plastic dish pans or bowls allow children to practice pouring skills. Between 1.1. 2 .1 2003 and 2005, a study of drowning deaths of children Minimum Age to Enter Child Care younger than five years of age attributed the highest percent - Re a der ’s Note : This standard reflects a desirable goal when age of drowning reports to an adult losing contact or knowl - sufficient resources are available; it is understood that for edge of the whereabouts of the child (5). During the time of some families, waiting until three months of age to enter lost contact, the child managed to gain access to the pool (3). their infant in child care may not be possible. COMMENTS Healthy full-term infants can be enrolled in child care set- Water play includes wading. Touch supervision means tings as early as three months of age. Premature infants or keeping swimming children within arm’s reach and in sight those with chronic health conditions should be evaluated at all times. Drowning is a “silent killer” and children may - by their primary care providers and developmental special slip into the water silently without any splashing or scream - ists to make an individual determination concerning the ing. Ratios for supervision of swimming, wading and water appropriate age for child care enrollment. play do not include personnel who have other duties that might preclude their involvement in supervision during RATIONALE swimming/wading/water play activities while they are Brain anatomy, chemistry, and physiology undergo rapid performing those duties. This ratio excludes cooks, main- development over the first ten to twelve weeks of life (1-6). tenance workers, or lifeguards from being counted in the Concurrently, and as a direct consequence of these shifts child:staff ratio if they are involved in specialized duties at in central nervous system structure and function, infants the same time. Proper ratios during swimming activities demonstrate significant growth, irregularity, and eventu - with infants are important. Infant swimming programs ally, organization of their behavior, physiology, and social have led to water intoxication and seizures because infants responsiveness (1-3,5). Arousal responses to stimulation may swallow excessive water when they are engaged in any mature before the ability to self-regulate and control such submersion activities (1). responses in the first six to eight weeks of life causing infants to demonstrate an expanding range and fluctuation TYPE OF FACILITY of behavioral state changes from quiet to alert to irritable Center, Large Family Child Care Home (1-3,6). Infant behavior is most disorganized, most difficult RELATED STANDARDS to read and most frustrating to support at the six to eight 2.2.0.4 Supervision Near Bodies of Water week period (2,3). At approximately eight to twelve weeks Sensors or Remote Monitors 6.3.1.3 after birth, full term infants typically undergo changes in

35 8 Caring for Our Children: National Health and Safety Performance Standards leave, established for the first time job protected maternity brain function and behavior that helps caregivers/teachers - leave for qualifying employees (16,20). Despite the impor understand and respond effectively to infants’ increasingly - tance of FMLA, only about 60% of the women in the work stable sleep-wake states, attention, self-calming efforts, force are eligible for job protected maternity leave. FMLA feeding patterns and patterns of social engagement. Over does not provide paid leave, which may force many women the course of the third month, infants demonstrate an to return to work sooner than preferred (18). FMLA is not emerging capacity to sustain states of sleep and alert atten- transferable between parents/guardians. However, five tion. Infants, birth to three months of age, can become U.S. states support five to six weeks of paid maternity leave seriously ill very quickly without obvious signs (7). This and a few companies allow generous paid leaves for select increased risk to infants, birth to three months makes it employees (21). important to minimize their exposure to children and In a nationally representative sample, 84% of women and adults outside their family, including exposures in child 74% of men supported expansion of the FMLA; furthermore, care (8). In addition, infants of mothers who return to work, 90% of women and 72% of men reported that employers and particularly full-time, before twelve weeks of age, and are government should do more to support families (21). placed in group care may be at even greater risk for devel - oping serious infectious diseases. These infants are less Substantial evidence exists to strengthen social policies, likely to receive recommended well-child care and specifically job protected paid leave for all families, for at immunizations and to be breastfed or are likely to least the first twelve weeks of life, in order to promote the have a shorter duration of breastfeeding (16,22). health and development of children and families (22). Investing in families during an important life transition, - Researchers report that breastfeeding duration was signifi the birth or adoption of a child, reflects a society’s values cantly higher in women with longer maternity leaves as and may in fact contribute to a healthier and more compared to those with less than nine to twelve weeks leave productive work force. (9,22). A leave of less than six weeks was associated with a much higher likelihood of stopping breastfeeding (10,22). TYPE OF FACILITY Continuing breastfeeding after returning to work may be Center, Large Family Child Care Home particularly difficult for lower income women who may RELATED STANDARD have fewer support systems (11). Helping Families Cope with Separation 2 .1.1. 5 It takes women who have given birth about six weeks to References return to the physical health they had prior to pregnancy 1. Staehelin, K., P. C. Bertea, E. Z. Stutz. 2007. Length of maternity leave (12). A significant portion of women reported child birth and health of mother and child–a review. Int J Public Health 52:202-9. related symptoms five weeks after delivery (17). In contrast, 2. Guendelman, S., J. L. Kosc, M. Pearl, S. Graham, J. Goodman, M. Kharrazi. 2009. Juggling work and breastfeeding: Effects of maternity leave and women’s general mental health, vitality, and role function occupational characteristics. Pediatrics 123: e38-e46. were improved with maternity leaves at twelve weeks or 3. McGovern P., B. Dowd, D. Gjerdingen, I. Moscovice, L. Kochevar, W. longer (13). Lohman. 1997. Time off work and the postpartum health of employed women. Medical Care 35:507-21. Birth of a child or adoption of a newborn, especially the 4. Cunningham, F. G., F. F. Gont, K. J. Leveno, L. C. Gilstrap, J. C. Hauth, K. D. Wenstrom. 2005. Williams obstretrics. 21st ed. first, requires significant transition in the family. First time New York: McGraw Hill. parents/guardians are learning a new role and even with 5. Kimbro, R. T. 2006. On-the-job moms: Work and breastfeeding subsequent children, integration of the new family member initiation and duration for a sample of low-income women. Maternal Child Health J 10:19-26. requires several weeks of adaptation. Families need time to Carter, B., M. McGoldrick, eds. 2005. The expanded family life cycle: 6. adjust physically and emotionally to the intense needs of a Individual, family, and social perspectives. 3rd ed. New York: Allyn newborn (14,15). and Bacon Classics. 7. Ishimine, P. 2006. Fever without source in children 0-36 months. COMMENTS Pediatric Clinics North Am 53:167. Harper, M. 2004. Update on the management of the febrile infant. 8. In an analysis of twenty-one wealthy countries including Clin Pediatric Emerg Med 5:5-12. Australia, New Zealand, Canada, United States, Japan, 9. Carey, W. B., A. C. Crocker, E. R. Elias, H. M. Feldman, W. L. Coleman. and several European countries, the U.S. ranked twentieth 2009. Developmental-behavioral pediatrics. 4th ed. Philadelphia: W. B. Saunders. in terms of unpaid and paid parental leave available to Parmelee, A. H. Jr, W. Weiner, H. Schultz. 1964. Infant sleep patterns: 10. two-parent families with the birth of their child (18,21). From birth to 16 weeks of age. J Pediatrics 65:576-82. Although Switzerland ranked twenty-first with fourteen Brazelton, T. B. 1962. Crying in infancy. Pediatrics 29:579-88. 11. 12. Huttenlocher, P. R., C. de Courten. 1987. The development of synapses versus twenty-four weeks as compared to the U.S. for in striate cortex of man. Human Neurobiology 6:1-9. both parents/guardians, eleven weeks of leave are paid in 13. Anders, T. F. 1992. Sleeping through the night: A developmental Switzerland. In this study of twenty-one countries, only perspective. Pediatrics 90:554-60. Edelstein, S., J. Sharlin, S. Edelstein. 2008. Life cycle nutrition: An 14. Australia and the U.S. do not provide for paid leave after evidence-based approach. Boston: Jones and Bartlett. the birth of a child (18). 15. Robertson, S. S. 1987. Human cyclic motility: Fetal-newborn continuities and newborn state differences. Devel Psychobiology 20:425-42. Major social policies in the U.S. were established with the Berger, L. M., J. Hill, J. Waldfogel. 2005. Maternity leave, early maternal 16. Social Security Act in 1935 at a time when the majority of employment and child health and development in the US. Economic J women were not employed (19,20). The Family and Medical 115: F29-F47. Leave Act (FMLA) of 1993, which allows twelve weeks of

36 9 Chapter 1: Staffing McGovern, P., B. Dowd, D. Gjerdingen, C. R. Gross, S. Kenney, L. 17. COMMENTS Ukestad, D. McCaffrey, U. Lundberg. 2006. Postpartum health of In staff recruiting, the hiring pool should extend beyond the employed mothers 5 weeks after childbirth. Annals Fam Med 4:159-67. Ray, R., J. C. Gornick, J. Schmitt. 2009. Parental leave policies in 21 18. immediate neighborhood of the child’s residence or location countries: Assessing generosity and gender equality. Rev. ed. of the facility, to reflect the diversity of the people with whom Washington, DC: Center for Economic and Policy Research. the child can be expected to have contact as a part of life ex- Social Security Act. 1935. 42 USC 7. 19. 20. Family and Medical Leave Act. 1993. 29 USC 2601. perience. Reasons to deny employment include the following: Lovell, V., E. O’Neill, S. Olsen. 2007. Maternity leave in the United 21. The applicant or employee is not qualified or is unable a. States: Paid parental leave is still not standard, even among the best U.S. employers. Washington, DC: Institute for Women’s Policy Research. to perform the essential functions of the job with or http://iwpr.org/pdf/parentalleaveA131.pdf. without reasonable accommodations; Human Rights Watch. 2011. Failing its families: Lack of paid leave 22. b. Accommodation is unreasonable or will result in undue and work-family supports in the U.S. http://www.hrw.org/en/ reports/2011/02/23/failing-its-families-0/. hardship to the program; The applicant’s or employee’s condition will pose a sig- c. nificant threat to the health or safety of that individual 1. 2 or of other staff members or children. d. Accommodations and undue hardship are based on RECRUITMENT AND BACKGROUND each individual situation. SCREENING The U.S. Equal Employment Opportunity Commission (EEOC) does not enforce the protections that prohibit dis- crimination and harassment based on sexual orientation, 1. 2 . 0 .1 status as a parent, marital status, or political affiliation. Staff Recruitment However, other federal agencies and many states and Staff recruitment should be based on a policy of non- municipalities do. For assistance in locating your state or discrimination with regard to gender, race, ethnicity, disa- local agency’s rules go to http://www.eeoc.gov/field/ (3). bility, or religion, as required by the Equal Employment Caregivers/teachers can obtain copies of the EEOA and the Opportunity Act (EEOA). Centers should have a plan of ADA from their local public library. Facilities should consult action for recruiting and hiring a diverse staff that is repre- with ADA experts through the U.S. Department of Education sentative of the children in the facility’s care and people funded Disability and Business Technical Assistance Cen- in the community with whom the child is likely to have ters (DBTAC) throughout the country. These centers can be contact as a part of life experience. Staff recruitment poli - reached by calling 1-800-949-4232 (callers will be routed to cies should adhere to requirements of the Americans with the appropriate region), or by visiting http://www.adata .org/ Disabilities Act (ADA) as it applies to employment. The Static/Home.aspx. job description for each position should be clearly written, TYPE OF FACILITY and the suitability of an applicant should be measured Center, Large Family Child Care Home with regard to the applicant’s qualifications and abilities to perform the tasks required in the role. References 1. Chang, H. 2006. Developing a skilled, ethnically and linguistically diverse RATIONALE early childhood workforce. Adapted from Getting ready for quality: The Child care businesses must adhere to federal law. In critical importance of developing and supporting a skilled, ethnically and linguistically diverse early childhood workforce. addition, child care businesses should model diversity http://www.buildinitiative.org/files/DiverseWorkforce.pdf. and non-discrimination in their employment practices 2. U.S. Department of Justice, Civil Rights Division, Disability Rights Section. to enhance the quality of the program by supporting 1997. Commonly asked questions about child care centers and the Americans . http://www.ada.gov/childq%26a.htm. with Disabilities Act diversity and tolerance for individuals on the staff who 3. U.S. Equal Employment Opportunity Commission. Discrimination based on - are competent caregivers/teachers with different back sexual orientation, status as a parent, marital status and ground and orientation in their private lives. Children political affiliation. http://www.eeoc.gov/federal/otherprotections.cfm. need to see successful role models from their own ethnic and cultural groups and be able to develop the ability to 1.2.0.2 relate to people who are different from themselves (1). Background Screening The goal of the ADA in employment is to reasonably - To ensure their safety and physical and mental health, chil accommodate applicants and employees with disabilities, dren should be protected from any risk of abuse or neglect. to provide them equal employment opportunity and to Directors of centers and large family child care homes and integrate them into the program’s staff to the extent feasi - caregivers/teachers in small family child care homes should ble, given the individual’s limitations. Under the ADA, conduct a complete background screening before employing employers are expected to make reasonable accommoda - any staff member, including substitutes, cooks, clerical staff, tions for persons with disabilities. Some disabilities may transportation staff, bus drivers, or custodians who will be be accommodated, whereas others may not allow the on the premises or in vehicles when children are present. person to do essential tasks. The fairest way to address this evaluation is to define the tasks and measure the abilities of applicants to perform them (2).

37 10 Caring for Our Children: National Health and Safety Performance Standards The background screening should include (1-4). Performing diligent background screenings also protects the child care facility against future legal challenges (2,3). a. Name and address verification COMMENTS b. Social Security number verification c. Education verification The following resources can help the director screen d. Employment history individual applicants: Alias search e. • If fingerprinting is required, it can be secured at Driving history through state Department of Motor f. local law enforcement offices or the State Bureau of Vehicles records Investigation. g. Background screening of • Court records are public information and can be 1. State, tribal, and federal criminal history records, obtained from county court offices; some states including fingerprint checks have statewide online court records. 2. Child abuse and neglect registries • Driving records are available from the state Department 3. Licensing history with any other state agencies of Motor Vehicles. (eg, foster care, mental health, nursing homes) • A Social Security number trace is a report, derived from 4. Sex offender registries credit bureau records, that will return all current and e. Court records (misdemeanors and felonies) reported addresses for the last 7 to 10 years on a specific Reference checks; These should come from a variety f. individual based on his or her Social Security number. of employment or volunteer sources and should not If there are alternate names (aliases), these are also be limited to an applicant’s family and/or friends (5). reported on the Social Security record. g. In-person interview; Open-ended questions about https://www. • State child abuse registries can be accessed at establishing appropriate and inappropriate boundaries adoptuskids.org/for-professionals/interstate-adoptions/ with young children should be asked to all job applicants Sex offender registries can state-child-abuse-registries. during the in-person interview; for example, “How would be accessed at https://www.nsopw.gov. you handle a situation in which a child asked you to keep • Companies also offer background check services. a secret?” (6). The National Association of Professional Background Directors should contact their state child care licensing https://www.napbs.com Screeners ( ) provides a directory agency for the appropriate background screening docu- of its membership. mentation required by their state’s licensing regulations. For more information on state licensing requirements All family members older than 10 years living in large and regarding criminal background screenings, see the current small family child care homes should also have background National Association for Regulatory Administration screenings. Drug tests/screens may be incorporated into www.naralicensing.org/resources. Licensing Study at the background screening. Written permission to obtain TYPE OF FACILITY the background screening (with or without a drug screen) should be obtained from the prospective employee. Con- Center, Large Family Child Care Home, Small Family sent to the background investigation should be required for Child Care Home employment consideration. Prospective employers should References verbally ask applicants about previous convictions and 1. Child Care and Development Block Grant Act, 42 USC §9857 Social Security Act, 42 USC §618 2. arrests, in- vestigation findings, or court cases with child 3. Child Care and Development Fund, 42 USC §9858f(c)(1)(D), 42 USC - abuse/neglect or child sexual abuse. Failure of the prospec §9 85 8f ( h)(1) tive employee to disclose previous history of child abuse/ Head Start Early Childhood Learning & Knowledge Center. 1302.90 4. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii/ personnel policies. neglect or child sexual abuse is grounds for immediate Accessed January 11, 2018 1302-90-personnel-policies. dismissal. Persons should not be hired or allowed to work 5. Alliance of Schools for Cooperative Insurance Programs. Best Practices for or volunteer in the child care facility if they acknowledge Child Abuse Prevention. Cerritos, CA: Alliance of Schools for Cooperative Insurance Programs; 2015. http://ascip.org/wp-content/uploads/2014/05/ being sexually attracted to children or having physically Published April 15, 2015. Accessed January Child-Abuse-Best-Practices.pdf. or sexually abused children, or if they are known to have 11, 2018 committed such acts. 6. Berkower F. Preventing child sexual abuse in your organization. Denver’s Early Childhood Council Web site. https://denverearlychildhood.org/ Background screenings should be repeated periodically, Published April 23, 2016. preventing-child-sexual-abuse-organization. mirroring state laws and/or requirements. If there are Accessed January 11, 2018 concerns about an employee’s performance or behavior, NOTES background screenings should be conducted as needed. Content in the STANDARD was modified on 5/22/2018. 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.

38 11 Chapter 1: Staffing skills are essential for this individual to manage the facility 1. 3 and set appropriate expectations. College-level coursework PRE-SERVICE QUALIFICATIONS has been shown to have a measurable, positive effect on quality child care, whereas experience per se has not (1-3,5). 1. 3 .1 The director of a center plays a pivotal role in ensuring the DIRECTOR’S QUALIFICATIONS day-to-day smooth functioning of the facility within the framework of appropriate child development principles 1. 3 .1.1 and knowledge of family relationships (6). General Qualifications of Directors The well-being of the children, the confidence of the The director of a center enrolling fewer than sixty children parents/guardians of children in the facility’s care, and the should be at least twenty-one-years-old and should have all high morale and consistent professional growth of the staff the following qualifications: depend largely upon the knowledge, skills, and dependable Have a minimum of a Baccalaureate degree with at least a. presence of a director who is able to respond to long-range nine credit-bearing hours of specialized college-level and immediate needs and able to engage staff in decision- course work in administration, leadership, or manage - making that affects their day-to-day practice (5,6). Manage- ment, and at least twenty-four credit-bearing hours of ment skills are important and should be viewed primarily specialized college-level course work in early childhood - as a means of support for the key role of educational leader education, child development, elementary education, ship that a director provides (6). A skilled director should or early childhood special education that addresses know how to use early care and education consultants, child development, learning from birth through kin- such as health, education, mental health, and community dergarten, health and safety, and collaboration with resources and to identify specialized personnel to enrich consultants OR documents meeting an appropriate the staff ’s understanding of health, development, behavior, combination of relevant education and work and curriculum content. Past experience working in an experiences (6); early childhood setting is essential to running a facility. b. A valid certificate of successful completion of pediatric Life experience may include experience rearing one’s own first aid that includes CPR; children or previous personal experience acquired in any c. Knowledge of health and safety resources and access to child care setting. Work as a hospital aide or at a camp for education, health, and mental health consultants; children with special health care needs would qualify, as d. Knowledge of community resources available to chil - would experience in school settings. This experience, how- dren with special health care needs and the ability to use ever, must be supplemented by competency-based training these resources to make referrals or achieve interagency to determine and provide whatever new skills are needed coordination; to care for children in child care settings. e. Administrative and management skills in facility COMMENTS operations; Capability in curriculum design and implementation, f. The profession of early childhood education is being ensuring that an effective curriculum is in place; informed by research on the association of developmental Oral and written communication skills; g. outcomes with specific practices. The exact combination Certificate of satisfactory completion of instruction in h. of collegecoursework and supervised experience is still medication administration; being developed. For example, the National Association for i. Demonstrated life experience skills in working with the Education of Young Children (NAEYC) has published children in more than one setting; the Standards for Early Childhood Professional Preparation Interpersonal skills; j. Programs (4). The National Child Care Association (NCCA) Clean background screening. k. has developed a curriculum based on administrator com- petencies; more information on the NCCA is available at Knowledge about parenting training/counseling and ability http://www.nccanet.org. to communicate effectively with parents/guardians about developmental-behavioral issues, child progress, and in TYPE OF FACILITY creating an intervention plan beginning with how the Center center will address challenges and how it will help if those RELATED STANDARDS efforts are not effective. Mixed Director/Teacher Role 1. 3.1. 2 The director of a center enrolling more than sixty children 1. 3. 2 .1 Differentiated Roles should have the above and at least three years experience Qualifications of Lead Teachers and Teachers 1.3.2.2 as a teacher of children in the age group(s) enrolled in the 1.3.2.3 Qualifications for Assistant Teachers, Teacher center where the individual will act as the director, plus Aides, and Volunteers at least six months experience in administration. Initial Orientation of All Staff 1. 4 . 2 .1 RATIONALE Orientation for Care of Children with Special 1.4.2.2 The director of the facility is the team leader of a small Health Care Needs business. Both administrative and child development

39 12 Caring for Our Children: National Health and Safety Performance Standards Orientation Topics 1.4. 2. 3 1. 3. 2 First Aid and CPR Training for Staff 1. 4 . 3.1 CAREGIVER’S/TEACHER’S AND 1.4. 3. 2 Topics Covered in First Aid Training OTHER STAFF QUALIFICATIONS 1.4.3.3 CPR Training for Swimming and Water Play Continuing Education for Directors and 1.4.4.1 1. 3 . 2 .1 Caregivers/Teachers in Centers and Large Family Differentiated Roles Child Care Homes Centers should employ a caregiving/teaching staff for direct 1.4.4.2 Continuing Education for Small Family Child work with children in a progression of roles, as listed in Care Home Caregivers/Teachers descending order of responsibility: 1. 4 . 5.1 Training of Staff Who Handle Food Program administrator or training/curriculum a. Child Abuse and Neglect Education 1.4.5. 2 specialists; Training on Occupational Risk Related to 1.4.5. 3 b. Lead teachers; Handling Body Fluids Teachers; c. Assistant teachers or teacher aides. d. 1.4.5.4 Education of Center Staff 1. 4 . 6 .1 Training Time and Professional Development Each role with increased responsibility should require Leave increased educational qualifications and experience, as well as increased salary. Payment for Continuing Education 1.4.6. 2 RATIONALE References 1. Roupp, R., J. Travers, F. M., Glantz, C. Coelen. 1979. Children at the A progression of roles enables centers to offer career ladders center: Summary findings and their implications. Vol. 1 of Final report rather than dead-end jobs. It promotes a mix of college- of the National day care study. Cambridge, MA: Abt Associates. Howes, C. 1997. Children’s experiences in center-based child care as a 2. trained staff with other members of a child’s own commu- function of teacher background and adult:child ratio. Merrill-Palmer nity who might have entered at the aide level and moved Q43:404-24. into higher roles through college or on-the-job training. 3. Helburn, S., ed. 1995. Cost, quality and child outcomes in child care centers. Denver, CO: University of Colorado at Denver. Professional education and pre-professional in-service National Association for the Education of Young Children (NAEYC). 4. training programs provide an opportunity for career pro- 2009. Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/ gression and can lead to job and pay upgrades and fewer positions/ProfPrepStandards09.pdf. turnovers. Turn-over rates in child care positions in 1997 5. Fiene, R. 2002. 13 indicators of quality child care: Research update. averaged 30% (3). Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. ht tp:// COMMENTS aspe.hhs.gov/basic-report/13-indicators-quality-child-care. National Association for the Education of Young Children (NAEYC). 6. Early childhood professional knowledge must be required 2007. Early childhood program standards and accreditation criteria. whether programs are in private centers, public schools, or Washington, DC: NAEYC. other settings. The National Association for the Education of Young Children’s (NAEYC) Academy of Early Child- 1. 3.1. 2 hood Programs recommends a multi-level training program Mixed Director/Teacher Role that addresses pre-employment educational requirements Centers enrolling thirty or more children should employ and continuing education requirements for entry-level a non-teaching director. Centers with fewer than thirty assistants, caregivers/teachers, and administrators. It also children may employ a director who teaches as well. establishes a table of qualifications for accredited programs (1). The NAEYC requirements include development of an RATIONALE employee compensation plan to increase salaries and bene - The duties of a director of a facility with more than thirty fits toensure recruitment and retention of qualified staff children do not allow the director to be involved in the - and continuity of relationships (2). The NAEYC’s recom classroom in a meaningful way. mendations should be consulted in conjunction with the COMMENTS standards in this document. This standard does not prohibit the director from occasional TYPE OF FACILITY substitute teaching, as long as the substitute teaching is not Center a regular and significant duty. Occasional substitute teach- References ing may keep the director in touch with the caregivers’/ 1. National Association for the Education of Young Children (NAEYC). 2005. teachers’ issues. Accreditation and criteria procedures of the National Academy of Early Childhood Programs. Washington, DC: NAEYC. TYPE OF FACILITY 2. National Association for the Education of Young Children (NAEYC). 2009. Center Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/positions/ ProfPrepStandards09.pdf. 3. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: The National child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce.

40 13 Chapter 1: Staffing care staff, refer to the Standards for Early Childhood 1.3.2.2 Professional Preparation Programs from the National Qualifications of Lead Teachers and Teachers Association for the Education of Young Children (NAEYC) Lead teachers and teachers should be at least twenty-one (4). Additional information on the early childhood educa - years of age and should have at least the following education, tion profession is available from the Center for the Child experience, and skills: Care Workforce (CCW). A Bachelor’s degree in early childhood education, a. TYPE OF FACILITY school-age care, child development, social work, Center nursing, or other child-related field, or an associate’s degree in early childhood education and currently RELATED STANDARDS working towards a bachelor’s degree; 1. 4 . 3.1 First Aid and CPR Training for Staff A minimum of one year on-the-job training in pro- b. Topics Covered in First Aid Training 1.4. 3. 2 viding a nurturing indoor and outdoor environment 1.4.3.3 CPR Training for Swimming and Water Play and meeting the child’s out-of-home needs; References c. One or more years of experience, under qualified 1. National Institute of Child Health and Human Development (NICHD) supervision, working as a teacher serving the ages Early Child Care Research Network. 1996. Characteristics of infant child and developmental abilities of the children in care; care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306. d. A valid certificate in pediatric first aid, including CPR; Bredekamp, S., C. Copple, eds. 1997. Developmentally appropriate practice 2. Thorough knowledge of normal child development e. in early childhood programs. Rev ed. Washington, DC: National and early childhood education, as well as knowledge Association for the Education of Young Children. 3. U.S. Department of Justice. 2011. Americans with Disabilities Act. of indicators that a child is not developing typically; http://www.ada.gov. f. The ability to respond appropriately to children’s needs; 4. National Association for the Education of Young Children (NAEYC). 2009. g. The ability to recognize signs of illness and safety/injury Standards for early childhood professional preparation programs. Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/positions/ hazards and respond with prevention interventions; ProfPrepStandards09.pdf. h. Oral and written communication skills; 5. Committee on Integrating the Science of Early Childhood Development, Medication administration training (8). i. Board on Children, Youth, and Families. 2000. From neurons to neighborhoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: Every center, regardless of setting, should have at least one National Academy Press. licensed/certified lead teacher (or mentor teacher) who 6. 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 meets the above requirements working in the child care College Press. facility at all times when children are in care. 7. U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough Additionally, facilities serving children with special health and cold medication: Unsupervised ingestion accounts for 66 percent of care needs associated with developmental delay should incidents. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/media/pressrel/2008/r080128.htm. employ an individual who has had a minimum of eight American Academy of Pediatrics, Council on School Health. 2009. Policy 8. hours of training in inclusion of children with special statement: Guidance for the administration of medication in school. health care needs. Pediatrics 124:1244-51. RATIONALE Child care that promotes healthy development is based 1.3.2.3 on the developmental needs of infants, toddlers, and pre- Qualifications for Assistant Teachers, school children. Caregivers/teachers are chosen for their Teacher Aides, and Volunteers knowledge of, and ability to respond appropriately to, the Assistant teachers and teacher aides should be at least needs of children of this age generally, and the unique eighteen years of age, have a high school diploma or GED, characteristics of individual children (1-4). Both early and participate in on-the-job training, including a struc - childhood and special educational experience are useful tured orientation to the developmental needs of young in a center.Caregivers/teachers that have received formal children and access to consultation, with periodic review, education from an accredited college or university have by a supervisory staff member. At least 50% of all assistant shown to have better quality of care and outcomes of pro- teachers and teacher aides must have or be working on grams. Those teachers with a four-year college degree either a Child Development Associate (CDA) credential exhibit optimal teacher behavior and positive effects on or equivalent, or an associate’s or higher degree in early - children (6). Caregivers/teachers are more likely to admin childhood education/child development or equivalent (9). ister medications than to perform CPR. Seven thousand Volunteers should be at least sixteen years of age and should children per year require emergency department visits participate in on-the-job training, including a structured for problems related to cough and cold medication (7). orientation to the developmental needs of young children. COMMENTS Assistant teachers, teacher aides, and volunteers should The profession of early childhood education is being work only under the continual supervision of lead teacher informed by the research on early childhood brain develop - or teacher. Assistant teachers, teacher aides, and volunteers ment, child development practices related to child outcomes should never be left alone with children. Volunteers should (5). For additional information on qualifications for child not be counted in the child:staff ratio.

41 14 Caring for Our Children: National Health and Safety Performance Standards - have personal characteristics, experience, and skills in work All assistant teachers, teacher aides, and volunteers should possess: ing with parents, guardians and children, and the potential for development on the job or in a training program. a. The ability to carry out assigned tasks competently under the supervision of another staff member; States may have different age requirements for volunteers. b. An understanding of and the ability to respond TYPE OF FACILITY appropriately to children’s needs; Center, Large Family Child Care Home Sound judgment; c. RELATED STANDARD Emotional maturity; and d. e. Clearly discernible affection for and commitment to Qualifications for Drivers 6 . 5.1. 2 the well-being of children. References 1. National Institute of Child Health and Human Development (NICHD) RATIONALE Early Child Care Research Network. 1996. Characteristics of infant child While volunteers and students can be as young as sixteen, care: Factors contributing to positive caregiving. Early Child Res Q 11:269-306. - age eighteen is the earliest age of legal consent. Mature lead National Association for the Education of Young Children (NAEYC). 2. ership is clearly preferable. Age twenty-one allows for the 2005. Accreditation and criteria procedures of the National Academy of maturity necessary to meet the responsibilities of managing Early Childhood Programs. Washington, DC: NAEYC. 3. National Association for the Education of Young Children (NAEYC). a center or independently caring for a group of children 2009. Developmentally appropriate practice in early childhood programs who are not one’s own. serving children from birth through age 8. Washington, DC: NAEYC. statement Web.pdf. http://www.naeyc.org/files/naeyc/file/positions/position Child care that promotes healthy development is based on 4. U.S. Department of Justice. 2011. Americans with Disabilities Act. the developmental needs of infants, toddlers, preschool, and http://www.ada.gov. school-age children. Caregivers/teachers should be chosen 5. National Association for the Education of Young Children (NAEYC). 2009. Standards for Early Childhood professional preparation programs. for their knowledge of, and ability to respond appropriately Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/ to, the general needs of children of this age and the unique positions/ProfPrepStandards09.pdf. characteristics of individual children (1,3-5). 6. National Child Care Association (NCCA). NCCA official Website. http://www.nccanet.org. Staff training in child development and/or early childhood 7. National Association for Family Child Care (NAFCC). NAFCC official Website. http://nafcc.net. education is related to positive outcomes for children. This 8. Da Ros-Voseles, D., S. Fowler-Haughey. 2007. Why children’s dispositions training enables the staff to provide children with a variety should matter to all teachers. Young Children (September): 1-7. of learning and social experiences appropriate to the age http://www.naeyc.org/files/yc/file/200709/ DaRos-Voseles.pdf. 9. National Association for the Education of Young Children (NAEYC). of the child. Everyone providing service to, or interacting Candidacy requirements. http://www.naeyc.org/academy/pursuing/ with, children in a center contributes to the child’s total candreq/. experience (8). 10. Council for Professional Recognition. 2011. How to obtain a CDA. http://www.cdacouncil.org/the-cda-credential/ how-to-earn-a-cda/. Adequate compensation for skilled workers will not be given priority until the skills required are recognized and 1. 3. 2.4 valued. Teaching and caregiving requires skills to promote Additional Qualifications for Caregivers/ development and learning by children whose needs and abilities change at a rapid rate. Teachers Serving Children Three to Thirty-Five Months of Age COMMENTS Caregivers/teachers should be prepared to work with Experience and qualifications used by the Child Develop- - infants and toddlers and, when asked, should be knowl ment Associate (CDA) program and the National Child Care edgeable and demonstrate competency in tasks associated Association (NCCA) credentialing program, and included with caring for infants and toddlers: in degree programs with field placement are valued (10). Early childhood professional knowledge must be required Diapering and toileting; a. whether programs are in private homes, centers, public Bathing; b. schools, or other settings. Go to http://www .cdacouncil. c. Feeding, including support for continuation of to view appro org/the-cda-credential/how-to-earn-a-cda/ - breastfeeding; priate training and qualification information on the Holding; d. CDA Credential. Comforting; e. Practicing safe sleep practices to reduce the risk of f. The National Association for the Education of Young Chil- Sudden Infant Death Syndrome (SIDS) (3); dren’s (NAEYC) National Academy for Early Childhood g. Providing warm, consistent, responsive caregiving and Program Accreditation, the National Early Childhood opportunities for child-initiated activities; Program Accreditation (NECPA) and the National Asso- h. Stimulating communication and language development ciation of Family Child Care (NAFCC) have established and pre-literacy skills through play, shared reading, criteria for staff qualifications (2,6,7). song, rhyme, and lots of talking; Caregivers/teachers who lack educational qualifications may Promoting cognitive, physical, and social emotional i. be employed as continuously supervised personnel while development; they acquire the necessary educational qualifications if they

42 15 Chapter 1: Staffing Preventing shaken baby syndrome/abusive head trauma; j. 1.4. 2. 3 Orientation Topics Promoting infant mental health; k. First Aid and CPR Training for Staff 1. 4 . 3.1 Promoting positive behaviors; l. Topics Covered in First Aid Training 1.4. 3. 2 Setting age-appropriate limits with respect to safety, m. 1.4.3.3 CPR Training for Swimming and Water Play health, and mutual respect; Continuing Education for Directors and 1.4.4.1 Using routines to teach children what to expect from n. Caregivers/Teachers in Centers and caregivers/teachers and what caregivers/teachers expect Large Family Child Care Homes from them. Continuing Education for Small Family Child Care 1.4.4.2 Caregivers/teachers should demonstrate knowledge of Home Caregivers/Teachers development of infants and toddlers as well as knowledge Training of Staff Who Handle Food 1. 4 . 5.1 of indicators that a child is not developing typically; knowledge of the importance of attachment for infants 1.4.5. 2 Child Abuse and Neglect Education and toddlers, the importance of communication and Training on Occupational Risk Related to Handling 1.4.5. 3 language development, and the importance of nurturing Body Fluids consistent relationships on fostering positive self-efficacy 1.4.5.4 Education of Center Staff development. Training Time and Professional Development Leave 1. 4 . 6 .1 - To help manage atypical or undesirable behaviors of chil 1.4.6. 2 Payment for Continuing Education dren, caregivers/teachers, in collaboration with parents/ 1.6.0. 3 Early Childhood Mental Health Consultants guardians, should seek professional consultation from Safe Sleep Practices and Sudden Unexpected Infant 3.1. 4 .1 the child’s primary care provider, an early childhood Death (SUID)/SIDS Risk Reduction mental health professional, or an early childhood mental health consultant. General Plan for Feeding Infants 4 . 3.1.1 Feeding Infants on Cue by a Consistent 4 . 3.1. 2 RATIONALE Caregiver/Teacher The brain development of infants is particularly sensitive to Preparing, Feeding, and Storing Human Milk 4.3.1.3 the quality and consistency of interpersonal relationships. Much of the stimulation for brain development comes from Feeding Human Milk to Another Mother’s Child 4 . 3.1. 4 - the responsive interactions of caregivers/teachers and chil 4 . 3.1. 5 Preparing, Feeding, and Storing Infant Formula dren during daily routines. Children need to be allowed Use of Soy-Based Formula and Soy Milk 4 . 3.1. 6 to pursue their interests within safe limits and to be Feeding Cow’s Milk 4 . 3.1.7 encouraged to reach for new skills (1-7). Techniques for Bottle Feeding 4 . 3.1. 8 COMMENTS Warming Bottles and Infant Foods 4 . 3.1. 9 Since early childhood mental health professionals are not Cleaning and Sanitizing Equipment Used for 4 . 3.1.10 always available to help with the management of challenging Bottle Feeding behaviors in the early care and education setting early child - 4 . 3.1.11 Introduction of Age-Appropriate Solid Foods hood mental health consultants may be able to help. The to Infants consultant should be viewed as an important part of the program’s support staff and should collaborate with all Feeding Age-Appropriate Solid Foods to Infants 4 . 3.1.12 regular classroom staff, consultants, and other staff. Quali- References fied potential consultants may be identified by contacting 1. Shore, R. 1997. Rethinking the brain: New insights into early development. New York: Families and Work Inst. mental health and behavioral providers in the local area, as 2. National Forum on Early Childhood Policy and Programs, National Scien- well as accessing the National Mental Health Information tific Council on the Developing Child. 2007. A science-based framework for Center (NMHIC) at http://store.samhsa.gov/mhlocator/ early childhood policy: Using evidence to improve outcomes in learning, http://developingchild.harvard. behavior, and health for vulnerable children. and Healthy Child Care America (HCCA) at http://www. edu/index.php/library/reports_and_working_papers/policy_framework/. . healthychildcare.org/Contacts.html 3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: Lessons TYPE OF FACILITY learned from a demonstration project. Pediatrics 122:788-98. Center, Large Family Child Care Home Fiene, R. 2002. 13 indicators of quality child care: Research update. 4. Washington, DC: U.S. Department of Health and Human Services, Office RELATED STANDARDS of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ basic-report/13-indicators-quality-child-care. General Qualifications of Directors 1. 3.1.1 5. Centers for Disease Control and Prevention. Learn the signs. Act early. Mixed Director/Teacher Role 1. 3.1. 2 http://www.cdc.gov/ncbddd/actearly/. 6. Shonkoff, J. P., D. A. Phillips, eds. 2000. From neurons to neighborhoods: Qualifications of Lead Teachers and Teachers 1.3.2.2 The science of early childhood development. Washington, DC: National 1.3.2.3 Qualifications for Assistant Teachers, Teacher Academy Press. 7. Cohen, J., N. Onunaku, S. Clothier, J. Poppe. 2005. Helping young children Aides, and Volunteers succeed: Strategies to promote early childhood social and emotional 1. 4 . 2 .1 Initial Orientation of All Staff development. Washington, DC: National Conference of State Legislatures; Zero to Three. http://main.zerotothree.org/site/DocServer/help_yng_child_ 1.4.2.2 Orientation for Care of Children with Special succeed.pdf. Health Care Needs

43 16 Caring for Our Children: National Health and Safety Performance Standards 1.4. 3. 2 Topics Covered in First Aid Training 1. 3. 2. 5 CPR Training for Swimming and Water Play 1.4.3.3 Additional Qualifications for Caregivers/ 1.4.4.1 Continuing Education for Directors and Teachers Serving Children Three to Caregivers/Teachers in Centers and Large Five Years of Age Family Child Care Homes Caregivers/teachers should demonstrate the ability to apply Continuing Education for Small Family Child 1.4.4.2 their knowledge and understanding of the following to chil - Care Home Caregivers/Teachers dren three to five years of age within the program setting: 1. 4 . 5.1 Training of Staff Who Handle Food a. Typical and atypical development of three- to ive-year- 1.4.5. 2 Child Abuse and Neglect Education old children; Social and emotional development of children, including b. Training on Occupational Risk Related to Handling 1.4.5. 3 children’s development of independence, their ability to Body Fluids - adapt to their environment and cope with stress, prob 1.4.5.4 Education of Center Staff - lem solve and engage in conflict resolution, and success 1. 4 . 6 .1 Training Time and Professional Development Leave fully establish friendships; Payment for Continuing Education 1.4.6. 2 c. Cognitive, language, early literacy, scientific inquiry, and mathematics development of children; References 1. National Institute of Child Health and Human Development (NICHD) d. Cultural backgrounds of the children in the facility’s care; Early Child Care Research Network. 1999. Child outcomes when child e. Talking to parents/guardians about observations and center classes meet recommended standards for quality. Am J Public concerns and referrals to parents/guardians; He a l t h 8 9 :10 7 2 -7 7. Shore, R. 1997. Rethinking the brain: New insights into early development. 2. Changing needs of populations served, e.g., culture, f. New York: Families and Work Inst. income, etc. 3. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office To help manage atypical or undesirable behaviors of children http://aspe.hhs.gov/ of the Assistant Secretary for Planning and Evaluation. three to five years of age, caregivers/teachers serving this age basic-report/13-indicators-qualitychild-care. - group should seek professional consultation, in collabora tion with parents/guardians, from the child’s primary care 1. 3. 2.6 provider, a mental health professional, a child care health Additional Qualifications for Caregivers/ consultant, or an early childhood mental health consultant. Teachers Serving School-Age Children RATIONALE Caregivers/teachers should demonstrate knowledge about Three- and four-year-old children continue to depend and competence with the social and emotional needs and on the affection, physical care, intellectual guidance, and developmental tasks of five- to twelve-year old children, be emotional support of their caregivers/teachers (1,2). A sup- - able to recognize and appropriately manage difficult behav portive, nurturing setting that supports a demonstration iors, and know how to implement a socially and cognitively of feelings and accepts regression as part of development enriching program that has been developed with input from continues to be vital for preschool children. Preschool chil - parents/guardians. Issues that are significant within school- dren need help building a positive self-image, a sense of self age programs include having a sense of community, bullying, as a person of value from a family and a culture of which sexuality, electronic media, and social networking. they are proud. Children should be enabled to view them - With this age group as well, caregivers/teachers, in collabora - selves as coping, problem-solving, competent, passionate, tion with parents/guardians, should seek professional con- expressive, and socially connected to peers and staff (3). sultation from the child’s primary care provider, a mental TYPE OF FACILITY health professional, a child care health consultant, or an early Center, Large Family Child Care Home childhood mental health consultant to help manage atypical or undesirable behaviors. RELATED STANDARDS 1. 3.1.1 General Qualifications of Directors RATIONALE Mixed Director/Teacher Role 1. 3.1. 2 A school-age child develops a strong, secure sense of identity through positive experiences with adults and peers (1,2). Differentiated Roles 1. 3. 2 .1 An informal, enriching environment that encourages self- Qualifications of Lead Teachers and Teachers 1.3.2.2 paced cultivation of interests and relationships promotes 1.3.2.3 Qualifications for Assistant Teachers, Teacher the self-worth of school-age children (1). Balancing free Aides, and Volunteers exploration with organized activities including homework 1. 4 . 2 .1 Initial Orientation of All Staff assistance and tutoring among a group of children also Orientation for Care of Children with Special 1.4.2.2 supports healthy emotional and social development (1,3). Health Care Needs When children display behaviors that are unusual or 1.4. 2. 3 Orientation Topics difficult to manage, caregivers/teachers should work with 1. 4 . 3.1 First Aid and CPR Training for Staff parents/guardians to seek a remedy that allows the child to succeed in the child care setting, if possible (4).

44 17 Chapter 1: Staffing COMMENTS Payment for Continuing Education 1.4.6. 2 The first resource for addressing behavior problems is the 2.2.0.8 Preventing Expulsions, Suspensions, and Other child’s primary care provider. School personnel, including Limitations in Services professional serving school-based health clinics may also be References able to provide valuable insights. Support from a mental 1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office health professional may be needed. If the child’s primary of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ care provider cannot help or obtain help from a mental basic-report/13-indicators-quality-child-care. health professional, the caregiver/teacher and the family 2. Deschenes, S. N., A. Arbreton, P. M. Little, C. Herrera, J. B. Grossman, H. B. Weiss, D. Lee. 2010. Engaging older youth: Program and city-level may need an early childhood mental health consultant to ht tp:// strategies to support sustained participation in out-of-school time. advise about appropriate management of the child. Local www.hfrp.org/out-of-schooltime/publications-resources/engaging-older- mental health agencies or pediatric departments of medical youth-program-and-city -level-strategies-to-support-sustained-participation- in-out-of -school-time/. - schools may offer help from child psychiatrists, psycholo 3. New York State Department of Social Services, Cornell Cooperative gists, other mental health professionals skilled in the issues Extension. 2004. A parent’s guide to child care for school-age children. - of early childhood, and pediatricians who have a subspe http://www .nncc.org/choose.quality.care/ National Network for Child Care. parents.sac.html#anchor68421/. references cialty in developmental and behavioral pediatrics. Local Harvard Family Research Project. 2010. Family engagement as a systemic, 4. or area education agencies serving children with special ht tp:// sustained, and integrated strategy to promote student achievement. health or developmental needs may be useful. State Title V www.hfrp.org/publications-resources/browse -our-publications/family- engagement-as-a-systemic-sustained -and-integrated-strategy-to-promote- (Children with Special Health Care Needs) may be con- student-achievement/. tacted. All state Maternal Child Health (MCH) programs are required to have a toll-free number to link consumers 1. 3. 2.7 to appropriate programs for children with special health care needs. The toll-free number listing is located at https:// Qualifications and Responsibilities perfdata.hrsa.gov/MCHB/MCHReports/search/program/ for Health Advocates . Dis- missal from the program should be the prgsch16.asp Each facility should designate at least one administrator last resort and only after consultation with the parent/ or staff person as the health advocate to be responsible for g ua rd ia n(s). - policies and day-to-day issues related to health, develop ment, and safety of individual children, children as a group, TYPE OF FACILITY staff, and parents/guardians. In large centers it may be Center, Large Family Child Care Home important to designate health advocates at both the center RELATED STANDARDS and classroom level. The health advocate should be the General Qualifications of Directors 1. 3.1.1 primary con- tact for parents/guardians when they have 1. 3.1. 2 Mixed Director/Teacher Role health concerns, including health-related parent/guardian/ staff observations, health-related information, and the 1. 3. 2 .1 Differentiated Roles provision of resources. The health advocate ensures that Qualifications of Lead Teachers and Teachers 1.3.2.2 health and safety is addressed, even when this person does 1.3.2.3 Qualifications for Assistant Teachers, Teacher Aides, not directly and Volunteers perform all necessary health and safety tasks. 1. 4 . 2 .1 Initial Orientation of All Staff The health advocate should also identify children who have Orientation for Care of Children with Special 1.4.2.2 no regular source of health care, health insurance, or posi- Health Care Needs tive screening tests with no referral documented in the Orientation Topics 1.4. 2. 3 child’s health record. The health advocate should assist 1. 4 . 3.1 First Aid and CPR Training for Staff the child’s parent/guardian in locating a Medical Home by referring them to a primary care provider who offers Topics Covered in First Aid Training 1.4. 3. 2 routine child health services. CPR Training for Swimming and Water Play 1.4.3.3 For centers, the health advocate should be licensed/certified/ Continuing Education for Directors and 1.4.4.1 credentialed as a director or lead teacher or should be a Caregivers/Teachers in Centers and Large Family health professional, health educator, or social worker who Child Care Homes works at the facility on a regular basis (at least weekly). Continuing Education for Small Family Child Care 1.4.4.2 Home Caregivers/Teachers The health advocate should have documented training in the following: 1. 4 . 5.1 Training of Staff Who Handle Food Child Abuse and Neglect Education 1.4.5. 2 a. Control of infectious diseases, including Standard Precautions, hand hygiene, cough and sneeze etiquette, Training on Occupational Risk Related to Handling 1.4.5. 3 and reporting requirements; Body Fluids b. Childhood immunization requirements, record-keeping, Education of Center Staff 1.4.5.4 and at least quarterly review and follow-up for children Training Time and Professional Development Leave 1. 4 . 6 .1 who need to have updated immunizations;

45 18 Caring for Our Children: National Health and Safety Performance Standards enroll, but they sometimes miss scheduled immunizations c. Child health assessment form review and follow-up thereafter. Because the risk of vaccine-preventable disease of children who need further medical assessment or increases in group settings, assuring appropriate immuniza - updating of their information; How to plan for, recognize, and handle an emergency; d. tions is an essential responsibility in child care. Caregivers/ teachers should contact their child care health consultant Poison awareness and poison safety; e. Recognition of safety, hazards, and injury prevention f. or the health department if they have a question regarding interventions; immunization updates/ schedules. They can also provide information to share with parents/guardians about the Safe sleep practices and the reduction of the risk of g. importance of vaccines. Sudden Infant Death Syndrome (SIDS); h. How to help parents/guardians, caregivers/teachers, Child health records are intended to provide information and children cope with death, severe injury, and that indicates that the child has received preventive health natural or man-made catastrophes; services to stay well, and to identify conditions that might i. Recognition of child abuse, neglect/child maltreatment, interfere with learning or require special care. Review of shaken baby syndrome/abusive head trauma (for facilities the information on these records should be performed by caring for infants), and knowledge of when to report someone who can use the information to plan for the care of and to whom suspected abuse/neglect; the child, and recognize when updating of the information Facilitate collaboration with families, primary care j. by the child’s primary care provider is needed.Children must providers, and other health service providers to create be healthy to be ready to learn. Those who need accommo - a health, developmental, or behavioral care plan; dation for health problems or are susceptible to vaccine- k. Implementing care plans; preventable diseases will suffer if the staff of the child care Recognition and handling of acute health related l. program is unable to use information provided in child situations such as seizures, respiratory distress, allergic health records to ensure that the child’s needs are met (5,6). reactions, as well as other conditions as dictated by the COMMENTS special health care needs of children; The director should assign the health advocate role to a m. Medication administration; staff member who seems to have an interest, aptitude, and n. Recognizing and understanding the needs of children training in this area. This person need not perform all the with serious behavior and mental health problems; health and safety tasks in the facility but should serve as Maintaining confidentiality; o. the person who raises health and safety concerns. This staff Healthy nutritional choices; p. person has designated responsibility for seeing that plans q. The promotion of developmentally appropriate types are implemented to ensure a safe and healthful facility (1). and amounts of physical activity; A health advocate is a regular member of the staff of a center r. How to work collaboratively with parents/guardians or large or small family child care home, and is not the same and family members; as the child care health consultant recommended in Child s. How to effectively seek, consult, utilize, and collaborate Care Health Consultants, Standard 1.6.0.1. The health with child care health consultants, and in partnership advocate works with a child care health consultant on with a child care health consultant, how to obtain infor- health and safety issues that arise in daily interactions (4). mation and support from other education, mental For small family child care homes, the health advocate will health, nutrition, physical activity, oral health, and usually be the caregiver/teacher. If the health advocate is social service consultants and resources; not the child’s caregiver/teacher, the health advocate should t. Knowledge of community resources to refer children work with the child’s caregiver/teacher. The person who is and families who need health services including access most familiar with the child and the child’s family will to State Children’s Health Insurance (SCHIP), impor- recognize atypical behavior in the child and support tance of a primary care provider and medical home, effective communication with parents/guardians. and provision of immunizations and Early Periodic Screening, Diagnosis, and Treatment (EPSDT). A plan for personal contact with parents/guardians should be developed, even though this contact will not be possible RATIONALE daily. A plan for personal contact and documentation of a - The effectiveness of an intentionally designated health advo designated caregiver/teacher as health advocate will ensure cate in improving the quality of performance in a facility specific attempts to have the health advocate communicate has been demonstrated in all types of early childhood directly with caregivers/teachers and families on health- settings (1). A designated caregiver/teacher with health related matters. training is effective in developing an ongoing relationship with the parents/guardians and a personal interest in the - The immunization record/compliance review may be accom child (2,3). Caregivers/ teachers who are better trained are plished by manual review of child health records or by use more able to prevent, recog- nize, and correct health and of software programs that use algorithms with the currently safety problems. An internal advocate for issues related recommended vaccine schedules and service intervals to test to health and safety can help integrate these concerns with the dates when a child received recommended services and other factors involved in formulating facility plans. Children the child’s date of birth to identify any gaps for which refer - may be current with required immunizations when they rals should be made. On the Website of the Centers for

46 19 Chapter 1: Staffing 3. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A Disease Control and Prevention (CDC), individual vaccine manual for health professionals. 4th ed. Elk Grove Village, IL: American recommendations for children six years of age and younger Academy of Pediatrics. can be checked at http://www.cdc.gov/vaccines/recs/ 4. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, and . scheduler/catchup.htm facilitators. Public Health Nurs 25:126-39. 5. Centers for Disease Control and Prevention (CDC). 2011. Immunization TYPE OF FACILITY http://www.cdc.gov/vaccines/recs/schedules/. schedules. Center, Large Family Child Care Home Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines 6. for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove RELATED STANDARDS Village, IL: American Academy of Pediatrics. 1. 3.1.1 General Qualifications of Directors Mixed Director/Teacher Role 1. 3.1. 2 1. 3. 2 .1 Differentiated Roles 1.3.3 1.3.2.2 Qualifications of Lead Teachers and Teachers FAMILY CHILD CARE HOME 1.3.2.3 Qualifications for Assistant Teachers, Teacher CAREGIVER/TEACHER QUALIFICATIONS Aides, and Volunteers 1. 4 . 2 .1 Initial Orientation of All Staff 1.3.3.1 General Qualifications of Family Child Care Orientation for Care of Children with Special 1.4.2.2 Health Care Needs Caregivers/Teachers to Operate a Family Orientation Topics 1.4. 2. 3 Child Care Home First Aid and CPR Training for Staff 1. 4 . 3.1 All caregivers/teachers in large and small family child care homes should be at least twenty-one years of age, hold an Topics Covered in First Aid Training 1.4. 3. 2 official credential as granted by the authorized state agency, 1.4.3.3 CPR Training for Swimming and Water Play meet the general requirements specified in Standard 1.3.2.4 Continuing Education for Directors and 1.4.4.1 through Standard 1.3.2.6, based on ages of the children Caregivers/Teachers in Centers and Large served, and those in Section 1.3.3, and should have the Family Child Care Homes following education, experience, and skills: 1.4.4.2 Continuing Education for Small Family Child a. Current accreditation by the National Association for Care Home Caregivers/Teachers Family Child Care (NAFCC) (including entry-level quali- Training of Staff Who Handle Food 1. 4 . 5.1 fications and participation in required training) and a 1.4.5. 2 Child Abuse and Neglect Education college certificate representing a minimum of three credit Training on Occupational Risk Related to 1.4.5. 3 hours of early childhood education leadership or master Handling Body Fluids caregiver/teacher training or hold an Associate’s degree in early childhood education or child development; 1.4.5.4 Education of Center Staff b. A provider who has been in the field less than twelve Training Time and Professional Development 1. 4 . 6 .1 months should be in the self-study phase of NAFCC Leave accreditation; Payment for Continuing Education 1.4.6. 2 c. A valid certificate in pediatric first aid, including CPR; 1. 6 . 0.1 Child Care Health Consultants Pre-service training in health management in child care, d. Routine Health Supervision and Growth 3.1. 2 .1 including the ability to recognize signs of illness, knowl - Monitoring edge of infectious disease prevention and safety injury hazards; Active Opportunities for Physical Activity 3.1. 3.1 If caring for infants, knowledge on safe sleep practices e. Playing Outdoors 3.1.3.2 including reducing the risk of sudden infant death syn- Protection from Air Pollution While Children 3.1.3.3 drome (SIDS) and prevention of shaken baby syndrome/ Are Outside abusive head trauma (including how to cope with a 3.1.3.4 Caregivers’/Teachers’ Encouragement of crying infant); Physical Activity Knowledge of normal child development, as well as f. 7. 2 . 0 .1 Immunization Documentation knowledge of indicators that a child is not developing typically; 7.2.0.2 Unimmunized Children The ability to respond appropriately to children’s needs; g. 8.7.0.3 Review of Plan for Serving Children with h. Good oral and written communication skills; Disabilities or Children with Special Health Willingness to receive ongoing mentoring from other i. Care Needs teachers; References j. Pre-service training in business practices; 1. Ulione, M. S. 1997. Health promotion and injury prevention in a child k. Knowledge of the importance of nurturing adult-child development center. J Pediatr Nurs 12:148-54. 2. Kendrick, A. S., R. Kaufmann, K. P. Messenger, eds. 1991. Healthy young relationships on self-efficacy development; children: A manual for programs. Washington, DC: National Association Medication administration training (6). l. for the Education of Young Children.

47 20 Caring for Our Children: National Health and Safety Performance Standards Additionally, large family child care home caregivers/ Additional Qualifications for Caregivers/Teachers 1. 3. 2.4 teachers should have at least one year of experience serving Serving Children Three to Thirty-Five Months the ages and developmental abilities of the children in their of Age large family child care home. 1. 3. 2.5 Additional Qualifications for Caregivers/Teachers Serving Children Three to Five Years of Age Assistants, aides, and volunteers employed by a large family child care home should meet the qualifications specified in Additional Qualifications for Caregivers/Teachers 1. 3. 2.6 Standard 1.3.2.3. Serving School-Age Children First Aid and CPR Training for Staff 1. 4 . 3.1 RATIONALE 1.4. 3. 2 Topics Covered in First Aid Training In both large and small family child care homes, staff mem- bers must have the education and experience to meet the 1.4.3.3 CPR Training for Swimming and Water Play needs of the children in care (7). Small family child care Safe Sleep Practices and Sudden Unexpected 3.1. 4 .1 home caregivers/teachers often work alone and are solely Infant Death (SUID)/SIDS Risk Reduction responsible for the health and safety of small numbers of References children in their care. 1. Center for Child Care Workforce. 1999. Creating better family child care jobs: Model work standards. Washington, DC: Center for Child Care Most SIDS deaths in child care occur on the first day of Workforce. care or within the first week; unaccustomed prone (tummy) National Association for Family Child Care. NAFCC official Website. 2. sleeping increases the risk of SIDS eighteen times (3). Shaken http://nafcc.net. 3. Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant - baby syndrome/abusive head trauma is completely prevent death syndrome in child care and changing provider practices: Lessons able. Pre-service training and frequent refresher training learned from a demonstration project. Pediatrics 122:788-98. can prevent deaths (4). 4. Centers for Disease Control and Prevention. Learn the signs. Act early. http://www.cdc.gov/ncbddd/actearly/. Caregivers/teachers are more likely to administer medica - 5. U.S. Department of Health and Human Services. 2008. CDC study estimates 7,000 pediatric emergency departments visits linked to cough and tions than to perform CPR. Seven thousand children per cold medication: Unsupervised ingestion accounts for 66 percent of year require emergency department visits for problems http://www. incidents. Centers for Disease Control and Prevention (CDC). related to cough and cold medications (5). cdc.gov/media/pressrel/2008/r080128.htm. 6. American Academy of Pediatrics, Council on School Health. 2009. Policy Age eighteen is the earliest age of legal consent. Mature statement: Guidance for the administration of medication in school. leadership is clearly preferable. Age twenty-one is more likely Pediatrics 124:1244-51. 7. National Association for Family Child Care (NAFCC). 2005. Quality - to be associated with the level of maturity necessary to inde standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. pendently care for a group of children who are not one’s own. The NAFCC has established an accreditation process to 1.3.3.2 enhance the level of quality and professionalism in small Support Networks for Family Child Care and large family child care (2). Large and small family child care home caregivers/teachers COMMENTS should have active membership in a national, and/or state A large family child care home caregiver/teacher, caring and local early care and education organization(s). National for more than six children and employing one or more organizations addressing concerns of family child care assistants, functions as the primary caregiver as well as the home caregivers/teachers include the American Academy facility director. An operator of a large family-child-care of Pediatrics (AAP), the National Association for Family home should be offered training relevant to the manage - Child Care (NAFCC), and the National Association for ment of a small child care center, including training on the Educa-tion of Young Children (NAEYC). In addition, providing a quality work environment for employees. For belonging to a local network of family child care home more information on assessing the work environment of caregivers/teachers that offers education, training and family child care employees, see Creating Better Family networking opportunities provides the opportunity to Child Care Jobs: Model Work Standards, a publication focus on local needs. Child care resource and referral by the Center for the Child Care Workforce (CCW) (1). agencies may provide additional support networks for caregivers/teachers that include professional development TYPE OF FACILITY opportunities and information about electronic Large Family Child Care Home networking. RELATED STANDARDS RATIONALE 1. 3.1.1 General Qualifications of Directors Membership in peer professional organizations shows a Mixed Director/Teacher Role 1. 3.1. 2 commitment to quality child care and also provides a Differentiated Roles 1. 3. 2 .1 conduit for information to otherwise isolated caregivers/ Qualifications of Lead Teachers and Teachers 1.3.2.2 teachers. Membership in a family child care association and attendance at meetings indicate the desire to gain 1.3.2.3 Qualifications for Assistant Teachers, Teacher new knowledge about how to work with children (1). Aides, and Volunteers

48 21 Chapter 1: Staffing pre-service training. This training should cover health, COMMENTS psychosocial, and safety issues for out-of-home child care For more information about family child care associations, facilities. Small family child care home caregivers/teachers contact the NAFCC at http://nafcc.net and/or the NAEYC at may have up to ninety days to secure training after opening http://www.naeyc.org . Also, caregivers/teachers should check except for training on basic health and safety procedures to see if their state has specific accreditation standards. and regulatory requirements. TYPE OF FACILITY All directors or program administrators and caregivers/ Large Family Child Care Home teachers should document receipt of pre-service training RELATED STANDARDS prior to working with children that includes the following 1. 3.1.1 General Qualifications of Directors content on basic program operations: Mixed Director/Teacher Role 1. 3.1. 2 Typical and atypical child development and appropriate a. Qualifications of Lead Teachers and Teachers 1.3.2.2 best practice for a range of developmental and mental - health needs including knowledge about the developmen 1.3.2.3 Qualifications for Assistant Teachers, Teacher tal stages for the ages of children enrolled in the facility; Aides, and Volunteers b. Positive ways to support language, cognitive, social, and Initial Orientation of All Staff 1. 4 . 2 .1 emotional development including appropriate guidance 1.4.2.2 Orientation for Care of Children with Special and discipline; Health Care Needs Developing and maintaining relationships with c. 1.4. 2. 3 Orientation Topics families of children enrolled, including the resources First Aid and CPR Training for Staff 1. 4 . 3.1 to obtain supportive services for children’s unique 1.4. 3. 2 Topics Covered in First Aid Training developmental needs; d. Procedures for preventing the spread of infectious CPR Training for Swimming and Water Play 1.4.3.3 disease, including hand hygiene, cough and sneeze 1.4.4.1 Continuing Education for Directors and etiquette, cleaning and disinfection of toys and equip - Caregivers/Teachers in Centers and ment, diaper changing, food handling, health depart - Large Family Child Care Homes ment notification of reportable diseases, and health 1.4.4.2 Continuing Education for Small Family Child issues related to having animals in the facility; Care Home Caregivers/Teachers e. Teaching child care staff and children about infection Training of Staff Who Handle Food 1. 4 . 5.1 control and injury prevention through role modeling; 1.4.5. 2 Child Abuse and Neglect Education Safe sleep practices including reducing the risk of f. Sudden Infant Death Syndrome (SIDS) (infant sleep Training on Occupational Risk Related to Handling 1.4.5. 3 position and crib safety); Body Fluids g. Shaken baby syndrome/abusive head trauma preven- Education of Center Staff 1.4.5.4 tion and identification, including how to cope with a Training Time and Professional Development Leave 1. 4 . 6 .1 crying/fussy infant; Payment for Continuing Education 1.4.6. 2 Poison prevention and poison safety; h. 10. 6 . 2 .1 Development of Child Care Provider Organizations i. Immunization requirements for children and staff; and Networks Common childhood illnesses and their management, j. including child care exclusion policies and recognizing Reference signs and symptoms of serious illness; 1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of Reduction of injury and illness through environmental k. the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ design and maintenance; basic-report/13-indicators-quality-child-care. l. Knowledge of U.S. Consumer Product Safety Commis-sion (CPSC) product recall reports; m. Staff occupational health and safety practices, such as 1.4 proper procedures, in accordance with Occupational PROFESSIONAL Safety and Health Administration (OSHA) bloodborne DEVELOPMENT/TRAINING pathogens regulations; Emergency procedures and preparedness for disasters, n. 1. 4 .1 emergencies, other threatening situations (including PRE-SERVICE TRAINING weather-related, natural disasters), and injury to infants and children in care; 1. 4 .1.1 Promotion of health and safety in the child care setting, o. Pre-service Training including staff health and pregnant workers; In addition to the credentials listed in Standard 1.3.1.1, upon p. First aid including CPR for infants and children; employment, a director or administrator of a center or the q. Recognition and reporting of child abuse and neglect in lead caregiver/teacher in a family child care home should compliance with state laws and knowledge of protective provide documentation of at least thirty clock-hours of factors to prevent child maltreatment;

49 22 Caring for Our Children: National Health and Safety Performance Standards recommends annual training based on the needs of the Nutrition and age-appropriate child-feeding including r. program and the pre-service qualifications of staff (4). food preparation, choking prevention, menu planning, Training should address the following areas: and breastfeeding supportive practices; s. Physical activity, including age-appropriate activities Health and safety (specifically reducing the risk of SIDS, a. and limiting sedentary behaviors; infant safe sleep practices, shaken baby syndrome/abusive Prevention of childhood obesity and related chronic t. head trauma), and poison prevention and poison safety; diseases; Child growth and development, including motor b. u. Knowledge of environmental health issues for both development and appropriate physical activity; children and staff; c. Nutrition and feeding of children; v. Knowledge of medication administration policies and d. Planning learning activities for all children; practices; e. Guidance and discipline techniques; Caring for children with special health care needs, w. f. Linkages with community services; mental health needs, and developmental disabilities Communication and relations with families; g. in compliance with the Americans with Disabilities Detection and reporting of child abuse and neglect; h. Act (ADA); i. Advocacy for early childhood programs; x. Strategies for implementing care plans for children with j. Professional issues (5). special health care needs and inclusion of all children In the early childhood field there is often “crossover” in activities; regarding professional preparation (pre-service programs) Positive approaches to support diversity; y. and ongoing professional development (in-service programs). Positive ways to promote physical and intellectual z. This field is one in which entry-level requirements differ development. across various sectors within the field (e.g., nursing, family RATIONALE support, and bookkeeping are also fields with varying entry- The director or program administrator of a center or level requirements). In early childhood, the requirements large family child care home or the small family child care differ across center, home, and school based settings. An in- home caregiver/teacher is the person accountable for all dividual could receive professional preparation (pre-service) policies. Basic entry-level knowledge of health and safety to be a teaching staff member in a community-based organi - and social and emotional needs is essential to administer zation and receive subsequent education and training as part the facility. Caregivers/teachers should be knowledgeable of an ongoing professional development system (in-service). about infectious disease and immunizations because pro- The same individual could also be pursuing a degree for a perly implemented health policies can reduce the spread of role as a teacher in a program for which licensure is required— disease, not only among the children but also among staff this in-service program would be considered pre-service members, family members, and in the greater community education for the certified teaching position. Therefore, the (1). Knowledge of injury prevention measures in child care labels pre-service and in-service must be seen as related to is essential to control known risks. Pediatric first aid train - a position in the field, and not based on the individual’s ing that includes CPR is important because the director professional development program (5). or small family child care home caregiver/teacher is fully COMMENTS responsible for all aspects of the health of the children in Training in infectious disease control and injury preven- care. Medication administration and knowledge about tion may be obtained from a child care health consultant, caring for children with special health care needs is essen - pediatricians, or other qualified personnel of children’s tial to maintaining the health and safety of children with and community hospitals, managed care companies, health special health care needs. Most SIDS deaths in child care agencies, public health departments, EMS and fire pro- occur on the first day of child care or within the first week fessionals, pediatric emergency room physicians, or other due to unaccustomed prone (on the stomach) sleeping; the health and safety professionals in the community. risk of SIDS increases eighteen times when an infant who sleeps supine (on the back) at home is placed in the prone For more information about training opportunities, contact position in child care (2). Shaken baby syndrome/abusive the local Child Care Resource and Referral Agency (CCRRA), head trauma is completely preventable. It is crucial for the local chapter of the American Academy of Pediatrics caregivers/teachers to be knowledgeable of both syndromes (AAP) (AAP provides online SIDS and medication adminis- and how to prevent them before they care for infants. Early tration training), the Healthy Child Care America Project, or childhood expertise is necessary to guide the curriculum the National Resource Center for Health and Safety in Child - and opportunities for children in programs (3). The mini Care and Early Education (NRC). California Child-care mum of a Child Development Associate credential with Health Program (CCHP) has free curricula for health and a system of required contact hours, specific content areas, safety for caregivers/teachers to become child care health and a set renewal cycle in addition to an assessment advocates. The curriculum (English and Spanish) is free to requirement would add significantly to the level of care download on the Web at http://www.ucsfchildcarehealth.org/ and education for children. The National Association for html/pandr/trainingcurrmain.htm , and is based on the the Education of Young Children (NAEYC), a leading National Training Institute for Child Care Health Consul- organization in child care and early childhood education, tants (NTI) curriculum for child care health consultants.

50 23 Chapter 1: Staffing Online training for caregivers/teachers is also available children in care can enter the field. Training ensures that staff members are challenged and stimulated, have access through some state agencies. to current knowledge (2), and have access to education For more information on social-emotional training, contact that will qualify them for new roles. the Center on the Social and Emotional Foundations for . Early Learning (CSEFEL) at http://csefel.vanderbilt.edu Use of videos and other passive methods of training should be supplemented by interactive training approaches that TYPE OF FACILITY help verify content of training has been learned (3). Center, Large Family Child Care Home Health training for child care staff protects the children in RELATED STANDARDS care, staff, and the families of the children enrolled. Infec- 1. 3.1.1 General Qualifications of Directors tious disease control in child care helps prevent spread of First Aid and CPR Training for Staff 1. 4 . 3.1 infectious disease in the community. Outbreaks of infec- tious diseases and intestinal parasites in young children Pre-Employment and Ongoing Adult Health 1.7.0.1 in child care have been shown to be associated with Appraisals, Including Immunization community outbreaks (4). Emergency and Evacuation Drills/Exercises Policy 9.2.4.5 Child care health consultants can be an excellent resource Training Record 9.4.3.3 for providing health and safety orientation or referrals to 10. 6 .1.1 Regulatory Agency Provision of Caregiver/Teacher resources for such training. and Consumer Training and Support Services COMMENTS 10. 6 .1. 2 Provision of Training to Facilities by Health Agencies Many states have pre-service education and experience qualifications for caregivers/teachers by role and function. References Offering a career ladder and utilizing employee incentives 1. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office such as Teacher Education and Compensation Helps of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ (TEACH) will attract individuals into the child care field, basic-report/13-indicators-quality-child-care. where labor is in short supply. Colleges, accrediting bodies, Hayney M. S., J. C. Bartell. 2005. An immunization education program for 2. childcare providers. J of School Health 75:147-49. - and state licensing agencies should examine teacher prepara 3. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care tion guidelines and substantially increase the health con- providers? Pediatrics 112:878-82. tent of early childhood professional preparation. Child care Ritchie, S., B. Willer. 2008. Teachers: A guide to the NAEYC early childhood 4. program standard and related accreditation criteria. Washington, DC: staff members are important figures in the lives of the young National Association for the Education of Young Children (NAEYC). children in their care and in the well-being of families and 5. National Association for the Education of Young Children. 2010. Definition the community. Child care staff training should include of early childhood professional development, 12. Eds. M. S. Donovan, J. D. Bransford, J. W. Pellegrino. Washington, DC: National Academy Press. new developments in children’s health. For example; a new training program could discuss up-to-date information on the prevention of obesity and its impact on early onset of chronic diseases. 1.4. 2 TYPE OF FACILITY ORIENTATION TRAINING Center, Large Family Child Care Home 1. 4 . 2 .1 RELATED STANDARDS Initial Orientation of All Staff Continuing Education for Directors and 1.4.4.1 All new full-time staff, part-time staff and substitutes Caregivers/Teachers in Centers and Large should be oriented to the policies listed in Standard 9.2.1.1 Family Child Care Homes and any other aspects of their role. The topics covered and 1.4.4.2 Continuing Education for Small Family Child the dates of orientation training should be documented. Care Home Caregivers/Teachers Caregivers/teachers should also receive continuing educa - 1. 4 . 5.1 Training of Staff Who Handle Food tion each year, as specified in Continuing Education, Standard 1.4.4.1 through Standard 1.4.6.2. 1.4.5. 2 Child Abuse and Neglect Education 1.4.5. 3 Training on Occupational Risk Related to Handling RATIONALE Body Fluids Orientation ensures that all staff members receive specific 1.4.5.4 Education of Center Staff and basic training for the work they will be doing and are informed about their new responsibilities. Because of fre- 1. 4 . 6 .1 Training Time and Professional Development Leave quent staff turnover, directors should institute orientation 1.4.6. 2 Payment for Continuing Education programs on a regular basis (1). Orientation and ongoing 1. 6 . 0.1 Child Care Health Consultants training are especially important for aides and assistant Content of Policies 9. 2 .1.1 teachers, for whom pre-service educational requirements 9.4.3.3 Training Record are limited. Entry into the field at the level of aide or assis - tant teacher should be attractive and facilitated so that capable members of the families and cultural groups of the

51 24 Caring for Our Children: National Health and Safety Performance Standards Methods of helping the child with special health care f. References 1. Fiene, R. 2002. 13 indicators of quality child care: Research update needs or behavior problems to participate in the facility’s Washington, DC: U.S. Department of Health and Human Services, programs, including physical activity programs; Office of the Assistant Secretary for Planning and Evaluation. ht tp://a spe. g. Role modeling, peer socialization, and interaction; hhs.gov/ basic-report/13-indicators-quality-child-care. Moon R. Y., R. P. Oden. 2003. Back to sleep: Can we influence child care 2. Behavior modification techniques, positive behavioral h. providers? Pediatrics 112:878-82. supports for children, promotion of self-esteem, and 3. National Association for the Education of Young Children (NAEYC). other techniques for managing behavior; Leadership and management: A guide to the NAEYC early childhood 2008. Washington, DC: program standards and related accreditation criteria. Grouping of children by skill levels, taking into account i. NA EYC. the child’s age and developmental level; Crowley, A. A. 1990. Health services in child day-care centers: A survey. 4. Health services or medical intervention for children j. J Pediatr Health Care 4:252-59. with special health care problems; Communication methods and needs of the child; k. 1.4.2.2 Dietary specifications for children who need to avoid l. Orientation for Care of Children with specific foods or for children who have their diet Special Health Care Needs modified to maintain their health, including When a child care facility enrolls a child with special health support for continuation of breastfeeding; care needs, the facility should ensure that all staff members m. Medication administration (for emergencies or on an have been oriented in understanding that child’s special ongoing basis); health care needs and have the skills to work with that n. Recognizing signs and symptoms of impending illness child in a group setting. or change in health status; Recognizing signs and symptoms of injury; o. Caregivers/teachers in small family child care homes, who p. Understanding temperament and how individual care for a child with special health care needs, should meet behavioral differences affect a child’s adaptive skills, with the parents/guardians and meet or speak with the motivation, and energy; child’s primary care provider (if the parent/guardian has Potential hazards of which staff should be aware; q. provided prior, informed, written consent) or a child care r. Collaborating with families and outside service pro- health con- sultant to ensure that the child’s special health viders to create a health, developmental, and behavioral care needs care plan for children with special needs; will be met in child care and to learn how these needs may Awareness of when to ask for medical advice and s. affect his/her developmental progression or play with other recommendations for non-emergent issues that arise children. in school (e.g., head lice, worms, diarrhea); In addition to Orientation Training, Standard 1.4.2.1, the Knowledge of professionals with skills in various con- t. orientation provided to staff in child care facilities should ditions, e.g., total communication for children with deaf - be based on the special health care needs of children who ness, beginning orientation and mobility training for will be assigned to their care. All staff oriented for care children with blindness (including arranging the physical of children with special health needs should be knowledge- environment effectively for such children), language able about the care plans created by the child’s primary promotion for children with hearing- care provider in their medical home as well as any care impairment and language delay/disorder, etc.; plans created by other health professionals and therapists u. How to work with parents/guardians and other pro- involved in the child’s care. A template for a care plan for fessionals when assistive devices or medications are not children with special health care needs can be found in consistently brought to the child care program or school; Appendix O. Child care health consultants can be an v. How to safely transport a child with special health excellent resource for providing health and safety orienta- care needs. tion or referrals to resources for such training. This training RATIONALE may include, but is not limited to, the following topics: A basic understanding of developmental disabilities and a. Positioning for feeding and handling, and risks for special care requirements of any child in care is a funda - injury for children with physical/mental disabilities; mental part of any orientation for new employees. Training b. Toileting techniques; is an essential component to ensure that staff members Knowledge of special treatments or therapies (e.g., PT, c. develop and maintain the needed skills. A comprehensive OT, speech, nutrition/diet therapies, emotional support curriculum is required to ensure quality services. However, and behavioral therapies, medication administration, lack of specialized training for staff does not constitute etc.) the child may need/receive in the child care setting; grounds for exclusion of children with disabilities (1). Proper use and care of the individual child’s adaptive d. equipment, including how to recognize defective equip- Staff members need information about how to help children ment and to notify parents/guardians that repairs are use and maintain adaptive equipment properly. Staff mem- needed; bers need to understand how and why various items are used How different disabilities affect the child’s ability to e. and how to check for malfunctions. If a problem occurs with participate in group activities; adaptive equipment, the staff must recognize the problem

52 25 Chapter 1: Staffing and inform the parent/guardian so that the parent/guardian Exclusion and readmission procedures and policies; b. Cleaning, sanitation, and disinfection procedures and c. can notify the health care or equipment provider of the policies; problem and request that it be remedied. While the parent/ Procedures for administering medication to children d. guardian is responsible for arranging for correction of equipment problems, child care staff must be able to and for documenting medication administered to children; observe and report the problem to the parent/guardian. Routine care of adaptive and treatment equipment, e. Procedures for notifying parents/guardians of an such as nebulizers, should be taught. infectious disease occurring in children or staff within the facility; COMMENTS Procedures and policies for notifying public health f. These training topics are generally applicable to all officials about an outbreak of disease or the occurrence personnel serving children with special health care of a reportable disease; needs and apply to child care facilities. The curriculum g. Emergency procedures and policies related to may vary depending on the type of facility, classifications unintentional injury, medical emergency, and of disabilities of the children in the facility, and ages of the natural disasters; children. The staff is assumed to have the training described h. Procedure for accessing the child care health consultant in Orientation Training, Standard 1.4.2.1, including child for assistance; growth and development. These additional topics will ex- i. Injury prevention strategies and hazard identification tend their basic knowledge and skills to help them work procedures specific to the facility, equipment, etc.; more effectively with children who have special health care and needs and their families. The number of hours offered in Proper hand hygiene. j. any in-service training program should be determined by Before being assigned to tasks that involve identifying and the staff ’s experience and professional background. Service responding to illness, staff members should receive orienta- - plans in small family child care homes may require a modi tion training on these topics. Small family child care home fied implementation plan. The parent/guardian is responsi - caregivers/teachers should not commence operation before ble for solving equipment problems. The parent/guardian receiving orientation on these topics in pre-service training. can request that the child care facility remedy the problem directly if the caregiver/teacher has been trained on the RATIONALE maintenance and repair of the equipment and if the Children in child care are frequently ill (1). Staff members staff agrees to do it. responsible for child care must be able to recognize illness and injury, carry out the measures required to prevent the TYPE OF FACILITY spread of communicable diseases, handle ill and injured Center, Large Family Child Care Home children appropriately, and appropriately administer RELATED STANDARDS required medications (2). Hand hygiene is one of the Initial Orientation of All Staff 1. 4 . 2 .1 most important means of preventing spread of 3. 5. 0.1 Care Plan for Children with Special Health infectious disease (3). Care Needs TYPE OF FACILITY 9.4.3.3 Training Record Center, Large Family Child Care Home Appendix O: Care Plan for Children With Special Health RELATED STANDARDS Needs 1. 4 .1.1 Pre-service Training Reference Conduct of Daily Health Check 3.1.1.1 1. U.S. Department of Justice. 2011. Americans with Disabilities Act. http://www.ada.gov. 3.1.1. 2 Documentation of the Daily Health Check 9.4.3.3 Training Record 1.4. 2. 3 References Orientation Topics 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide. 4th ed. Elk Grove Village, IL: During the first three months of employment, the director American Academy of Pediatrics. of a center or the caregiver/teacher in a large family home 2. American Academy of Pediatrics, Council on School Health. 2009. Policy should document, for all full-time and part-time staff statement: Guidance for the administration of medication in school. Pediatrics 124:1244-51. members, additional orientation in, and the employees’ 3. Centers for Disease Control and Prevention (CDC). 2016. Handwashing: satisfactory knowledge of, the following topics: Clean hands save lives. http://www.cdc.gov/handwashing/. a. 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;

53 26 Caring for Our Children: National Health and Safety Performance Standards COMMENTS 1.4. 3 The recommendations from the American Heart Asso- FIRST AID AND CPR TRAINING ciation (AHA) changed in 2010 from “A-B-C” (Airway, Breathing, Chest compressions) to “C-A-B” (Chest com- 1. 4 . 3 .1 pressions, Airway, Breathing) for adults and pediatric First Aid and CPR Training for Staff patients (children and infants, excluding newborns). Except The director of a center or a large family child care home for newborns, the ratio of chest compressions to ventilations and the caregiver/teacher in a small family child care home in the 2010 guidelines is 30:2. CPR skills are lost without should ensure all staff members involved in providing practice and ongoing education (3,5). direct care have documentation of satisfactory completion The most common renewal cycle required by organizations of training in pediatric first aid and pediatric CPR skills. that offer pediatric first aid and pediatric CPR training is to Pediatric CPR skills should be taught by demonstration, require successful completion of training every three years practice, and return demonstration to ensure the technique (4), though the AHA requires successful completion of can be per- formed in an emergency. These skills should be CPR class every two years. - current according to the requirement specified for retrain Inexpensive self-learning kits that require only thirty ing by the organization that provided the training. minutes to review the skills of pediatric CPR with a video At least one staff person who has successfully completed and an inflatable manikin are available from the AHA. training in pediatric first aid that includes CPR should be See “Infant CPR Anytime” and “Family and Friends in attendance at all times with a child whose special care . CPR Anytime” at http://www.heart.org/HEARTORG/ plan indicates an increased risk of needing respiratory or Child care facilities should consider having an Automated cardiac resuscitation. External Defibrillators (AED) on the child care premises for Records of successful completion of training in pediatric potential use with adults. The use of AEDs with children first aid should be maintained in the personnel files of would be rare. the facility. TYPE OF FACILITY RATIONALE Center, Large Family Child Care Home To ensure the health and safety of children in a child RELATED STANDARDS care setting, someone who is qualified to respond to life- 1.4. 3. 2 Topics Covered in First Aid Training threatening emergencies must be in attendance at all times (1). A staff trained in pediatric first aid, including pediatric CPR Training for Swimming and Water Play 1.4.3.3 CPR, coupled with a facility that has been designed or 9.4.3.3 Training Record modified to ensure the safety of children, can mitigate the Regulatory Agency Provision of Caregiver/Teacher 10. 6 .1.1 consequences of injury, and reduce the potential for death and Consumer Training and Support Services from life-threatening conditions. Knowledge of pediatric 10. 6 .1. 2 Provision of Training to Facilities by Health first aid, including pediatric CPR which addresses manage - Agencies ment of a blocked airway and rescue breathing, and the confidence to use these skills, are critically important References 1. Alkon, A., P. J. Kaiser, J. M. Tschann, W. T. Boyce, J. L. Genevro, M. Chesney. to the outcome of an emergency situation. 1994. Injuries in child-care centers: Rates, severity, and etiology. Pediatrics 94:1043-46. Small family child care home caregivers/teachers often Stevens, P. B., K. A. Dunn. 1994. Use of cardiopulmonary resuscitation by 2. work alone. They must have the necessary skills to manage North Carolina day care providers. J School Health 64:381-83. emergencies while caring for all the children in the group. 3. American Heart Association (AHA). 2010 AHA guidelines for cardiopul- monary resuscitation and emergency cardiovascular care science. Children with special health care needs who have compro - Circulation 122: S640-56. mised airways may need to be accompanied to child care Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 4. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; Sudbury, with nurses who are able to respond to airway problems (e.g., MA: Jones and Bartlett. the child who has a tracheostomy and needs suctioning). 5. American Heart Association (AHA). 2010. Hands-only CPR. http://handsonlycpr.org. First aid skills are the most likely tools caregivers/teachers - will need. Minor injuries are common. For emergency situ 1.4. 3. 2 ations that require attention from a health professional, first aid procedures can be used to control the situation until a Topics Covered in First Aid Training health professional can provide definitive care. However, First aid training should present an overview of Emergency - management of a blocked airway (choking) is a life-threat Medical Services (EMS), accessing EMS, poison center ening emergency that cannot wait for emergency medical services, accessing the poison center, safety at the scene, personnel to arrive on the scene (2). and isolation of body substances. First aid instruction should include, but not be limited to, recognition and Documentation of current certification of satisfactory com- first response of pediatric emergency management in pletion of pediatric first aid and demonstration of pediatric a child care setting of the following situations: CPR skills in the facility assists in implementing and in monitoring for proof of compliance.

54 27 Chapter 1: Staffing a. Management of a blocked airway and rescue breathing Small family child care home caregivers/teachers often for infants and children with return demonstration by work alone and are solely responsible for the health and safety of children in care. Such caregivers/teachers must the learner (pediatric CPR); Abrasions and lacerations; b. have pediatric first aid competence. c. Bleeding, including nosebleeds; COMMENTS d. Burns; Other children will have to be supervised while the injury Fainting; e. is managed. Parental notification and communication with Poisoning, including swallowed, skin or eye contact, f. emergency medical services must be carefully planned. and inhaled; First aid information can be obtained from the American Puncture wounds, including splinters; g. and the Academy of Pediatrics (AAP) at http://www.aap.org h. Injuries, including insect, animal, and human bites; American Heart Association (AHA) at http://www.heart. i. Poison control; org/HEARTORG/ . Shock; j. TYPE OF FACILITY k. Seizure care; Musculoskeletal injury (such as sprains, fractures); l. Center, Large Family Child Care Home m. Dental and mouth injuries/trauma; RELATED STANDARDS n. Head injuries, including shaken baby syndrome/ First Aid and CPR Training for Staff 1. 4 . 3.1 abusive head trauma; 3. 6 .1. 3 Thermometers for Taking Human Temperatures Allergic reactions, including information about when o. 5. 6 . 0.1 First Aid and Emergency Supplies epinephrine might be required; Asthmatic reactions, including information about p. Training Record 9.4.3.3 when rescue inhalers must be used; Reference Eye injuries; q. 1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; r. Loss of consciousness; Sudbury, MA: Jones and Bartlett. s. Electric shock; Drowning; t. u. Heat-related injuries, including heat exhaustion/ 1.4.3.3 heat stroke; CPR Training for Swimming and Water Play v. Cold related injuries, including frostbite; Facilities that have a swimming pool should require at least Moving and positioning injured/ill persons; w. one staff member with current documentation of successful x. - Illness-related emergencies (such as stiff neck, inexpli completion of training in infant and child (pediatric) CPR cable confusion, sudden onset of blood-red or purple (Cardiopulmonary Resuscitation) be on duty at all times rash, severe pain, temperature above 101°F [38.3°C] during business hours. orally, above 102°F [38.9°C] rectally, or 100°F [37.8°C] At least one of the caregivers/teachers, volunteers, or other or higher taken axillary [armpit] or measured by an adults who is counted in the child:staff ratio for swimming equivalent method, and looking/acting severely ill); and water play should have documentation of successful Standard Precautions; y. completion of training in basic water safety, proper use of Organizing and implementing a plan to meet an emer- z. swimming pool rescue equipment, and infant and child gency for any child with a special health care need; CPR according to the criteria of the American Red Cross aa. Addressing the needs of the other children in the group or the American Heart Association (AHA). while managing emergencies in a child care setting; ab. Applying first aid to children with special health care For small family child care homes, the person trained needs. in water safety and CPR should be the caregiver/teacher. Written verification of successful completion of CPR and RATIONALE lifesaving training, water safety instructions, and emergency First aid for children in the child care setting requires a procedures should be kept on file. more child-specific approach than standard adult-oriented RATIONALE first aid offers. To ensure the health and safety of children in a child care setting, someone who is qualified to respond Drowning involves cessation of breathing and rarely to common injuries and life-threatening emergencies must requires cardiac resuscitation of victims. Nevertheless, be in attendance at all times. A staff trained in pediatric because of the increased risk for cardiopulmonary arrest first aid, including pediatric CPR, coupled with a facility related to wading and swimming, the facility should have that has been designed or modified to ensure the safety of personnel trained to provide CPR and to deal promptly with children, can reduce the potential for death and disability. a life-threatening drowning emergency. During drowning, Knowledge of pediatric first aid, including the ability to cold exposure provides the possibility of protection of the demonstrate pediatric CPR skills, and the confidence to brain from irreversible damage associated with respiratory use these skills, are critically important to the outcome and cardiac arrest. Children drown in as little as two inches of an emergency situation (1). of water. The difference between a life and death situation is the submersion time. Thirty seconds can make a difference.

55 28 Caring for Our Children: National Health and Safety Performance Standards The timely administration of resuscitation efforts by a and skills. Child health and employee health are integral to caregiver/teacher trained in water safety and CPR is critical. - any education/training curriculum and program manage Studies have shown that prompt rescue and the presence of ment plan. Planning and evaluation of training should be a trained resuscitator at the site can save about 30% of the based on performance of the staff member(s) involved. Too victims without significant neurological consequences (1). often, staff members make training choices based on what they like to learn about (their “wants”) and not the areas TYPE OF FACILITY in which their performance should be improved (their Center, Large Family Child Care Home “needs”). Participation in training does not ensure that the RELATED STANDARDS participant will master the information and skills offered in the training experience. Therefore, caregiver/teacher change Ratios and Supervision for Swimming, Wading, 1.1.1.5 in behavior or the continuation of appropriate practice and Water Play resulting from the training, not just participation in train - 2.2.0.4 Supervision Near Bodies of Water ing, should be assessed by supervisors and directors (4). Behavior Around a Pool 2.2.0.5 In addition to low child:staff ratio, group size, age mix of Pool Safety Rules 6 . 3.1.7 children, and stability of caregiver/teacher, the training/ 6 . 4 .1.1 Po o l To y s education of caregivers/teachers is a specific indicator of 9.4.3.3 Training Record child care quality (2). Most skilled roles require training Reference related to the functions and responsibilities the role requires. 1. Aronson, S. S., ed. 2007. Pediatric first aid for caregivers and teachers. Staff members who are better trained are better able to pre- Rev. 1st ed. Elk Grove Village, IL: American Academy of Pediatrics; vent, recognize, and correct health and safety problems. The Sudbury, MA: Jones and Bartlett. number of training hours recommended in this standard reflects the central focus of caregivers/teachers on child development, health, and safety. 1.4.4 Children may come to child care with identified special CONTINUING EDUCATION/ health care needs or special needs may be identified while PROFESSIONAL DEVELOPMENT attending child care, so staff should be trained in recog- nizing health problems as well as in implementing care 1.4.4.1 plans for previously identified needs. Medications are often Continuing Education for Directors required either on an emergent or scheduled basis for a and Caregivers/Teachers in Centers and child to safely attend child care. Caregivers/teachers should be well trained on medication administration and appro- Large Family Child Care Homes priate policies should be in place. All directors and caregivers/teachers of centers and large family child care homes should successfully complete at The National Association for the Education of Young least thirty clock-hours per year of continuing education/ Children (NAEYC), a leading organization in child care professional development in the first year of employment, and early childhood education, recommends annual - sixteen clock-hours of which should be in child develop training/professional development based on the needs ment pro- gramming and fourteen of which should be in of the program and the pre-service qualifications of child health, safety, and staff health. In the second and each staff (1). Training should address the following areas: of the following years of employment at a facility, all direc - Promoting child growth and development correlated a. tors and with developmentally appropriate activities; caregivers/teachers should successfully complete at least b. Infant care; twenty-four clock-hours of continuing education based on Recognizing and managing minor illness and injury; c. individual competency needs and any special needs of the Managing the care of children who require the special d. children in their care, sixteen hours of which should be in procedures listed in Standard 3.5.0.2; child development programming and eight hours of which Medication administration; e. should be in child health, safety, and staff health. Business aspects of the small family child care home; f. Programs should conduct a needs assessment to identify Planning developmentally appropriate activities in g. areas of focus, trainer qualifications, adult learning strate - mixed age groupings; gies, and create an annual professional development plan h. Nutrition for children in the context of preparing for staff based on the needs assessment. The effectiveness nutritious meals for the family; of training should be evident by the change in performance Age-appropriate size servings of food and child feeding i. as measured by accreditation standards or other quality practices; assurance systems. j. Acceptable methods of discipline/setting limits; Organizing the home for child care; k. RATIONALE l. Preventing unintentional injuries in the home Because of the nature of their caregiving/teaching tasks, (e.g., falls, poisoning, burns, drowning); caregivers/teachers must attain multifaceted knowledge

56 29 Chapter 1: Staffing Available community services; m. 5. Visiting Nurse Association (VNA); Detecting, preventing, and reporting child abuse n. 6. National Association of Pediatric Nurse Practitioners and neglect; (NAPNAP); Advocacy skills; o. 7. National Association for the Education of Young p. Pediatric first aid, including pediatric CPR; Children (NAEYC); q. Methods of effective communication with children and National Association for Family Child Care (NAFCC); 8. parents/guardians; 9. National Association of School Nurses (NASN); r. Socio-emotional and mental health (positive approaches 10. Emergency Medical Services for Children (EMSC) with consistent and nurturing relationships); National Resource Center; s. Evacuation and shelter-in-place drill procedures; National Association for Sport and Physical 11. Occupational health hazards; t. Education (NASPE); u. Infant safe sleep environments and practices; u. 12. American Dietetic Association (ADA); v. Standard Precautions; 13. American Association of Poison Control Centers w. Shaken baby syndrome/abusive head trauma; (AAPCC). Dental issues; x. For nutrition training, facilities should check that the Age-appropriate nutrition and physical activity. y. nutritionist/registered dietician (RD), who provides advice, has experience with, and knowledge of, child development, There are few illnesses for which children should be ex- infant and early childhood nutrition, school-age child nutri- cluded from child care. Decisions about management of tion, prescribed nutrition therapies, food service and food ill children are facilitated by skill in assessing the extent safety issues in the child care setting. Most state Maternal to which the behavior suggesting illness requires special and Child Health (MCH) programs, Child and Adult Care management (3). Continuing education on managing in- Food Programs (CACFP), and Special Supplemental Nutri- fectious diseases helps prepare caregivers/teachers to make tion Programs for Women, Infants, and Children (WIC) these decisions devoid of personal biases (5). Recommen- have a nutrition specialist on staff or access to a local con- dations regarding responses to illnesses may change sultant. If this nutrition specialist has knowledge and ex- (e.g., H1N1), so caregivers/teachers need to know where perience in early childhood and child care, facilities might they can find the most current information. All caregivers/ negotiate for this individual to serve or identify someone teachers should be trained to prevent, assess, and treat to serve as a consultant and trainer for the facility. injuries common in child care settings and to comfort an injured child and children witnessing an injury. Many resources are available for nutritionists/RDs who provide training in food service and nutrition. Some COMMENTS resources to contact include: Tools for assessment of training needs are part of the accreditation self-study tools available from the NAEYC, a. Local, county, and state health departments to locate the National Association for Family Child Care (NAFCC), MCH, CACFP, or WIC programs; National Early Childhood Professional Accreditation State university and college nutrition departments; b. (NECPA), Association for Christian Education Interna- c. Home economists at utility companies; tional (ACEI), National AfterSchool Association (NAA), State affiliates of the American Dietetic Association; d. and the National Child Care Association (NCCA). Suc- State and regional affiliates of the American Public e. cessful completion of training can be measured by a Health Association; performance test at the end of training and by ongoing f. The American Association of Family and Consumer evaluation of performance on the job. Services; g. National Resource Center for Health and Safety in Resources for training on health and safety issues include: Child Care and Early Education; State and local health departments (health education, a. h. Nutritionist/RD at a hospital; environmental health and sanitation, nutrition, public High school home economics teachers; i. health nursing departments, fire and EMS, etc.); j. The Dairy Council; b. Networks of child care health consultants; The local American Heart Association affiliate; k. Graduates of the National Training Institute for Child c. The local Cancer Society; l. Care Health Consultants (NTI); m. The Society for Nutrition Education; Child care resource and referral agencies; d. n. The local Cooperative Extension office; University Centers for Excellence on Disabilities; e. Local community colleges and trade schools. o. Local children’s hospitals; f. Nutrition education resources may be obtained from the State and local chapters of: g. Food and Nutrition Information Center at ht t p://f n ic .na l . 1. American Academy of Pediatrics (AAP), including usda.gov . The staff ’s continuing education in nutrition may AAP Chapter Child Care Contacts; be supplemented by periodic newsletters and/or literature 2. American Academy of Family Physicians (AAFP); (frequently bilingual) or audiovisual materials prepared 3. American Nurses’ Association (ANA); or recommended by the Nutrition Specialist. American Public Health Association (APHA); 4.

57 30 Caring for Our Children: National Health and Safety Performance Standards Caregivers/teachers should have a basic knowledge of spe- References 1. National Association for the Education of Young Children (NAEYC). - cial health care needs, supplemented by specialized train 2009. Standards for Early Childhood professional preparation programs. ing for children with special health care needs. The type Washington, DC: NAEYC. http://www.naeyc .org/files/naeyc/file/ of special health care needs of the children in care should positions/ProfPrepStandards09.pdf. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable 2. influence the selection of the training topics. The number wages: The National child care staffing study, 1988-1997. Washington, DC: of hours offered in any in-service training program should Center for the Child Care Workforce. be determined by the experience and professional back - 3. Crowley, A. A. 1990. Health services in child care day care centers: A survey. J Pediatr Health Care 4:252-59. ground of the staff, which is best achieved through a Fiene, R. 2002. 13 indicators of quality child care: Research update. 4. regular staff conference mechanism. Washington, DC: U.S. Department of Health and Human Services, Office http://aspe.hhs.gov/ of the Assistant Secretary for Planning and Evaluation. Financial support and accessibility to training programs basic-report/13-indicators-quality-child-care. requires attention to facilitate compliance with this standard. 5. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: Many states are using federal funds from the Child Care and American Academy of Pediatrics. Development Block Grant to improve access, quality, and affordability of training for early care and education pro- 1.4.4.2 fessionals. College courses, either online or face to face, and training workshops can be used to meet the training Continuing Education for Small Family hours requirement. These training opportunities can also Child Care Home Caregivers/Teachers be conducted on site at the child care facility. Completion Small family child care home caregivers/teachers should have of training should be documented by a college transcript or at least thirty clock-hours per year (2) of continuing education a training certificate that includes title/content of training, in areas determined by self-assessment and, where possible, contact hours, name and credentials of trainer or course by a performance review of a skilled instructor and date of training. Whenever possible the sub- mentor or peer reviewer. - mission of documentation that shows how the learner imple RATIONALE mented the concepts taught in the training in the child care In addition to low child:staff ratio, group size, age mix of chil - program should be documented. Although on-site training dren, and continuity of caregiver/teacher, the training/educa - can be costly, it may be a more effective approach than tion of caregivers/teachers is a specific indicator of child care participation in training at a remote location. quality (1). Most skilled roles require training related to the Projects and Outreach: Early Childhood Research and functions and responsibilities the role requires. Caregivers/ Evaluation Projects, Midwest Child Care Research Con- teachers who engage in on-going training are more likely to sortium at http://ccfl.unl.edu/projects_outreach/projects/ decrease morbidity and mor- tality in their setting (3) and are current/ecp/mwcrc.php , identifies the number of hours for better able to prevent, recognize, and correct health and safety education of staff and fourteen indicators of quality from problems. a study conducted in four Midwestern states. Children may come to child care with identified special TYPE OF FACILITY health care needs or may develop them while attending Center, Large Family Child Care Home child care, so staff must be trained in recognizing health problems as well as in implementing care plans for RELATED STANDARDS previously identified needs. 1.8.2.2 Annual Staff Competency Evaluation 3.5.0.2 Caring for Children Who Require Medical Because of the nature of their caregiving/teaching tasks, Procedures caregivers/teachers must attain multifaceted knowledge and skills. Child health and employee health are integral to 3.6.3.1 Medication Administration - any education/training curriculum and program manage 9.4.3.3 Training Record ment plan. Planning and evaluation of training should be Licensing Agency Provision of Child Abuse 10.3.3.4 based on performance of the caregiver/teacher. Provision of Prevention Materials workshops and courses on all facets of a small family child Compensation for Participation in 10.3.4.6 care business may be difficult to access and may lead to Multidisciplinary Assessments for Children caregivers/teachers enrolling in training opportunities in with Special Health Care or Education Needs curriculum related areas only. Too often, caregivers/teachers 10. 6 .1.1 Regulatory Agency Provision of Caregiver/ make training choices based on what they like to learn about Teacher and Consumer Training and (their “wants”) and not the areas in which their performance Support Services should be improved (their “needs”). Provision of Training to Facilities by Health 10. 6 .1. 2 Small family child care home caregivers/teachers often work Agencies alone and are solely responsible for the health and safety of Appendix C: Nutrition Specialist, Registered Dietitian, small numbers of children in care. Peer review is part of Licensed Nutritionist, Consultant, and Food the process for accreditation of family child care and can be Service Staff Qualifications valuable in assisting the caregiver/teacher in the identification of areas of need for training. Self-evaluation may not identify

58 31 Chapter 1: Staffing training needs or focus on areas in which the caregiver/ work and promotes networking and support. Satellite train - teacher is particularly interested and may be skilled ing via down links at local extension service sites, high schools, and community colleges scheduled at convenient a l ready. evening or weekend times is another way to mix quality COMMENTS training with local availability and some networking. The content of continuing education for small family child RELATED STANDARDS - care home caregivers/teachers should include the follow Continuing Education for Directors and Caregivers/ ing topics: 1.4.4.1 Teachers in Centers and Large Family Child Care a. Promoting child growth and development correlated Homes with developmentally appropriate activities; 1.7.0.4 Occupational Hazards b. Infant care; c. Recognizing and managing minor illness and injury; 3.5.0.2 Caring for Children Who Require Medical d. Managing the care of children who require the special Procedures procedures listed in Standard 3.5.0.2; 9.2.4.3 Disaster Planning, Training, and Communication Medication administration; e. 9.2.4.4 Written Plan for Seasonal and Pandemic Influenza Business aspects of the small family child care home; f. 9.2.4.5 Emergency and Evacuation Drills/Exercises Policy Planning developmentally appropriate activities in g. 9.4.3.3 Training Record mixed age groupings; h. Nutrition for children in the context of preparing References 1. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable nutritious meals for the family; wages: The national child care staffing study, 1988-1997. Washington, DC: Age-appropriate size servings of food and child i. Center for the Child Care Workforce. feeding practices; The National Association of Family Child Care (NAFCC). 2005. Quality 2. standards for NAFCC accreditation. 4th ed. Salt Lake City, UT: NAFCC. j. Acceptable methods of discipline/setting limits; http://www.nafcc.org/documents/QualStd.pdf. Organizing the home for child care; k. 3. Fiene, R. 2002. 13 indicators of quality child care: Research update. l. Preventing unintentional injuries in the home Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (falls, poisoning, burns, drowning); http://aspe.hhs.gov/basic-report/13-indicators-qualitychild-care. m. Available community services; Detecting, preventing, and reporting child abuse and n. neglect; Advocacy skills; o. 1.4. 5 Pediatric first aid, including pediatric CPR; p. SPECIALIZED TRAINING/EDUCATION q. Methods of effective communication with children and parents/guardians; 1. 4 . 5 .1 r. Socio-emotional and mental health (positive Training of Staff Who Handle Food approaches with consistent and nurturing All staff members with food handling responsibilities should relationships); obtain training in food service and safety. The director of a Evacuation and shelter-in-place drill procedures; s. center or a large family child care home or the designated Occupational health hazards; t. supervisor for food service should be a certified food protec - u. Infant-safe sleep environments and practices; tion manager or equivalent as demonstrated by completing v. Standard Precautions; an accredited food protection manager course. Small family w. Shaken baby syndrome/abusive head trauma; child care personnel should secure training in food service x. Dental issues; and safety appropriate for their setting. Age-appropriate nutrition and physical activity. y. RATIONALE Small family child care home caregivers/teachers should Outbreaks of foodborne illness have occurred in many maintain current contact lists of community pediatric settings, including child care facilities. Some of these out- primary care providers, specialists for health issues of breaks have led to fatalities and severe disabilities. Young individual children in their care and child care health children are particularly susceptible to foodborne illness, due consultants who could provide training when needed. to their body size and immature immune systems. Because In-home training alternatives to group training for small large centers serve more meals daily than many restaurants family child care home caregivers/teachers are available, do, the supervisors of food handlers in these settings should such as distance courses on the Internet, listening to audio- have successfully completed food service certification, and tapes or viewing media (e.g., DVDs) with self-checklists. the food handlers in these settings should have successfully These training alternatives provide more flexibility for completed courses on appropriate food handling (1). caregivers/teachers who are remote from central training COMMENTS locations or have difficulty arranging coverage for their Sponsors of the Child and Adult Care Food Program child care duties to attend training. Nevertheless, gather- (CACFP) provide this training for some small family child ing family child care home caregivers/teachers for training care home caregivers/teachers. For training in food handling, when possible provides a break from the isolation of their

59 32 Caring for Our Children: National Health and Safety Performance Standards Child abuse and neglect materials should be designed for caregivers/teachers should contact the state or local health department, or the delegate agencies that handle nutrition nonmedical audiences. and environmental health inspection programs for the RATIONALE child care facility. Training for food workers is mandatory Education is important in identifying manifestations of child in some jurisdictions. Other sources for food safety infor - maltreatment that can increase the likelihood of appropriate mation are the Food and Drug Administration (FDA) reports to child protection and law enforcement agencies (5). Food Code, family child care associations, child care COMMENTS resource and referral agencies, licensing agencies, and state departments of education. Child abuse and neglect resources are available from the American Academy of Pediatrics at https://www.aap.org/ TYPE OF FACILITY en-us/advocacy-and-policy/aap-health-initiatives/resilience/ Center, Large Family Child Care Home , the Child Welfare Pages/Child-Abuse-and-Neglect.aspx RELATED STANDARD , Prevent Information Gateway at www.childwelfare.gov , Child Abuse America at www.preventchildabuse.org Training Record 9.4.3.3 and The Early Childhood Learning & Knowledge Reference Center at https://eclkc.ohs.acf.hhs.gov/browse/ 1. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration (FDA). 2009. Food code 2009. College Park, . keyword/child-abuse http://www.fda.gov/Food/FoodSafety RetailFoodProtection/ M D: FDA. TYPE OF FACILITY FoodCode/FoodCode2009/default.htm. Center, Large Family Child Care Home 1.4. 5. 2 RELATED STANDARDS Child Abuse and Neglect Education 2.2.0.9 Prohibited Caregiver/Teacher Behaviors Caregivers/teachers are mandatory reporters of child abuse 2.4.2.1 Health and Safety Education Topics for Staff and neglect. Caregivers/teachers should attend child abuse 3.4.4.1 Recognizing and Reporting Suspected Child and neglect prevention education programs to educate Abuse, Neglect, and Exploitation themselves and establish child abuse and neglect preven- 3.4.4.2 Immunity for Reporters of Child Abuse tion and recognition guidelines for the children, caregivers/ and Neglect teachers, and parents/guardians. The prevention education Preventing and Identifying Shaken Baby 3.4.4.3 program should address physical, sexual, and psychological Syndrome/Abusive Head Trauma or emotional abuse and neglect. The dangers of shaking infants and toddlers and repeated exposure to domestic Care for Children Who Have Been Abused/ 3.4.4.4 violence should be included in the education and prevention Neglected materials. Caregivers/teachers should also receive education Facility Layout to Reduce Risk of Child Abuse 3.4.4.5 - on promoting protective factors to prevent child maltreat and Neglect includes all types of abuse and ment. (Child maltreatment 9. 2 .1.1 Content of Policies neglect of a child under the age of 18 by a parent, caregiver, Training Record 9.4.3.3 or another person in a custodial role (e.g., clergy, coach, teacher, etc.) (1). Caregivers/teachers should be able to References 1. Centers for Disease Control and Prevention. Child abuse and neglect identify signs of stress in families and assist families by prevention. https://www.cdc.gov/violenceprevention/childmaltreatment/ providing support and access/referral to resources when index.html. Updated April 17, 2017. Accessed March 8, 2018 needed. Children with disabilities are at a higher risk of 2. Centers for Disease Control and Prevention. Violence prevention. Child abuse and neglect: risk and protective factors. https://www.cdc.gov/ being abused than healthy children. Special training in violenceprevention/childmaltreatment/riskprotectivefactors.html. child abuse and neglect of children with disabilities Updated April 18, 2017. Accessed January 11, 2018 should be provided (2). 3. Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Risk factors for victimization include a child’s age and Programmatic Activities. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; special needs that may require increased attention from https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention- 2016. the caregiver. Risk factors for perpetration include young Technical-Package.pdf. Accessed January 11, 2018 parental age, single parenthood, many dependent children, US Department of Health and Human Services, Administration for 4. Children and Families, Administration on Children, Youth and Families, low parental income or parental unemployment, substance http://www.acf.hhs.gov/sites/ Children’s Bureau. Child Maltreatment 2014. abuse, and family history of child abuse/neglect, violence, default/files/cb/cm2014.pdf. Published 2016. Accessed January 11, 2018 and/or mental illness (2,3). Caregivers/teachers should 5. Admon Livny K, Katz C. Schools, families, and the prevention of child maltreatment: lessons that can be learned from a literature review. be aware of these factors so they can support parenting Trauma Violence Abuse. 2016;pii:1524838016650186 practices when appropriate. Caregivers/teachers should be trained in compliance with their state’s child abuse and NOTES neglect reporting laws. Child abuse reporting requirements Content in the STANDARD was modified on 5/22/2018 are available from the child care regulation department in each state (4).

60 33 Chapter 1: Staffing RATIONALE 1.4. 5. 3 Young children’s identities cannot be separated from family, Training on Occupational Risk Related culture, and their home language. Children need both to see to Handling Body Fluids successful role models from their own ethnic and cultural All caregivers/teachers who are at risk of occupational groups and to develop the ability to relate to people who are exposure to blood or other blood-containing body fluids different from themselves (1). should be offered hepatitis B immunizations and should receive annual training in Standard Precautions and TYPE OF FACILITY exposure control planning. Training should be consistent Center with applicable standards of the Occupational Safety and RELATED STANDARD Health Administration (OSHA) Standard 29 CFR 1910.1030, Training Record 9.4.3.3 “Occupational Exposure to Bloodborne Pathogens” and local occupational health requirements and should include, References 1. Chang, H. 2006. Developing a skilled, ethnically and linguistically diverse but not be limited to: early childhood workforce. Adapted from Getting ready for quality: The critical importance of developing and supporting a skilled, ethnically and Modes of transmission of bloodborne pathogens; a. http://www.buildinitiative. linguistically diverse early childhood workforce. Standard Precautions; b. org/files/DiverseWorkforce.pdf. c. Hepatitis B vaccine use according to OSHA 2. National Association for the Education of Young Children (NAEYC). 2009. Quality benchmark for cultural competence project. Washington, DC: requirements; http://www.naeyc.org/files/naeyc/file/policy/state/QBCC_Tool.pdf. NA EYC. Program policies and procedures regarding exposure d. to blood/body fluid; e. Reporting procedures under the exposure control plan to ensure that all first-aid incidents involving exposure 1.4.6 are reported to the employer before the end of the work EDUCATIONAL LEAVE/COMPENSATION shift during which the incident occurs (1). 1. 4 . 6 .1 RATIONALE Training Time and Professional Providing first aid in situations where blood is present is an intrinsic part of a caregiver’s/teacher’s job. Split lips, Development Leave scraped knees, and other minor injuries associated with A center, large family child care home or a support agency bleeding are common in child care. for a network of small family child care homes should make provisions for paid training time for staff to participate in Caregivers/teachers who are designated as responsible for required professional development (that includes training rendering first aid or medical assistance as part of their job as well as education) during work hours, or reimburse staff duties are covered by the scope of this standard. for time spent attending professional development outside COMMENTS of regular work hours. Any hours worked in excess of forty OSHA has model exposure control plan materials for use hours in a week must be paid according to state and federal by child care facilities. Using the model exposure control wage and hour regulations. plan materials, caregivers/teachers can prepare a plan to RATIONALE comply with the OSHA requirements. The model plan Most caregivers/teachers work long hours and most are materials are available from regional offices of OSHA. poorly paid (1). Using personal time for education required TYPE OF FACILITY as a condition of employment is an unfair expectation until Center, Large Family Child Care Home compensation for work done in child care is much more equitable. Many child care workers also employed in another RELATED STANDARDS vocation work at other jobs to make a living wage and would Training Record 9.4.3.3 miss income from their other jobs or risk losing that employ- Cleaning Up Body Fluids Appendix L: ment. Additionally, the caregiver/teacher may incur stress in Reference their family life when required to take time outside of child 1. U.S. Department of Labor, Occupational Safety and HealthAdministra- care hours to participate in work-related training. tion. 2008. Toxic and hazardous substances: Bloodborne pathogens. http://www.osha.gov/pls/oshaweb/owadisp.show _document?p_ COMMENTS table=STANDARDS&p_id=10051. Professional development in child care often takes place when the participant is not released from other work-related duties, 1.4.5.4 such as caring for children or answering phones. Providing Education of Center Staff substitutes and released time during work hours for such Centers should educate staff to support the cultural, lan- training is likely to enhance the effectiveness of training; guage, and ethnic backgrounds of children enrolled in the and improve employee satisfaction/retention. program. In addition, all staff members should participate Large family child care homes employ staff in the same - in diversity training that will ensure respectful service deliv way as centers, except for size and location in a residence. ery to all families and a staff that works well together (2). For small family child care home caregivers/teachers,

61 34 Caring for Our Children: National Health and Safety Performance Standards released time and compensation while engaged in training to provide medical care for children with special health care needs is particularly challenging. A substitute nurse can be arranged only if the small family child care home should be experienced in delivering the expected medical caregiver/teacher is part of a support network that makes services. Decisions should be made on whether a parent/ such arrange-ments. This standard does not apply to small guardian will be allowed to provide needed on-site medical family child care home caregivers/teachers independent services. Substitutes should be aware of the care plans of networks. (including emergency procedures) for children with The Fair Labor Standard Act mandates payment of time special health care needs. and a half for all hours worked in excess of forty hours RATIONALE in a week. The risk to children from care by unqualified caregivers/ TYPE OF FACILITY teachers is the same whether the caregiver/teacher is a Center, Large Family Child Care Home paid substitute or a volunteer (1). Reference COMMENTS 1. Center for the Child Care Workforce, American Federation of Teachers (AFT). 2009. Wage data: Early childhood workforce hourly wage data. 2009 Substitutes are difficult to find, especially at the last minute. ed. Washington, DC: AFT. http://www.ccw.org/storage/ccworkforce/ Planning for a competent substitute pool is essential for documents/04-30-09 wwd fact sheet.pdf. child care operation. Requiring substitutes for small family child care homes to obtain first aid and CPR certification 1.4.6. 2 forces small family child care home caregivers/teachers to Payment for Continuing Education close when they cannot be covered by a competent substi - Directors of centers and large family child care homes tute. Since closing a child care home has a negative impact should arrange for continuing education that is paid for on the families and children they serve, systems should be by the government, by charitable organizations, or by the developed to provide qualified alternative homes or substi - facility, rather than by the employee. Small family child tutes for family child care home caregivers/teachers. care home caregivers/teachers should avail themselves of The lack of back-up for family child care home caregivers/ training opportunities offered in their communities or teachers is an inherent liability in this type of care. Parents/ online and claim their educational expenses as a business guardians who use family child care must be sure they have expense on tax forms. - suitable alternative care, such as family or friends, for situa RATIONALE tions in which the child’s usual caregiver/teacher cannot Caregivers/teachers often make low wages and may not be provide the service. able to pay for mandated training. A majority of child care Substitutes should have orientation and training on basic workers earnings are at or near minimum wage (1). health and safety topics. Substitutes should not have an TYPE OF FACILITY infectious disease when providing care. Center, Large Family Child Care Home TYPE OF FACILITY Reference Center, Large Family Child Care Home 1. Center for the Child Care Workforce, American Federation of Teachers. RELATED STANDARDS 2009. Wage data: Early childhood workforce hourly wage data. 2009 ed. http://www.ccw.org/storage/ccworkforce/ Washington, DC: AFT. Ratios for Small Family Child Care Homes 1.1.1.1 documents/04-30-09 wwd fact sheet.pdf. 1.1.1. 2 Ratios for Large Family Child Care Homes and Centers 1. 5 Ratios for Facilities Serving Children with Special 1.1.1. 3 Health Care Needs and Disabilities SUBSTITUTES 1.1.1.4 Ratios and Supervision During Transportation Ratios and Supervision for Swimming, Wading, and 1.1.1.5 Water Play 1. 5 . 0 .1 Differentiated Roles 1. 3. 2 .1 Employment of Substitutes Qualifications of Lead Teachers and Teachers 1.3.2.2 Substitutes should be employed to ensure that child:staff - ratios and requirements for direct supervision are main 1.3.2.3 Qualifications for Assistant Teachers, Teacher tained at all times. Substitutes and volunteers should be Aides, and Volunteers - at least eighteen years of age and must meet the require Additional Qualifications for Caregivers/Teachers 1. 3. 2.4 ments specified throughout Standards 1.3.2.1 to 1.3.2.6. Serving Children Three to Thirty-Five Months Those without licenses/certificates should work under of Age direct supervision and should not be alone with a group 1. 3. 2.5 Additional Qualifications for Caregivers/Teachers of children. Serving Children Three to Five Years of Age - A substitute should complete the same background screen 1. 3. 2.6 Additional Qualifications for Caregivers/Teachers ing processes as the caregiver/teacher. Obtaining substitutes Serving School-Age Children

62 35 Chapter 1: Staffing 2. Diapering technique, if care is provided to children 1.3.3.1 General Qualifications of Family Child Care in diapers, including appropriate diaper disposal and Caregivers/Teachers to Operate a Family Child diaper changing techniques and use and wearing Care Home of gloves Support Networks for Family Child Care 1.3.3.2 3. Preventing shaken baby syndrome/abusive head Orientation of Substitutes 1.5.0. 2 trauma Pre-Employment and Ongoing Adult Health 1.7.0.1 Strategies for coping with crying, fussing, or 4. Appraisals, Including Immunization distraught infants and children Reference 5. Early brain development and its vulnerabilities 1. National Association for Family Child Care (NAFCC). NAFCC official 6. Other injury prevention and safety, including the Website. http://nafcc.net. role of a mandatory child abuse reporter to report any suspected abuse/neglect 1. 5.0. 2 7. Correct food preparation and storage techniques, if Orientation of Substitutes employee prepares food Proper handling and storage of human (breast) milk, 8. The director of any center or large family child care home when applicable, and formula preparation, if formula and the small family child care home caregiver/teacher is handled should provide orientation training to newly hired substi - 9. Bottle preparation, including guidelines for human tutes, including a review of all the program’s policies and milk and formula, if care is provided to infants or procedures (see sample that follows). This training should children with bottles include the opportunity for an evaluation and a repeat 10. Proper use of gloves in compliance with demonstration of the training lesson. Orientation should Occupational Safety and Health Administration be documented in all child care settings. Substitutes blood-borne pathogen regulations should have background screenings. Emergency plans and practices k. All substitutes should be oriented to, and demonstrate competence in, the tasks for which they will be responsible. On employment, substitutes should be able to carry out the duties assigned to them. On the first day a substitute caregiver/teacher should be oriented on the following topics: RATIONALE Because facilities and the children enrolled in them vary, a. Safe infant sleep practices orientation programs for new substitutes can be most pro- 1. The practice of putting infants down to sleep posi - ductive. Because of frequent staff turnover, comprehensive tioned on their backs and on a firm surface, along orientation programs are critical to protecting the health with all safe infant sleep practices, to reduce the risk Most SIDS deaths and safety of children and new staff (1,2). of sudden infant death syndrome (SIDS), as well as in child care occur on the first day of care or within the first general nap time routines and healthy sleep hygiene week due to unaccustomed prone (on stomach) sleeping. for all ages. Unaccustomed prone sleeping increases the risk of SIDS Any emergency medical procedure or medication needs b. 18 times (3). of the children c. Access to the list of authorized individuals for releasing TYPE OF FACILITY children Center, Large Family Child Care Home, Small Family Any special dietary needs of the children d. Child Care Home During the first week of employment, all substitute RELATED STANDARDS caregivers/teachers should be oriented to, and should 1.2.0.2 Background Screening demonstrate competence in, at least the following items: 2.2.0.6 Discipline Measures e. The names of the children for whom the caregiver/ 2.2.0.7 Handling Physical Aggression, Biting, and Hitting - teacher will be responsible and their specific develop Preventing Expulsions, Suspensions, and Other 2.2.0.8 mental and special health care needs Limitations in Services The planned program of activities at the facility f. 2.2.0.9 Prohibited Caregiver/Teacher Behaviors g. Routines and transitions h. Acceptable methods of discipline 3.1.4.4 Scheduled Rest Periods and Sleep Arrangements Meal patterns and safe food-handling policies of the i. Type of Diapers Worn 3. 2 .1.1 facility (Special attention should be given to life- Situations that Require Hand Hygiene 3.2.2.1 threatening food allergies.) 3.2.2.2 Handwashing Procedure Emergency health and safety procedures j. Assisting Children with Hand Hygiene 3.2.2.3 General health policies and procedures as appropriate k. for the ages of the children cared for, including, but not 3.2.2.4 Training and Monitoring for Hand Hygiene limited to 3.2.2.5 Hand Sanitizers 1. Hand hygiene techniques, including indications for 3.2.3.4 Prevention of Exposure to Blood and Body Fluids hand hygiene

63 36 Caring for Our Children: National Health and Safety Performance Standards CCHCs have knowledge of resources and regulations 3.4.3.1 Emergency Procedures and are comfortable linking health resources with child 3.4.3.2 Use of Fire Extinguishers care facilities. 3.4.3.3 Response to Fire and Burns The child care health consultant should be knowledgeable 5. 4 .1.1 General Requirements for Toilet and in the following areas: Areas Handwashing - Consultation skills both as a child care health consul a. 5. 4 .1. 2 Location of Toilets and Privacy Issues tant as well as a member of an interdisciplinary team Ability to Open Toilet Room Doors 5. 4 .1. 3 of consultants; Preventing Entry to Toilet Rooms by Infants and 5.4.1.4 National health and safety standards for out-of-home b. To d d l e r s child care; 5. 4 .1. 5 Chemical Toilets Indicators of quality early care and education; c. 5. 4 .1. 6 Ratios of Toilets, Urinals, and Hand Sinks to d. Day-to-day operations of child care facilities; Children e. State child care licensing and public health requirements; f. State health laws, Federal and State education laws (e.g., Toilet Learning/Training Equipment 5. 4 .1.7 ADA, IDEA), and state professional practice acts for Cleaning and Disinfecting Toileting Equipment 5. 4 .1. 8 licensed professionals (e.g., State Nurse Practice Acts); Waste Receptacles in the Child Care Facility 5. 4 .1. 9 Infancy and early childhood development, social and g. and in Child Care Facility Toilet Room(s) emotional health, and developmentally appropriate Sleeping Equipment and Supplies 5.4.5.1 practice; Cribs 5.4.5.2 Recognition and reporting requirements for infectious h. diseases; 5.4.5.3 Stackable Cribs i. American Academy of Pediatrics (AAP) and Early and 5.4.5.4 Futons Periodic Screening, Diagnosis, and Treatment (EPSDT) Bunk Beds 5.4.5.5 screening recommendations and immunizations Exchange of Information at Transitions 9.2.2.3 schedules for children; 9. 2 . 3 .11 Food and Nutrition Service Policies and Plans j. Importance of medical home and local and state 9. 2 . 3.12 Infant Feeding Policy resources to facilitate access to a medical home as well as child health insurance programs including 9. 2 . 4 .1 Written Plan and Training for Handling Urgent Medicaid and State Children’s Health Insurance Medical Care or Threatening Incidents Program (SCHIP); 9.2.4.2 Review of Written Plan for Urgent Care Injury prevention for children; k. Records of Nutrition Service 9. 4 .1.18 l. Oral health for children; Gloving Appendix D: m. Nutrition and age-appropriate physical activity recommendations for children including feeding of References 1. Landry SH, Zucker TA, Taylor HB, et al. Enhancing early child care quality infants and children, the importance of breastfeeding and learning for toddlers at risk: the responsive early childhood program. and the prevention of obesity; Dev Psychol. 2014;50(2):526–541 Inclusion of children with special health care needs, n. 2. Ellenbogen S, Klein B, Wekerle C. Early childhood education as a resilience intervention for maltreated children. Early Child Dev Care. 2014;184:1364– and developmental disabilities in child care; 1377 o. Safe medication administration practices; 3. Ball HL, Volpe LE. Sudden infant death syndrome (SIDS) risk reduction Health education of children; p. and infant sleep location—moving the discussion forward. Soc Sci Med. 2013;79:84–91 Recognition and reporting requirements for child abuse q. and neglect/child maltreatment; NOTES r. Safe sleep practices and policies (including reducing the Content in the STANDARD was modified on 5/22/2018 risk of SIDS); Development and implementation of health and safety s. policies and practices including poison awareness and 1.6 poison prevention; CONSULTANTS Staff health, including adult health screening, occupa - t. tional health risks, and immunizations; Disaster planning resources and collaborations within u. child care community; 1. 6 . 0 .1 v. Community health and mental health resources for Child Care Health Consultants child, parent/guardian and staff health; A facility should identify and engage/partner with a child Importance of serving as a healthy role model for w. care health consultant (CCHC) who is a licensed health children and staff. professional with education and experience in child and community health and child care and preferably specialized training in child care health consultation.

64 37 Chapter 1: Staffing Working with other consultants such as nutritionists/ t. The child care health consultant should be able to perform RDs, kinesiologists (physical activity specialists), oral or arrange for performance of the following activities: health consultants, social service workers, early child - Assessing caregivers’/teachers’ knowledge of health, a. hood mental health consultants, and education development, and safety and offering training as consultants. indicated; Assessing parents’/guardians’ health, development, and The role of the CCHC is to promote the health and develop - b. ment of children, families, and staff and to ensure a healthy safety knowledge, and offering training as indicated; and safe child care environment (11). Assessing children’s knowledge about health and safety c. and offering training as indicated; The CCHC is not acting as a primary care provider at d. Conducting a comprehensive indoor and outdoor health the facility but offers critical services to the program and and safety assessment and on-going observations of the families by sharing health and developmental expertise, child care facility; assessments of child, staff, and family health needs and Consulting collaboratively on-site and/or by telephone e. community resources. The CCHC assists families in care or electronic media; coordination with the medical home and other health and Providing community resources and referral for health, f. developmental specialists. In addition, the CCHC should mental health and social needs, including accessing collaborate with an interdisciplinary team of early child - medical homes, children’s health insurance programs hood consultants, such as, early childhood education, (e.g., CHIP), and services for special health care needs; mental health, and nutrition consultants. Developing or updating policies and procedures for g. In order to provide effective consultation and support child care facilities (see comment section below); to programs, the CCHC should avoid conflict of interest h. Reviewing health records of children; related to other roles such as serving as a caregiver/teacher i. Reviewing health records of caregivers/teachers; or regulator or a parent/guardian at the site to which child Assisting caregivers/teachers and parents/guardians j. care health consultation is being provided. in the management of children with behavioral, social and emotional problems and those with special health The CCHC should have regular contact with the facility’s care needs; - administrative authority, the staff, and the parents/guard Consulting a child’s primary care provider about the k. ians in the facility. The administrative authority should child’s individualized health care plan and coordinating review, and collaborate with the CCHC in implementing services in collaboration with parents/guardians, the pri- recommended changes in policies and practices. In the case mary care provider, and other health care professionals of consulting about children with special health care needs, (the CCHC shows commitment to communicating with the CCHC should have contact with the child’s medical and helping coordinate the child’s care with the child’s home with permission from the child’s parent/guardian. medical home, and may assist with the coordination of Programs with a significant number of non-English- skilled nursing care services at the child care facility); speaking families should seek a CCHC who is culturally Consulting with a child’s primary care provider about l. sensitive and knowledgeable about community health medications as needed, in collaboration with parents/ resources for the parents’/guardians’ native culture guardians; and languages. m. Teaching staff safe medication administration practices; RATIONALE n. Monitoring safe medication administration practices; o. Observing children’s behavior, development and health CCHCs provide consultation, training, information and status and making recommendations if needed to staff referral, and technical assistance to caregivers/teachers (10). and parents/guardians for further assessment by a Growing evidence suggests that CCHCs support healthy child’s primary care provider; and safe early care and education settings and protect and p. Interpreting standards, regulations and accreditation promote the healthy growth and development of children requirements related to health and safety, as well as and their families (1-10). Setting health and safety policies providing technical advice, separate and apart from in cooperation with the staff, parents/guardians, health - an enforcement role of a regulation inspector or deter professionals, and public health authorities will help ensure mining the status of the facility for recognition; successful implementation of a quality program (3). The q. Understanding and observing confidentiality - specific health and safety consultation needs for an individ requirements; ual facility depend on the characteristics of that facility r. Assisting in the development of disaster/emergency (1-2). All facilities should have an overall child care medical plans (especially for those children with special health consultation plan (1,2,10). health care needs) in collaboration with community The special circumstances of group care may not be part resources; of the health care professional’s usual education. Therefore, Developing an obesity prevention program in consulta - s. caregivers/teachers should seek child care health consul - tion with a nutritionist/registered dietitian (RD) and tants who have the necessary specialized training or experi - physical education specialist; ence (10). Such training is available from instructors who

65 38 Caring for Our Children: National Health and Safety Performance Standards organizations, other non-profit organizations, and/or are graduates of the National Training Institute for Child Care Health Consultants (NTI) and in some states from universities. Some professional organizations include child state-level mentoring of seasoned child care health con- care health consultants in their special interest groups, sultants known to chapter child care contacts networked such as the AAP’s Section on Early Education and Child through the Healthy Child Care America (HCCA) Care and the National Association of Pediatric Nurse Practitioners (NAPNAP). initiatives of the AAP. - CCHCs who are not employees of health, education, family Some professionals may not have the full range of knowl service or child care agencies may be self-employed. Com- edge and expertise to serve as a child care health consultant - but can provide valuable, specialized expertise. For exam pensating them for their services via fee-for-service, an ple, a sanitarian may provide consultation on hygiene and hourly rate, or a retainer fosters access and accountability. infectious disease control and a Certified Playground Safety Listed below is a sample of the policies and procedures child Inspector would be able to provide consultation about gross care health consultants should review and approve: motor play hazards. Admission and readmission after illness, including a. COMMENTS inclusion/exclusion criteria; The U.S. Department of Health and Human Services b. Health evaluation and observation procedures on Maternal and Child Health Bureau (MCHB) has supported intake, including physical assessment of the child and the development of state systems of child care health con- other criteria used to determine the appropriateness sultants through HCCA and State Early Childhood Com- of a child’s attendance; prehensive Systems grants. Child care health consultants c. Plans for care and management of children with provide services to centers as well as family child care homes communicable diseases; through on-site visits as well as phone or email consultation. Plans for prevention, surveillance and management d. Approximately twenty states are funding child care health of illnesses, injuries, and behavioral and emotional consultant initiatives through a variety of funding sources, problems that arise in the care of children; including Child Care Development Block Grants, TANF, Plans for caregiver/teacher training and for communica e. - and Title V. In some states a wide variety of health consul - tion with parents/guardians and primary care providers; tants, e.g., nutrition, kinesiology (physical activity), mental f. Policies regarding nutrition, nutrition education, health, oral health, environmental health, may be available age-appropriate infant and child feeding, oral health, to programs and those consultants may operate through a and physical activity requirements; team approach. Connecticut is an example of one state that Plans for the inclusion of children with special health or g. has developed interdisciplinary training for early care and mental health care needs as well as oversight of their education consultants (health, education, mental health, care and needs; social service, nutrition, and special education) in order to Emergency/disaster plans; h. develop a multidisciplinary approach to consultation (8). i. Safety assessment of facility playground and indoor play equipment; Some states offer CCHC training with continuing educa- j. Policies regarding staff health and safety; tion units, college credit, and/or a certificate of completion. Policy for safe sleep practices and reducing the risk k. Credentialing is an umbrella term referring to the various of SIDS; - means employed to designate that individuals or organiza Policies for preventing shaken baby syndrome/abusive l. tions have met or exceeded established standards. These head trauma; may include accreditation of programs or organizations Policies for administration of medication; m. and certification, registration, or licensure of individuals. n. Policies for safely transporting children; - Accreditation refers to a legitimate state or national organi Policies on environmental health – handwashing, o. - zation verifying that an educational program or organiza sanitizing, pest management, lead, etc. tion meets standards. Certification is the process by which a non-governmental agency or association grants recognition TYPE OF FACILITY to an individual who has met predetermined qualifications Center, Large Family Child Care Home specified by the agency or association. Certification is RELATED STANDARDS applied for by individuals on a voluntary basis and repre- Early Childhood Mental Health Consultants 1.6.0. 3 sents a professional status when achieved. Typical qualifica - tions include 1) graduation from an accredited or approved 1.6.0.4 Early Childhood Education Consultants program and 2) acceptable performance on a qualifying References examination. While there is no national accreditation of 1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. Child care health consultation programs in California: Models, services, CCHC training programs or individual CCHCs at this and facilitators. Public Health Nurs 25:126-39. time, this is a future goal. 2. Alkon, A., J. Farrer, J. Bernzweig. 2004. Roles and responsibilities of child care health consultants: Focus group findings. Pediatric Nurs 30:315-21. CCHC services may be provided through the public 3. Crowley, A. A. 2000. Child care health consultation: The Connecticut health system, resource and referral agency, private source, experience. Maternal Child Health J 4:67-75. local community action program, health professional

66 39 Chapter 1: Staffing Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 4. consultant improves health policies and health and safety 2005. Opportunities for health promotion education in child care. practices and improves children’s immunization status, Pediatrics 116:499-505. access to a medical home, enrollment in health insurance, 5. Farrer, J., A. Alkon, K. To. 2007. Child care health consultation pro- grams: Barriers and opportunities. Maternal Child Health J 11:111-18. timely screenings, and potentially reduces the prevalence Heath, J. M., et al. 2005. Creating a statewide system of multi-disciplinary 6. of obesity with a targeted intervention (5-11). Furthermore, consultation system for early care and education in Connecticut. in one state, child care center medication administration Farmington, CT: Child Health and Development Institute of Connecticut. http://nitcci.nccic.acf.hhs.gov/resources/10262005_93815_901828.pdf. regulatory compliance was associated with weekly visits by 7. Crowley, A. A., J. M Kulikowich. 2009. Impact of training on child care a trained nurse child care health consultant who delivered health consultant knowledge and practice. Pediatric Nurs 35:93-100. a standardized best practice curriculum (12). Crowley, A. A., R. M. Sabatelli. 2008. Collaborative child care health 8. consultation: A conceptual model. J for Specialists in Pediatric Nurs COMMENTS 13:74-88. 9. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. State child care regulations display a wide range of fre- Outcomes of child care health consultation services for child care quency and recommendations in states that require CCHC providers in New Jersey: A pilot study. Pediatric Nurs 32:530-37. visits (5,6,13), from as frequently as once a week for pro- 10. 1Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. grams serving children under three years of age to twice Academic Pediatrics 9:366-70. a year for programs serving children three to five years 11. 1Crowley, A. A. 2001. Child care health consultation: An ecological of age (2,5,6,13). model. J Society Pediat Nurs 6:170-81. TYPE OF FACILITY 1.6.0. 2 Center, Large Family Child Care Home Frequency of Child Care Health RELATED STANDARDS Consultation Visits Ratios for Facilities Serving Children with 1.1.1. 3 The child care health consultant (CCHC) should visit each Special Health Care Needs and Disabilities facility as needed to review and give advice on the facility’s 1. 6 . 0.1 Child Care Health Consultants health component and review the overall health status of Specialized Consultation for Facilities Serving 1.6.0.5 the children and staff (1-4). Early childhood programs that Children with Disabilities serve any child younger than three years of age should be 3.6.2.7 Child Care Health Consultants for Facilities That visited at least once monthly by a health professional with Care for Children Who Are Ill general knowledge and skills in child health and safety and health consultation. Child care programs that serve 4.4.0.1 Food Service Staff by Type of Facility and Food children three to five years of age should be visited at least Service quarterly and programs serving school-age children should Nutritional Quality of Food Brought From Home 4.6.0.2 be visited at least twice annually. In all cases, the frequency 9. 4 .1.17 Documentation of Child Care Health of visits should meet the needs of the composite group of Consultation/Training Visits children and be based on the needs of the program for Support for Consultants to Provide Technical 10.3.4.3 training, support, and monitoring of child health and Assistance to Facilities safety needs, including (but not limited to) infectious 10.3.4.4 Development of List of Providers of Services to disease, injury prevention, safe sleep, nutrition, oral health, Facilities - physical activity and outdoor learning, emergency prepara tion, medication administration, and the care of children References 1. Alkon, A., J. Bernzweig, K. To, J. K. Mackie, M. Wolff, J. Elman. 2008. with special health care needs. Written documentation of Child care health consultation programs in California: Models, services, CCHC visits should be maintained at the facility. and facilitators. Public Health Nurs 25:126-39. 2. Crowley, A. A. 2000. Child care health consultation: The Connecticut RATIONALE experience. Maternal Child Health J 4:67-75. Almost everything that goes on in a facility and almost 3. Dellert, J. C., D. Gasalberti, K. Sternas, P. Lucarelli, J. Hall. 2006. Outcomes of child care health consultation services for child care everything about the facility itself affects the health of the providers in New Jersey: A pilot study. Pediatric Nursing 32:530-37. children, families, and staff. (1-4). Because infants are devel - 4. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. oping rapidly, environmental situations can quickly create 2005. Opportunities for health promotion education in child care. Pediatrics 116:499-505. harm. Their rapid changes in behavior make regular and 5. Healthy Child Care Consultant Network Support Center, CHT Resource frequent visits by the CCHC extremely important (2-4). Group. 2006. The influence of child care health consultants in promoting More frequent visits should be arranged for those facilities ht tp:// children’s health and well-being: A report on selected resources. hcccnsc.jsi.com/resources/publications/CC_lit_review_Screen_All.pdf. that care for children with special health care needs and Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care 6. those programs that experience health and safety problems health consultation improves health and safety policies and practices. and high turnover rate to ensure that staff have adequate 9:366 -70. Academic Pediatrics 7. Crowley, A. A. & Kulikowich, J. Impact of training on child care training and ongoing support (2). In one study, 84% of child health consultant knowledge and practice. Pediatric Nursing. care directors who were required to have weekly health 2009, 35 (2): 93-100. consultation visits considered the visits critical for chil - 8. Nurse Consultant Intervention Improves Nutrition and Physical Activity Knowledge, Policy, and Practice and Reduces Obesity in Child Care. A. dren’s health and program health and safety (2). Growing Crowley, A. Alkon, B Neelon, S. Hill, P. Yi, E. Savage, V. Ngyuen, J. Kotch. evidence suggests that frequent visits by a trained health Head Start Research Conference, Washington, DC. June 20, 2012.

67 40 Caring for Our Children: National Health and Safety Performance Standards 9. Benjamin, S. E., A. Ammerman, J. Sommers, J. Dodds, B. Neelon, D. S. f. Helping address mental health needs and reduce job Ward. 2007. Nutrition and physical activity self-assessment for child care stress within the staff; (NAP SACC): Results from a pilot intervention. Journal of Nutrition Improving management of children with challenging g. 39(3):142-9. Education and Behavior Early Care and Education.” Bryant, D. “Quality Interventions for Early 10. behaviors; Developments, Spring 2013, http://fpg.unc.edu/sites/default/files/ h. Preventing the development of problem behaviors; resources/early-developments/FPG_EarlyDevelopments_v14n1.pdf. Providing a classroom climate that promotes positive i. 11. Isbell P, Kotch JB, Savage E, Gunn E, Lu LS, Weber DJ. Improvement of child care programs’ policies, practices, and children’s access to health social-emotional development; care linked to child care health consultation. NHSA Dialog: A Research Recognizing and appropriately responding to the j. to Practice Journal 2013;16 (2):34-52 (ISSN:1930-1395). needs of children with internalizing behaviors, such Ensuring the health and Crowley, A. A. & Rosenthal, M. S. IMPACT: 12. safety of Connecticut’s early care and education programs. 2009. as persistent sadness, anxiety, and social withdrawal; Farmington, CT: The Child Health and Development Institute of Actively teaching developmentally appropriate social k. Connecticut. skills, conflict resolution, and emotional regulation; National Resource Center for Health and Safety in Child Care and Early 13. Education. 2010. Child care health consultant requirements and profiles Addressing the mental health needs and daily stresses l. by state. http://nrckids.org/default/assets/File/CCHC%20by%20state%20 of those who care for young children, such as families NOV%202012_FINAL.pdf. and caregivers/teachers; NOTES m. Helping the staff to address and handle unforeseen crises Content in the STANDARD was modified on 8/22/2013. or bereavements that may threaten the mental health of staff or children and families, such as the death of a caregiver/teacher or the serious illness 1.6.0. 3 of a child. Early Childhood Mental Health Consultants A facility should engage a qualified early childhood mental RATIONALE health consultant who will assist the program with a range As increasing numbers of children are spending longer hours of early childhood social-emotional and behavioral issues in child care settings, there is an increasing need to build the and who will visit the program at minimum quarterly and capacity of caregivers/teachers to attend to the social-emo - more often as needed. tional and behavioral well-being of children as well as their The knowledge base of an early childhood mental health health and learning needs. Early childhood mental health consultant should include: - underlies much of what constitutes school readiness, includ ing emotional and behavioral regulation, social skills (i.e., a. Training, expertise and/or professional credentials in taking turns, postponing gratification), the ability to mental health (e.g., psychiatry, psychology, clinical inhibit aggressive or anti-social impulses, and the skills to social work, nursing, developmental-behavioral verbally express emotions, such as frustration, anger, anxiety, medicine, etc.); and sadness. Supporting children’s health, mental health b. Early childhood development (typical and atypical) of and learning requires a comprehensive approach. Child infants, toddlers, and preschool age children; care programs need to have health, education, and mental Early care and education settings and practices; c. health consultants who can help them implement universal, d. Consultation skills and approaches to working as a team selected and targeted strategies to improve school readiness with early childhood consultants from other disciplines, in young children in their care (1-5). Mental health consul - - especially health and education consultants, to effec tants in collaboration with education and child care health tively support directors and caregivers/teachers. consultants can reduce the risk for children being expelled, The role of the early childhood mental health consultant can reduce levels of problem behaviors, increase social skills should be focused on building staff capacity and be both and build staff efficacy and capacity (1-11). proactive in decreasing the incidence of challenging class - room behaviors and reactive in formulating appropriate COMMENTS responses to challenging classroom behaviors and should Access to an early childhood mental health consultant include: should be in the context of an ongoing relationship, with at least quarterly regular visits to the classroom to consult. Developing and implementing classroom curricula a. However, even an on-call-only relationship is better than regarding conflict resolution, emotional regulation, no relationship at all. Regardless of the frequency of con- and social skills development; tact, this relationship should be established before a crisis Developing and implementing appropriate screening b. arises, so that the consultant can establish a useful proactive and referral mechanisms for behavioral and mental working relationship with the staff and be quickly mobilized health needs; when needs arise. This consultant should be viewed as an Forming relationships with mental health providers c. important part of the program’s support staff and should and special education systems in the community; collaborate with all regular classroom staff, administration, d. Providing mental health services, resources and/or and other consultants such as child care health consultants referral systems for families and staff; and education consultants, and support staff. In most cases, e. Helping staff facilitate and maintain mentally healthy there is no single place in which to look for early childhood environments within the classroom and overall system;

68 41 Chapter 1: Staffing mental health consultants. Qualified potential consultants written plan for this consultation which must be signed may be identified by contacting mental health and behav- annually by the consultant. This plan should outline the ioral providers (e.g., child clinical and school psychologists, responsibilities of the consultant and the services the - licensed clinical social workers, child psychiatrists, develop consultant will provide to the program. mental pediatricians, etc.), as well as training programs at The knowledge base of an early childhood education local colleges and universities where these professionals are consultant should include: being trained. Colleges and universities may be a good place Working knowledge of theories of child development a. to find well-supervised consultants-in-training at a poten- and learning for children from birth through eight tially reasonable cost, although consultant turnover may years across domains, including socio-emotional be higher. development and family development; TYPE OF FACILITY b. Principles of health and wellness across the domains, Center, Large Family Child Care Home including social and emotional wellness and approaches in the promotion of healthy development and resilience; RELATED STANDARDS Current practices and materials available related to c. Child Care Health Consultants 1. 6 . 0.1 screening, assessment, curriculum, and measurement Early Childhood Education Consultants 1.6.0.4 of child outcomes across the domains, including prac - References tices that aid in early identification and individualizing 1. Brennan, E. M., J. Bradley, M. D. Allen, D. F. Perry. 2008. The evidence for a wide range of needs; base for mental health consultation in early childhood settings: A research Resources that aid programs to support inclusion of d. syn- thesis addressing staff and program outcomes. Early Ed Devel 19:982-1022. children with diverse health and learning needs and 2. National Scientific Council on the Developing Child. 2008. Mental health families representing linguistic, cultural, and economic problems in early childhood can impair learning and behavior for life. diversity of communities; Working Paper no. 6. http://developingchild.harvard.edu/library/ reports_and_working_papers/working_papers/wp6/. Methods of coaching, mentoring, and consulting that e. 3. Perry, D. F., M. D. Allen, E. M. Brennan, J. R. Bradley. 2010. The evidence meet the unique learning styles of adults; base for mental health consultation in early childhood settings: A research Familiarity with local, state, and national regulations, f. synthesis addressing children’s behavioral outcomes. Early Ed Devel 21:795-824. standards, and best practices related to early education Perry, D. F., R. Kaufmann, J. Knitzer. 2007. Early childhood social and 4. and care; emotional health: Building bridges between services and systems. Community resources and services to identify and g. Baltimore, MD: Paul Brookes Publishing. 5. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing serve families and children at risk, including those the risk for preschool expulsion: Mental health consultation for young related to child abuse and neglect and parent education; children with challenging behaviors. J Child Fam Studies 17:44-54. Consultation skills as well as approaches to working h. Committee on Integrating the Science of Early Childhood Development, 6. Board on Children, Youth, and Families. 2000. From neurons to neighbor- as a team with early childhood consultants from other hoods. Ed. J. P. Shonkoff, D. A. Phillips. Washington, DC: National disciplines, especially child care health consultants, to Academy Press. effectively support program directors and their staff. 7. Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state prekindergarten programs. Foundation for Child Development (FCD). Policy The role of the early childhood education consultant http://www.challengingbehavior.org/ Brief Series no. 3. New York: FCD. explore/policy_docs/prek _expulsion.pdf. should include: 8. Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and a. Review of the curriculum and written policies, plans suspension: Rates and predictors in one state. Infants Young Children 19:228-45. and procedures of the program; 9. Gilliam, W. S. 2007. Early Childhood Consultation Partnership: Results of a b. Observations of the program and meetings with the http://www. random-controlled evaluation. New Haven, CT: Yale Universty. director, caregivers/teachers, and parents/guardians; chdi.org/admin/uploads/5468903394946c41768730.pdf. 10. American Academy of Pediatrics, Committee on School Health. 2003. Policy Review of the professional needs of staff and program c. statement: Out-of-school suspension and expulsion. Pediatrics 112:1206-9. and provision of recommendations of current resources; 11. Duran, F., K. Hepburn, M. Irvine, R. Kaufmann, B. Anthony, N. Horen, D. d. Reviewing and assisting directors in implementing and Perry. 2009. What works?: A study of effective early childhood mental health consultation programs. Washington, DC: Georgetown University Center for monitoring evidence based approaches to classroom Child and Human Development. http://gucchdtacenter.georgetown.edu/ management; publications/ECMHCStudy _Report.pdf. Maintaining confidences and following all Family e. Educational Rights and Privacy Act (FERPA) 1.6.0.4 regulations regarding disclosures; Early Childhood Education Consultants f. Keeping records of all meetings, consultations, recom - - A facility should engage an early childhood education consul mendations and action plans and offering/providing tant who will visit the program at minimum semi-annually summary reports to all parties involved; - and more often as needed. The consultant must have a mini g. Seeking and supporting a multidisciplinary approach mum of a Baccalaureate degree and preferably a Master’s to services for the program, children and families; degree from an accredited institution in early childhood h. Following the National Association for the Education education, administration and supervision, and a minimum of Young Children (NAEYC) Code of Ethics; of three years in teaching and administration of an early i. Availability by telecommunication to advise regarding care/education program. The facility should develop a practices and problems;

69 42 Caring for Our Children: National Health and Safety Performance Standards j. Availability for on-site visit to consult to the program; A physician with pediatric experience, especially those b. with developmental-behavioral training; k. Familiarity with tools to evaluate program quality, such c. A registered dietitian; as the Early Childhood Environment Rating Scale– d. Revised (ECERS–R), Infant/Toddler Environment A psychologist; A psychiatrist; Rating Scale–Revised (ITERS–R), Family Child Care e. Environment Rating Scale–Revised (FCCERS–R), f. A physical therapist; g. School-Age Care Environment Rating Scale (SACERS), An adaptive equipment technician; An occupational therapist; h. Classroom Assessment Scoring System (CLASS), as well i. as tools used to support various curricular approaches. A speech pathologist; An audiologist for hearing screenings conducted j. RATIONALE on-site at child care; The early childhood education consultant provides an objec - k. A vision screener; tive assessment of a program and essential knowledge about l. A respiratory therapist; implementation of child development principles through m. A social worker; curriculum which supports the social and emotional health n. A parent/guardian of a child with special health care and learning of infants, toddlers and preschool age children needs; (1-5). Furthermore, utilization of an early childhood edu- o. Part C representative/service coordinator; cation consultant can reduce the need for mental health p. A mental health consultant; consultation when challenging behaviors are the result of q. Special learning consultant/teacher (e.g., teacher developmentally inappropriate curriculum (6,7). Together specializing in work with visually impaired child with the child care health consultant, the early childhood or sign language interpreters); education consultant offers core knowledge for addressing r. A teacher with special education expertise; children’s healthy development. The caregiver/teacher; s. TYPE OF FACILITY t. Individuals identified by the parent/guardian; u. Certified child passenger safety technician with training Center, Large Family Child Care Home in safe transportation of children with special needs. RELATED STANDARDS RATIONALE Child Care Health Consultants 1. 6 . 0.1 The range of professionals needed may vary with the Early Childhood Mental Health Consultants 1.6.0. 3 facility, but the listed professionals should be available References as consultants when needed. These professionals need not 1. Dunn, L., K. Susan. 1997. What have we learned about developmentally be on staff at the facility, but may simply be available when appropriate practice? Young Children 52:4-13. 2. Wesley, P. W., V. Buysse. 2006. Ethics and evidence in consultation. Topics needed through a variety of arrangements, including con- Early Childhood Special Ed 26:131-41. - tracts, agreements, and affiliations. The parent’s participa 3. Wesley, P. W., S. A. Palsha. 1998. Improving quality in early childhood tion and written consent in the native language of the environments through on-site consultation. Topics Early Childhood Special Ed 18:243-53. parent, including Braille/sign language, is required to 4. Wesley, P. W., V. Buysee. 2005. Consultation in early childhood settings. include outside consultants (1). Baltimore, MD: Brookes Publishing. 5. Bredekamp, S., C. Copple, eds. 2000. Developmentally appropriate practice TYPE OF FACILITY in early childhood programs serving children from birth through age 8. Center, Large Family Child Care Home Rev ed. National Association for the Education of Young Children http://www. (NAEYC). Publication no. 234. Washington, DC: NAEYC. Reference naeyc.org/files/naeyc/file/positions/position statement Web.pdf. 1. Cohen, A. J. 2002. Liability exposure and child care health consultation. The Connecticut Early Education Consultation Network. CEECN: 6. http://www.ucsfchildcarehealth.org/pdfs/forms/CCHCLiability.pdf. Guidance, leadership, support. http://ctconsultationnetwork.org. 7. Connecticut Department of Public Health. Child day care licensing http://www.ct.gov/dph/cwp/view.asp?a=3141&Q=387158&dphNav_ program. G I D =18 2 3/. 1.7 STAFF HEALTH 1.6.0. 5 Specialized Consultation for Facilities Serving Children with Disabilities 1. 7. 0 .1 When children at the facility include those with special Pre-Employment and Ongoing Adult Health health care needs, developmental delay or disabilities, Appraisals, Including Immunization - and mental health or behavior problems, the staff or docu All paid and volunteer staff members should have a health mented consultants should involve any of the following appraisal before their first involvement in child care work. consultants in the child’s care, with prior informed, written The appraisal should identify any accommodations required parental consent and as appropriate to each child’s needs: of the facility for the staff person to function in his or her A registered nurse, nurse practitioner with pediatric a. assigned position. experience, or child care health consultant;

70 43 Chapter 1: Staffing Health appraisals for paid and volunteer staff members to adjust the activities of that person. For example, child should include: care facilities typically require the following activities of caregivers: a. Physical exam; Moving quickly to supervise and assist young children; a. b. Dental exam; b. c. Lifting children, equipment, and supplies; Vision and hearing screening; Sitting on the floor and on child-sized furniture; The results and appropriate follow up of a tuberculosis d. c. (TB) screening, using the Tuberculin Skin Test (TST) Washing hands frequently; d. Responding quickly in case of an emergency; or IGRA (interferon gamma release assay), once upon e. Eating the same food as is served to the children f. entering into the child care field with subsequent TB (unless the staff member has dietary restrictions); screening as determined by history of high risk for g. Hearing and seeing at a distance required for TB thereafter; playground supervision or driving; A review and certification of up-to-date immune status e. Being absent from work for illness no more often than h. per the current Recommended Adult Immunization Schedule found in Appendix H, including annual the typical adult, to provide continuity of caregiving influenza vaccination and up to date Tdap; relationships for children in child care. A review of occupational health concerns based on the f. Healthy Young Children: A Manual for Programs, from the performance of the essential functions of the job. National Association for the Education of Young Children All adults who reside in a family child care home who are (NAEYC), provides a model form for an assessment by a considered to be at high risk for TB, should have completed health professional. See also Model Child Care Health TB screening (1) as specified in Standard 7.3.10.1. Adults Policies, from NAEYC and from the American Academy who are considered at high risk for TB include those who of Pediatrics (AAP). are foreign-born, have a history of homelessness, are HIV- Concern about the cost of health exams (particularly when infected, have contact with a prison population, or have many caregivers/teachers do not receive health benefits and contact with someone who has active TB. earn minimum wage) is a barrier to meeting this standard. Testing for TB of staff members with previously negative When staff members need hepatitis B immunization to meet skin tests should not be repeated on a regular basis unless Occupational Safety and Health Administration (OSHA) required by the local or state health department. A record requirements (4), the cost of this immunization may or may of test results and appropriate follow-up evaluation should not be covered under a managed care contract. If not, the be on file in the facility. cost of health supervision (such as immunizations, dental and health exams) must be covered as part of the employee’s RATIONALE - preparation for work in the child care setting by the prospec Caregivers/teachers need to be physically and emotionally tive employee or the employer. Child care workers are among healthy to perform the tasks of providing care to children. those for whom annual influenza vaccination is strongly Performing their work while ill can spread infectious recommended. disease and illness to other staff and the children in their Facilities should consult with ADA experts through the U.S. care (2). Under the Americans with Disabilities Act (ADA), Department of Education funded Disability and Business employers are expected to make reasonable accommoda - Technical Assistance Centers (DBTAC) throughout the coun - tions for persons with disabilities. Under ADA, accommo - try. These centers can be reached by calling 1-800-949-4232 dations are based on an individual case by case situation. (callers are routed to the appropriate region) or by accessing Undue hardship is defined also on a case by case basis. regional center’s contacts directly at http://adata.org/Static/ Accommodation requires knowledge of conditions that . Home.aspx must be accommodated to ensure competent function of staff and the well-being of children in care (3). TYPE OF FACILITY Since detection of tuberculosis using screening of healthy Center, Large Family Child Care Home individuals has a low yield compared with screening of con- RELATED STANDARDS - tacts of known cases of tuberculosis, public health authori 1.7.0.3 Health Limitations of Staff ties have determined that routine repeated screening of 1.7.0.4 Occupational Hazards healthy individuals with previously negative skin tests is not 7. 2 . 0 .1 Immunization Documentation a reasonable use of resources. Since local circumstances and risks of exposure may vary, this recommendation should be 7.2.0.2 Unimmunized Children subject 7. 2 . 0 . 3 Immunization of Caregivers/Teachers to modification by local or state health authorities. 7. 3.10.1 Measures for Detection, Control, and COMMENTS Reporting of Tuberculosis Child care facilities should provide the job description or 7. 3 .10 . 2 Attendance of Children with Latent Tubercu- list of activities that the staff person is expected to perform. losis Infection or Active Tuberculosis Disease Unless the job description defines the duties of the role Child Care Staff Health Assessment Appendix E: specifically, under federal law the facility may be required

71 44 Caring for Our Children: National Health and Safety Performance Standards b. After serious or prolonged illness; References 1. Baldwin, D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female When their condition or health could affect promotion c. child care providers: Implications for quality of care. J Comm Health Nurs or reassignment to another role; 2 4 :1-7. Before return from a job-related injury; d. Keyes, C. R. 2008. Adults with disabilities in early childhood settings. 2. Child Care Info Exchange 179:82-85. If there are workers’ compensation issues or if the e. 3. Occupational Safety and Health Administration. 2008. Bloodborne facility is at risk of liability related to the employee’s pathogens. Title 29, pt. 1910.1030. http://www.osha.gov/pls/oshaweb/owadisp. or volunteer’s health problem. show_document?p_table=standards&p _id=10051. 4. Centers for Disease Control and Prevention. 2015. Recommended adult If a staff member is found to be unable to perform the acti- http://www.cdc.gov/ immunization schedule – United States, 2015. vaccines/schedules/easy-to-read/adult.html. vities required for the job because of health limitations, the staff person’s duties should be limited or modified until the health condition resolves or employment is terminated 1. 7. 0 . 2 because the facility can prove that it would be an undue hard- Daily Staff Health Check ship to accommodate the staff member with the disability. On a daily basis, the administrator of the facility or caregiver/ RATIONALE teacher should observe staff members, substitutes, and volunteers for obvious signs of ill health. When ill, staff Under the Americans with Disabilities Act (ADA), employ - members, substitutes and volunteers may be directed to go ers are expected to make reasonable accommodations for home. Staff members, substitutes, and volunteers should be persons with disabilities. Under ADA, accommodations are responsible for reporting immediately to their supervisor based on an individual case by case situation (1). Undue any injuries or illnesses they experience at the facility or hardship is defined also on a case by case basis (1). elsewhere, especially those that might affect their health or COMMENTS the health and safety of the children. It is the responsibility Facilities should consult with ADA experts through the U.S. of the administration, not the staff member who is ill or Department of Education funded Disability and Business injured, to arrange for a substitute caregiver/teacher. Technical Assistance Centers throughout the country. RATIONALE These centers can be reached by calling 1-800-949-4232 Sometimes adults report to work when feeling ill or become and callers are routed to the appropriate region or access- ill during the day but believe it is their responsibility to stay. . ing contacts directly at http://adata.org/Static/Home.aspx The administrator’s or caregiver’s/teacher’s observation of TYPE OF FACILITY illness followed by sending the staff member home may pre- Center, Large Family Child Care Home vent the spread of illness. Arranging for a substitute caregiver/ RELATED STANDARDS teacher ensures that the children receive competent care (1,2). Informing Public Health Authorities of Hepatitis B 7. 6 .1. 4 COMMENTS Virus (HBV) Cases Administrators and caregivers/teachers need guidelines to 7. 6 . 3 . 4 Ability of Caregivers/Teachers with HIV Infection - ensure proper application of this standard. For a demon to Care for Children stration of how to implement this standard, see the video series, Caring for Our Children, available from National Reference 1. ADA National Network. The Americans with Disabilities Act (ADA) from a Association for the Education of Young Children (NAEYC) civil rights perspective. http://adaanniversary.org/2010/ap03_ada_ and the American Academy of Pediatrics (AAP) (1). civilrights/03_ada_civilrights_09_natl.pdf. TYPE OF FACILITY Center, Large Family Child Care Home 1. 7. 0 . 4 Occupational Hazards References 1. Baldwin D., S. Gaines, J. L. Wold, A. Williams. 2007. The health of female Written personnel policies of centers and large family child child care providers: Implications for quality of care. J Comm Health Nurs care homes should address the major occupational health 2 4 :1-7. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A 2. hazards for workers in child care settings. Special health manual for health professionals. 4th ed. Elk Grove Village, IL: American concerns of pregnant caregivers/teachers should be carefully Academy of Pediatrics. - evaluated, and up-to-date information regarding occupa tional hazards for pregnant caregivers/teachers should 1. 7. 0 . 3 be made available to them and other workers. The occupa - Health Limitations of Staff tional hazards including those regarding pregnant workers Staff and volunteers must have a primary care provider’s listed in Appendix B: Major Occupational Health Hazards, release to return to work in the following situations: should be referenced and used in evaluations by caregivers/ teachers and supervisors. When they have experienced conditions that may affect a. their ability to do their job or require an accommodation to prevent illness or injury in child care work related to their conditions (such as pregnancy, specific injuries, or infectious diseases);

72 45 Chapter 1: Staffing l. Stated provisions for back-up staff, for example, to allow RATIONALE caregivers/teachers to take necessary time off when ill Early care and education employees need to learn about without compromising the function of the center or and practice ways to minimize risk of illness and injury incurring personal negative consequences from the and promote wellness for themselves (1). As a workforce employer (this back-up should also include a stated - composed primarily of women of childbearing age, preg plan to be implemented in the event a staff member nancy is common among caregivers/teachers in child care needs to have a short, but relatively immediate break settings. All female staff members of childbearing age away from the children); should be encouraged to discuss the potential exposure Adult size furniture in the classroom for the staff; m. to risks that could cause harm to their unborn child with n. Access to experts in child development and behavior to their primary health care provider (1). help problem solve child specific issues. TYPE OF FACILITY RATIONALE Center, Large Family Child Care Home One of the best indicators of quality child care is consistent RELATED STANDARD staff with low turnover rates (5,6). According to the Bureau 1.7.0.1 Pre-Employment and Ongoing Adult Health of Labor Statistics’ Website, “in 2007, hourly earnings of Appraisals, Including Immunization nonsupervisory workers in the child day care services industry averaged $10.53” (1). About 42% of all child care References 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in workers have a high school degree or less, reflecting the th Edition. child care and schools: A quick reference guide, pp. 43-48. 4 minimal training requirements for most jobs. Many child Elk Grove Village, IL: American Academy of Pediatrics. care workers leave the industry due to stressful working conditions and dissatisfaction with benefits and pay (1). 1. 7. 0 . 5 Stress reduction measures (particularly adequate wages and Stress reasonable health care benefits) contribute to decreased staff Caregivers/teachers should be able to: turnover and thereby promote quality care (2). The health, a. Identify risks associated with stress; welfare, and safety of adult workers in child care determine Identify stressors specific to child caregiving; b. their ability to provide care for the children. c. Identify specific ways to manage stress in the child care Serious physical abuse sometimes occurs when the caregiver/ environment. teacher is under high stress. Too much stress can not only The following measures to lessen stress for the staff should affect the caregiver’s/teacher’s health, but also the quality of be implemented to the maximum extent possible: the care that the adult is able to give. A caregiver/teacher who is feeling too much stress may not be able to offer the Wages and benefits (including health care insurance) a. praise, nurturing, and direction that children need for good - that fairly compensate the skills, knowledge, and perfor development (3). Regular breaks with substitutes when the mance required of caregivers/teachers, at the levels of caregiver/teacher cannot continue to provide safe care can wages and benefits paid for other jobs that require help ensure quality child care. comparable skills, knowledge, and performance; Job security; b. Sound-absorbing materials in the work area, break times, Training to improve skills and hazard recognition; c. and a separate lounge allow for respite from noise and from Stress management and reduction training; d. non-auditory stress. Unwanted sound, or noise, can be Written plan/policy in place for the situation in which a e. damaging to hearing as well as to psychosocial well-being. caregiver/teacher recognizes that s/he or a colleague is The stress effects of noise will aggravate other stress factors stressed and needs help immediately (the plan should present in the facility. Lack of adequate sound reduction allow for caregivers/teachers who feel they may lose measures in the facility can force the caregiver/teacher to control to have a short, but relatively immediate break speak at levels above those normally used for conversation, away from the children at times of high stress); and thus may increase the risk of throat irritation. When Regular work breaks and paid time-off; f. caregivers/teachers raise their voices to be heard, the g. Appropriate child:staff ratios; children tend to raise theirs, escalating the problem. Liability insurance for caregivers/teachers; h. COMMENTS Staff lounge separate from child care area with adult i. Documentation of implementation of stress reduction mea- size furniture; sures should be on file in the facility. Rest breaks of twenty The use of sound-absorbing materials in the workspace; j. minutes or less are customary in industry and are customar - Regular performance reviews which, in addition to k. ily paid for as working time. Meal periods (typically thirty addressing any areas requiring improvement, provide minutes or more) generally need not be compensated as constructive feedback, individualized encouragement work time as long as the employee is completely relieved and appreciation for aspects of the job well performed; from duty for the entire meal period (4). For resources on respite or crisis care, contact the ARCH National Respite Network at http://archrespite.org .

73 46 Caring for Our Children: National Health and Safety Performance Standards Caregivers/teachers who use tobacco can experience RATIONALE stress related to nicotine withdrawals. For help dealing with The quality and continuity of the child care workforce is the stress from tobacco addiction, see the Tobacco Research main determining factor of the quality of care. Nurturing the and Intervention Program’s Forever Free booklet on smok - - nurturers is essential to prevent burnout and promote reten ing, stress, and mood at http://www.smokefree.gov/pubs/ tion. Fair labor practices should apply to child care as well as . Or, for help quitting smoking, visit the FFree6.pdf other work settings. Child care workers should be considered Smoke Free Website at http://www.smokefree.gov . as worthy of benefits as workers in other careers. TYPE OF FACILITY Medical coverage should include the cost of the health Center, Large Family Child Care Home - appraisals and immunizations required of child care work ers, and care for the increased incidence of communicable RELATED STANDARDS disease and stress-related conditions in this work setting. 1.1.1.1 Ratios for Small Family Child Care Homes The potential for acquiring injuries and infections when 1.1.1. 2 Ratios for Large Family Child Care Homes and caring for young children is a health and safety hazard for Centers child care workers. Information abounds about the risk of Ratios for Facilities Serving Children with Special 1.1.1. 3 infectious disease for children in child care settings. Chil- Health Care Needs and Disabilities dren are reservoirs for many infectious agents. Staff mem- Ratios and Supervision During Transportation 1.1.1.4 bers come into close and frequent contact with children and 1.1.1.5 Ratios and Supervision for Swimming, Wading, their excretions and secretions and are vulnerable to these and Water Play illnesses. In addition, many child care workers are women who are planning a pregnancy or who are pregnant, and References they may be vulnerable to potentially serious effects of 1. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Career guide to industries: Child day care services, 2010-11 Edition. http://www.bls.gov/oco/ infection on the outcome of pregnancy (2). cg/cgs032.htm. 2. U.S. Department of Labor, Bureau of Labor Statistics. 2010. Occupational - Sick leave is important to minimize the spread of communi employment statistics: occupational employment and wages, May 2009. cable diseases and maintain the health of staff members. http://www.bls.gov/oes/current/oes399011.htm. Sick leave promotes recovery from illness and thereby 3. Healthy Childcare Consultants (HCCI). Stress management for child caregivers. Pelham, AL: HCCI. decreases the further spread or recurrence of illness. 4. U.S. Department of Labor, Wage and Hour Division. 2009. Fact sheet #46: Workplace benefits contribute to higher morale and less Daycare centers and preschools under the Fair Labor Standards Act (FLSA). http://www.dol.gov/whd/regs/compliance/whdfs46.pdf. Rev. ed . staff turnover, and thus promote quality child care. Lack 5. Fiene, R. 2002. 13 indicators of quality child care: Research update. of benefits is a major reason reported for high turnover of Washington, DC: U.S. Department of Health and Human Services, Office of child care staff (1). http://aspe.hhs.gov/ the Assistant Secretary for Planning and Evaluation. basic-report/13-indicators-qualitychild-care. COMMENTS National Institute of Child Health and Human Development (NICHD). 6. 2006. The NICHD study of early child care and youth development: Staff benefits may be appropriately addressed in center Findings for children up to age 4 1/2 years. Rockville, MD: NICHD. personnel policies and in state and federal labor standards. Not all the material that has to be addressed in these poli- cies is appropriate for state child care licensing require- 1. 8 ments. Having facilities acknowledge which benefits they HUMAN RESOURCE MANAGEMENT do provide will help enhance the general awareness of staff benefits among child care workers and other concerned 1. 8 .1 parties. Currently, this standard is difficult for many facilities BENEFITS to achieve, but new federal programs and shared access to small business benefit packages will help. Many options are 1. 8 .1.1 available for providing leave benefits and education reim - Basic Benefits bursements, ranging from partial to full employer contribu - The following basic benefits should be offered to staff: tion, based on time employed with the facility. Caregivers/ a. Affordable health insurance; teachers should be encouraged to have health insurance. b. Paid time-off (vacation, sick time, personal leave, Health benefits can include full coverage, partial coverage holidays, family, parental and medical leave, etc.); (at least 75% employer paid), or merely access to group rates. c. Social Security or other retirement plan; Some local or state child care associations offer reduced d. Workers’ compensation; group rates for health insurance for child care facilities e. Educational benefits. and individual caregivers/teachers. Centers and large family child care homes should have TYPE OF FACILITY written policies that detail these benefits of employees Center, Large Family Child Care Home at the facility.

74 47 Chapter 1: Staffing requirements, or by accrediting bodies (1). In some states, a RELATED STANDARDS central Child Development Personnel Registry may track 1. 4 . 6 .1 Training Time and Professional Development and certify the qualifications of staff. Leave TYPE OF FACILITY Payment for Continuing Education 1.4.6. 2 Center, Large Family Child Care Home 9. 3. 0.1 Written Human Resource Management Policies for RELATED STANDARDS Centers and Large Family Child Care Homes Continuing Education for Directors and 1.4.4.1 References Caregivers/Teachers in Centers and Large 1. Whitebook, M., C. Howes, D. Phillips. 1998. Worthy work, unlivable wages: Family Child Care Homes The national child care staffing study, 1988-1997. Washington, DC: Center for the Child Care Workforce. 1.4.4.2 Continuing Education for Small Family Child Care National Association for the Education of Young Children (NAEYC). 2008. 2. Home Caregivers/Teachers Leadership and management: A guide to the NAEYC early childhood pro- gram standards and related accreditation criteria. Washington, DC: NAEYC. 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 1. 8. 2 Handling Body Fluids E VALUATI O N Education of Center Staff 1.4.5.4 Training Time and Professional Development Leave 1. 4 . 6 .1 1.8.2.1 Payment for Continuing Education 1.4.6. 2 Staff Familiarity with Facility Policies, Annual Staff Competency Evaluation 1.8.2.2 Plans and Procedures References All caregivers/teachers should be familiar with the provisions 1. National Association for the Education of Young Children (NAEYC). 2008. of the facility’s policies, plans, and procedures, as described Leadership and management: A guide to the NAEYC early childhood in Chapter 9: Administration. The compliance with these program standards and related accreditation criteria. Washington, DC: NA EYC. policies, plans, and procedures should be used in staff per- 2. Owens, C. 1997. Rights in the workplace: A guide for child care teachers. formance evaluations and documented in the personnel file. Washington, DC: Worker Option Resource Center. RATIONALE Written policies, plans and procedures provide a means of 1.8.2.3 staff orientation and evaluation essential to the operation Staff Improvement Plan of any organization (1). When a staff member of a center or a large family child care TYPE OF FACILITY home does not meet the minimum competency level, that Center, Large Family Child Care Home employee should work with the employer to develop a plan to assist the person in achieving the necessary skills. The Reference - plan should include a timeline for completion and conse 1. Boone, L. E., D. L. Kurtz. 2010. Contemporary business. Hoboken, NJ: John Wiley and Sons. quences if it is not achieved. RATIONALE 1.8.2.2 Children must be protected from incompetent caregiving. Annual Staff Competency Evaluation A system for evaluation and a plan to promote continued For each employee, there should be a written annual development are essential to assist staff to meet performance self- evaluation, a performance review from the personnel requirements (1). - supervisor, and a continuing education/professional devel COMMENTS opment plan based on the needs assessment, described in Whether the caregiver/teacher meets the minimum com- Standard 1.4.4.1 through Standard 1.4.5.4. petency level is related to the director’s assessment of the RATIONALE caregiver’s/teacher’s performance. A system for evaluation of employees is a basic component of TYPE OF FACILITY any personnel policy (1). Staff members who are well trained Center, Large Family Child Care Home are better able to prevent, recognize, and correct health and RELATED STANDARDS safety problems (2). 1. 4 .1.1 Pre-service Training COMMENTS Initial Orientation of All Staff 1. 4 . 2 .1 Formal evaluation is not a substitute for continuing feedback on day-to-day performance. Performance appraisals should 1.4.2.2 Orientation for Care of Children with Special include a customer satisfaction component and/or a peer Health Care Needs review component. Compliance with this standard may be Orientation Topics 1.4. 2. 3 determined by licensing requirements set by the state and First Aid and CPR Training for Staff 1. 4 . 3.1 local regulatory processes, and by state and local funding

75 48 Caring for Our Children: National Health and Safety Performance Standards If the staff follows the National Association for the Educa- Continuing Education for Directors and 1.4.4.1 tion of Young Children (NAEYC) Code of Ethical Conduct, Caregivers/Teachers in Centers and Large peers are expected to observe, support and guide peers. In Family Child Care Homes addition within the role of the child care health consultant Continuing Education for Small Family Child 1.4.4.2 and the education consultant are guidelines for observation Care Home Caregivers/Teachers of staff within the classroom. It should be within the role 1. 4 . 5.1 Training of Staff Who Handle Food of the director and assistant director guidelines for direct 1.4.5. 2 Child Abuse and Neglect Education observation of staff for health, safety, developmentally 1.4.5. 3 Training on Occupational Risk Related to appropriate practice, and curriculum. For more information Handling Body Fluids on the NAEYC Code of Ethical Conduct, go to http://www. Education of Center Staff 1.4.5.4 naeyc.org/files/naeyc/file/positions/PSETH05.pdf. Training Time and Professional Development 1. 4 . 6 .1 TYPE OF FACILITY Leave Center, Large Family Child Care Home 1.4.6. 2 Payment for Continuing Education Reference 9. 4 . 3.1 Maintenance and Content of Staff and Volunteer 1. Nolan, Jr., J. F., L. A. Hoover. 2010. Teacher supervision and evaluation. Hoboken, NJ: John Wiley and Sons. Records Reference 1.8.2.5 1. University of California Berkeley Human Resources. Guide to managing http://hrweb. human resources. Chapter 7: Performance management. Handling Complaints About berkeley.edu/guides/managing-hr/managing -successfully/performance- management/introduction/. Caregivers/Teachers When complaints are made to licensing or referral agencies about caregivers/teachers, the caregivers/teachers should 1.8.2.4 receive formal notice of the complaint and the resulting Observation of Staff action, if any. Caregivers/teachers should maintain records Observation of staff by a designee of the program director of such complaints, post substantiated complaints with cor- should include an assessment of each member’s adherence rection action, make them available to parents/guardians on to the policies and procedures of the facility with respect to request, and post a notice of how to contact the state agency sanitation, hygiene, and management of infectious diseases. responsible for maintaining complaint records. Routine, direct observation of employees is the best way RATIONALE to evaluate hygiene and safety practices. The observation should be followed by positive and constructive feedback to Parents/guardians seeking child care should know if pre- staff. Staff will be informed in their job description and/or vious complaints have been made, particularly if the com- employee handbook that observations will be made. plaint is substantiated. This information should be easily accessible to the parents/guardians. Parents/guardians can RATIONALE then evaluate whether or not the complaint is valid, and - Ongoing observation is an effective tool to evaluate consis whether the complaint has been adequately addressed tency of staff adherence to program policies and procedures and necessary changes have been made. (1). It also serves to identify areas for additional orientation COMMENTS and training. This policy requires program development by licensing COMMENTS agencies. Videotaping of these assessments may be a useful way to TYPE OF FACILITY provide feedback to staff around their adherence to policies and procedures regarding hygiene and safety practices. If Center, Large Family Child Care Home videotaping includes interactions with children, parent/ guardian permission must be obtained before taping occurs. Desirable interactions can be encouraged and discussing methods of improvement can be facilitated through video - taping. Videotaped interactions can also prove useful to caregivers/teachers when informing, illustrating and dis- cussing an issue with the parents/guardians. It gives the parents/guardians a chance to interpret the observations and begin a healthy, respectful dialogue with caregivers/ teachers in developing a consistent approach to supporting their child’s healthy development. Sharing videotaping must have participant approval to avoid privacy issues.

76 CHAPTER 2 Program Activities for Healthy Development

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78 51 Chapter 2: Program Activities for Healthy Development - promotion and disease prevention topics (e.g., handwash 2 .1 ing, oral health, nutrition, physical activity, healthy sleep PROGRAM OF ha bit s) (1-3). DEVELOPMENTAL ACTIVITIES Health and safety behaviors should be modeled by staff to foster healthy habits for children during their time in 2 .1.1 child care. GENERAL PROGRAM ACTIVITIES Staff should ensure that children and parents/guardians understand the need for a safe indoor and outdoor learn - 2 .1.1.1 ing/play environment and feel comfortable when playing Written Daily Activity Program and indoors and outdoors. Statement of Principles Continuity and consistency by a caring staff are vital so that Facilities should have a written comprehensive and coor- children and parents/guardians know what to expect. dinated planned program of daily activities appropriate for groups of children at each stage of early childhood. This RATIONALE plan should be based on a statement of principles for the Children attending early care and education programs facility and each child’s individual development.The objec - with well-developed curricula are more likely to achieve tive of the program of daily activities should be to foster appropriate levels of development (4). incremental developmental progress in a healthy and safe Early childhood specialists agree on the environment, and the program should be flexible to capture the interests and individual abilities of the children. - Inseparability and interdependence of cognitive, physi a. cal, emotional, communication, and social development. Infants and toddlers learn through healthy and ongoing Social-emotional capacities do not develop or function relationships with primary caregivers/teachers, and a separately. relationship-based plan should be shared with parents/ b. Influence of the child’s health and safety on cognitive, guardians that includes opportunities for parents/ physical, emotional, communication, and social guardians to be an integral partner and member of development. this relationship system. c. - Central importance of continuity and consistent rela Centers and all family child care homes should develop tionships with affectionate care that is the formation of a written statement of principles that set out the basic strong, nurturing relationships between caregivers/ elements from which the daily indoor/outdoor program teachers and children. is to be built. Relevance of the development phase or stage of the d. These principles should address the following elements: child. Importance of action (including play) as a mode of e. a. Overall child health and safety learning and to express self (5). b. Physical development, which facilitates small and large motor skills Those who provide early care and education must be able c. Family partnership, which acknowledges the essential to articulate the components of the curriculum they are role of the family, and reflects their culture and implementing and the related values/principles on which language the curriculum is based. In centers and large family child d. Social development, which leads to cooperative play care homes, because more than 2 caregivers/teachers are with other children and the ability to make relationships involved in operating the facility, a written statement of - with other children, including those of diverse back principles helps achieve consensus about the basic elements grounds and ability levels and adults from which all staff will plan the daily program (4). Emotional development, which facilitates self-awareness e. A written description of the planned program of daily and self-confidence activities allows staff and parents/guardians to have a f. Cognitive development, which includes an understand - common understanding and gives them the ability to ing of the world and environment in which children live compare the program’s actual performance to the stated and leads to understanding science, math, and literacy intent. Early care and education is a “delivery of service” - concepts, as well as increasing the use and understand involving a contractual relationship between the caregiver/ ing of language to express feelings and ideas teacher and the consumer. A written plan helps to define All the principles should be developed with play being the the service and contributes to specific and responsible oper - foundation of the planned curriculum. Material such as ations that are conducive to sound child development and blocks, clay, paints, books, puzzles, and/or other manipula - safety practices and to positive consumer relations (4). tives should be available indoors and outdoors to children Professional development is often required to enable staff to further the planned curriculum. to develop proficiency in the development and implemen- The program plan should provide for the incorporation of tation of a curriculum that they use to carry out daily specific health education topics on a daily basis throughout activities appropriately (1). the year. Topics of health education should include health

79 52 Caring for Our Children: National Health and Safety Performance Standards Planning ensures that some thought goes into indoor and 2 . 4 .1. 2 Staff Modeling of Healthy and Safe Behavior and outdoor programming for children. The plan is a tool for Health and Safety Education Activities monitoring and accountability. Also, a written plan is a 2 . 4 .1. 3 Gender and Body Awareness tool for staff and parent/guardian orientation. 2.4.2.1 Health and Safety Education Topics for Staff COMMENTS 2 . 4 . 3.1 Opportunities for Communication and Modeling The National Association for the Education of Young Chil- of Health and Safety Education for Parents/ dren (NAEYC) accreditation criteria and procedures, the Guardians National Association for Family Child Care accreditation 2.4.3.2 Parent/Guardian Education Plan standards, and the National Child Care Association stan - References dards can serve as resources for planning program activities. 1. Rosenthal MS, Crowley AA, Curry L. Family child care providers’ self- perceived role in obesity prevention: working with children, parents, and Parents/guardians and staff can experience mutual learn- external influences. J Nutr Educ Behav. 2013;45(6):595–601 ing in an open, supportive early care and education setting. Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start 2. Suggestions for topics and methods of presentation are families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24 widely available. For example, the publication catalogs 3. Policy on oral health in child care centers. Pediatr Dent. 2016;38(6):34–36 of the NAEYC and the American Academy of Pediatrics Modigliani K. Quality Standards for NAFCC Accreditation. 4th ed. The 4. contain many materials for child, parent/guardian, and National Foundation for Family Child Care Foundation, Family Child Care Project - Wheelock College. Salt Lake City, UT: The National staff education on child development and physical and Association for Family Child Care Foundation; 2013 mental health development, covering topics such as the 5. Pinkham AM, Kaefer T, Neuman SB, eds. Knowledge Development in importance of attachment and temperament. A certified Early Childhood: Sources of Learning and Classroom Implications. New York, NY: The Guilford Press; 2012 health education specialist, a child care health consultant, or an early childhood mental health consultant can also NOTES be a source of assistance. Content in the STANDARD was modified on 5/30/2018 TYPE OF FACILITY Center, Large Family Child Care Home, Small Family 2 .1.1. 2 Child Care Home Health, Nutrition, Physical Activity, RELATED STANDARDS and Safety Awareness Early care and education programs should create and Health, Nutrition, Physical Activity, and Safety 2 .1.1. 2 implement written program plans addressing the physical, Awareness oral, mental, nutritional, and social and emotional health, Coordinated Child Care Health Program Model 2 .1.1. 3 - physical activity, and safety aspects of each formally struc Diversity in Enrollment and Curriculum 2 .1.1. 8 tured activity documented in the written curriculum. These 2 .1. 2 .1 Personal Caregiver/Teacher Relationships for plans should include daily opportunities to learn health Infants and Toddlers habits that prevent infection and significant injuries and 2.1.2.2 Interactions with Infants and Toddlers health habits that support healthful eating, nutrition edu- 2.1.2.3 Space and Activity to Support Learning of Infants cation, physical activity, and sleep. Awareness of healthy a n d To d d l e r s and safe behaviors, including good nutrition, physical Separation of Infants and Toddlers from Older 2.1.2.4 activity, and sleep habits, should be an integral part of Children the overall program. 2.1.2.5 Toilet Learning/Training Personal Caregiver/Teacher Relationships for 2 .1. 3.1 RATIONALE Three- to Five-Year-Olds - Young children learn better through experiencing an activ 2 .1. 3. 2 Opportunities for Learning for Three- to ity and observing behavior than through didactic methods Five-Year-Olds (1). There may be a reciprocal relationship between learning 2.1.3.3 Selection of Equipment for Three- to - and play so that play experiences are closely related to learn Five-Year-Olds ing (2). Children can accept and follow rules, routines, and 2 .1. 3. 4 Expressive Activities for Three- to Five-Year-Olds guidelines about health and safety when their personal 2 .1. 3. 5 Fostering Cooperation of Three- to Five-Year-Olds experience helps them to understand why these rules were Fostering Language Development of Three- to 2 .1. 3. 6 created. National guidelines for children birth to age 5 years Five-Year-Olds encourage their engagement in daily physical activity that 2 .1. 3.7 Body Mastery for Three- to Five-Year-Olds promotes movement, motor skills, and the foundations of 2 .1. 4 .1 Supervised School-Age Activities health-related fitness (3). Physical activity is important to Space for School-Age Activity 2 .1. 4 . 2 overall health and to overweight and obesity prevention (4). 2 .1. 4 . 3 Developing Relationships for School-Age Children Healthy sleep habits (e.g., a bedtime routine, an adequate amount of sleep) (5,6) helps children get the amount of Planning Activities for School-Age Children 2.1.4.4 uninterrupted sleep their brains and bodies need, which Community Outreach for School-Age Children 2 .1. 4 . 5 is associated with lower rates of overweight and obesity Communication Between Child Care and School 2 .1. 4 . 6 later in life (7-11). Health and Safety Education Topics for Children 2 . 4 .1.1

80 53 Chapter 2: Program Activities for Healthy Development care health consultation, nutrition services, mental health TYPE OF FACILITY services, healthy and safe indoor and outdoor learning Center, Large Family Child Care Home, Small Family environment, health and safety promotion for the staff, Child Care Home and family and community involvement. The guidelines RELATED STANDARDS consist of the following eight interactive components: 2 .1.1. 3 Coordinated Child Care Health Program 1. Health Education: A planned, sequential, curriculum Model that addresses the physical, mental, emotional, and social 3.1. 3.1 Active Opportunities for Physical Activity - dimensions of health. The curriculum is designed to moti vate and assist children in maintaining and improving Scheduled Rest Periods and Sleep 3.1.4.4 their health, preventing disease and injury, and reducing Arrangements health-related risk behaviors (1,2). 4.5.0.4 Socialization During Meals 2. A planned, sequential Physical Activity and Education: 4.7.0.1 Nutrition Learning Experiences for Children curriculum that provides learning experiences in a variety 4.7.0.2 Nutrition Education for Parents/Guardians of activity areas such as basic movement skills, physical fit- ness, rhythms and dance, games, sports, tumbling, outdoor Supply of Food and Water for Disasters 4.9.0.8 learning and gymnastics. Quality physical activity and edu- Appendix S: Physical Activity: How Much Is Needed? cation should promote, through a variety of planned phy- References sical activities indoors and outdoors, each child’s optimum 1. Stirrup J, Evans J, Davies B. Learning one’s place and position through physical, mental, emotional, and social development, and play: social class and educational opportunity in early years education. Int should promote activities and sports that all children J Early Years Educ. 2017;1–18 2. Weisberg D, Hirsh-Pasek K, Golinkoff R, Kittredge A, Klahr D. Guided enjoy and can pursue throughout their lives (1,2,6). play: principles and practices. Curr Dir Psychol Sci. 2016;25(3):177–182 3. Health Services and Child Care Health Consultants: 3. Roth K, Kriemler S, Lehmacher W, Ruf KC, Graf C, Hebestreit H. Effects of a physical activity intervention in preschool children. Med Sci Sports Services provided for child care settings to assess, protect, Exerc. 2015;47(12):2542–2551 and promote health. These services are designed to ensure 4. US Department of Health and Human Services, US Department of access or referral to primary health care services or both, Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. Washington, DC: US Government Printing Office; 2015. https://health. foster appropriate use of primary health care services, pre- gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf. vent and control communicable disease and other health Published December 2015. Accessed November 14, 2017 problems, provide emergency care for illness or injury, 5. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, Hysing M. Later emotional and behavioral problems associated with sleep promote and provide optimum sanitary conditions for problems in toddlers: a longitudinal study. JAMA Pediatr. a safe child care facility and child care environment, 2015;169(6):575–582 and provide educational opportunities for promoting 6. Kelly Y, Kelly J, Sacker A. Time for bed: associations with cognitive performance in 7-year-old children: a longitudinal population-based and maintaining individual, family, and community study. J Epidemiol Community Health. 2013;67(11):926–931 health. Qualified professionals such as child care health 7. Institute of Medicine. Early Childhood Obesity Prevention Policies: consultants may provide these services (1,2,4,5). Goals, Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/ 4. Access to a variety of nutritious Nutrition Services: media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention- Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. and appealing meals that accommodate the health and Published June 2011. Accessed November 14, 2017 nutrition needs of all children. School nutrition programs Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on 8. reflect the U.S. Dietary Guidelines for Americans and other overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149 criteria to achieve nutrition integrity. The school nutrition 9. Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a services offer children a learning laboratory for nutrition systematic review and meta-analysis of prospective cohort studies. J and health education and serve as a resource for linkages Paediatr Child Health. 2017;53(4):378–385 10. Anderson SE, Andridge R, Whitaker RC. Bedtime in preschool-aged with nutrition-related community services (1,2). children and risk for adolescent obesity. J Pediatr. 2016;176:17–22 5. Mental Health Services: Services provided to improve 11. Lumeng JC, Somashekar D, Appugliese D, Kaciroti N, Corwyn RF, Bradley RH. Shorter sleep duration is associated with increased risk for children’s mental, emotional, and social health. These being overweight at ages 9 to 12 years. Pediatrics. 2007;120(5):1020–1029 services include individual and group assessments, inter- NOTES ventions, and referrals. Organizational assessment and consultation skills of mental health professionals con- Content in the STANDARD was modified on 5/30/2018 tribute not only to the health of students but also to the health of the staff and child care environment (1,2). 2 .1.1. 3 6. Healthy Child Care Environment: The physical and Coordinated Child Care Health aesthetic surroundings and the psychosocial climate and Program Model culture of the child care setting. Factors that influence the Caregivers/teachers should follow these guidelines for physical environment include the building and the area implementing coordinated health programs in all early surrounding it, natural spaces for outdoor learning, any care and education settings. These coordinated health biological or chemical agents that are detrimental to health, programs should consist of health and safety education, indoor and outdoor air quality, and physical conditions physical activity and education, health services and child

81 54 Caring for Our Children: National Health and Safety Performance Standards such as temperature, noise, and lighting. Unsafe physical 2 .1.1. 4 environments include those such as where bookcases are Monitoring Children’s Development/ not attached to walls and doors that could pinch children’s Obtaining Consent for Screening fingers. The psychological environment includes the phy- Child care settings provide daily indoor and outdoor sical, emotional, and social conditions that affect the opportunities for promoting and monitoring children’s well-being of children and staff (1,2). development. Caregivers/teachers should monitor the 7. Opportunities for Health Promotion for the Staff: children’s development, share observations with parents/ caregivers/teachers to improve their own health status guardians, and provide resource information as needed for through activities such as health assessments, health screenings, evaluations, and early intervention and treat - education, help in accessing immunizations, health-related ment. Caregivers/teachers should work in collaboration to fitness activities, and time for staff to be outdoors. These monitor a child’s development with parents/guardians and opportunities encourage caregivers/teachers to pursue a in conjunction with the child’s primary care provider and healthy lifestyle that contributes to their improved health health, education, mental health, and early intervention status, improved morale, and a greater personal commit - consultants. Caregivers/teachers should utilize the services ment to the child care’s overall coordinated health program. of health and safety, education, mental health, and early This personal commitment often transfers into greater intervention consultants to strengthen their observation commitment to the health of children and creates positive skills, collaborate with families, and be knowledgeable of role modeling. Health promotion activities have improved community resources. productivity, decreased absenteeism, and reduced health - Programs should have a formalized system of developmen insurance costs (1,2). tal screening with all children that can be used near the 8. An integrated Family and Community Involvement: beginning of a child’s placement in the program, at least child care, parent/guardian, and community approach for yearly thereafter, and as developmental concerns become enhancing the health and safety, and well-being of children. apparent to staff and/or parents/guardians. The use of - Parent/guardian-teacher health advisory councils, coali authentic assessment and curricular-based assessments tions, and broadly based constituencies for child care health should be an ongoing part of the services provided to all can build support for child care health program efforts. children (5-9). The facility’s formalized system should Early care and education settings should actively solicit include a process for determining when a health or parent/guardian involvement and engage community developmental screening or evaluation for a child is resources and services to respond more effectively to necessary. This process should include parental/ the health-related needs of children (1,2). guardian consent and participation. RATIONALE Parents/guardians should be explicitly invited to: Early care and education settings provide a structure a. Discuss reasons for a health or developmental by which families, caregivers/teachers, administrators, assessment; primary care providers, and communities can promote b. Participate in discussions of the results of their child’s optimal health and well-being of children (3,4). The coor- evaluations and the relationship of their child’s needs dinated child care health program model was adapted to the caregivers’/teachers’ ability to serve that child from the Center for Disease Control and Prevention appropriately; (CDC) Division of Adolescent and School Health’s (DASH) c. Give alternative perspectives; Coordinated School Health Program (CSHP) model (2). d. Share their expectations and goals for their child and TYPE OF FACILITY have these expectations and goals integrated with any plan for their child; Center, Large Family Child Care Home e. Explore community resources and supports that might References assist in meeting any identified needs that child care 1. Centers for Disease Control and Prevention. 2008. Healthy youth! Coor- dinates school health programs. http://www.cdc.gov/healthyyouth/CSHP/. centers and family child care homes can provide; Cory, A. C. 2007. The role of the child care health consultant in promoting 2. Give written permission to share health information health literacy for children, families, and educators in early care and education settings. Paper presented at the annual meeting of the American with primary health care professionals (medical home), School Health Association. child care health consultants and other professionals 3. Fiene, R. 2002. 13 indicators of quality child care: Research update. as appropriate; Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ The facility should document parents’/guardians’ presence basic-report/13-indicators-qualitychild-care. 4. U.S. Department of health and Human Services, Office of Child Care. 2010. at these meetings and invitations to attend. Coordinating child care consultants: Combining multiple disciplines and If the parents/guardians do not attend the screening, the improving quality in infant/toddler care settings. http://nitcci.nccic.acf.hhs. gov/resources/consultation _brief.pdf. caregiver/teacher should inform the parents/guardians of 5. Coordinated Health/Care. Maximize your benefits: FAQs about care the results, and offer an opportunity for discussion. Efforts https://www.cchcare.com/router.php?action=about. coordination. should be made to provide notification of meetings in the Friedman, H. S., L. R. Martin, J. S. Tucker, M. H. Criqui, M. L. Kern, C. A. 6. Reynolds. 2008. Stability of physical activity across the lifespan. J Health primary language of the parents/guardians. Formal eval- Psychol 13:1092-1104.

82 55 Chapter 2: Program Activities for Healthy Development uations of a child’s health or development should also Pediatrics [AAP] list of developmental screening tools be shared with the child’s medical home with parent/ at http://www.medicalhomeinfo.org/downloads/pdfs/ guardian consent. DPIPscreeningtoolgrid.pdf). The caregiver/teacher should explain the results to parents/guardians honestly, with Programs are encouraged to utilize validated screening sensitivity, and without using technical jargon (11). tools to monitor children’s development, as well as various Resources for implementing a program that involves a measures that may inform their work facilitating children’s formalized system of developmental screening are available development and providing an enriching indoor and out- door environment, such as authentic-based assessment, at the Centers for Disease Control and Prevention (CDC) work sampling methods, observational assessments, and at http://www.cdc.gov/ncbddd/actearly/ and the AAP at http://www.healthychildcare.org. assessments intended to support curricular implementation (5,9). Programs should have clear policies for using reliable Scheduling meetings at times convenient for parent/guardian and valid methods of developmental screening with all chil - participation is optimal. Those conducting an evaluation, and dren and for making referrals for diagnostic assessment when subsequently discussing the findings with the family, and possible intervention for children who screen positive. should consider parents’/guardians’ input. Parents/guardians All programs should use methods of ongoing developmen - have both the motive and the legal right to be included in tal assessment that inform the curricular approaches used decision-making and to seek other opinions. by the staff. Care must be taken in communicating the A second, independent opinion could be provided by the results. Screening is a way to identify a child at risk of a program’s child care health consultant or the child’s primary developmental delay or disorder. It is not a diagnosis. care provider. If the screening or any observation of the child results TYPE OF FACILITY in any concern about the child’s development, after con- Center, Large Family Child Care Home sultation with the parents/guardians, the child should be referred to his or her primary care provider (medical RELATED STANDARDS home), or to an appropriate specialist or clinic for further 1. 3. 2.5 Additional Qualifications for Caregivers/Teachers evaluation. In some situations, a direct referral to the Serving Children Three to Five Years of Age Early Intervention System in the respective state may Qualifications and Responsibilities for Health 1. 3. 2.7 also be required. Advocates RATIONALE Unscheduled Access to Rest Areas 3.1. 4 . 5 Seventy percent of children with developmental disabilities 9. 4 .1. 3 Written Policy on Confidentiality of Records and mental health problems are not identified until school References entry (10). Daily interaction with children and families 1. Copple, C., S. Bredekamp. 2009. Developmentally appropriate practice in in early care and education settings offers an important early childhood programs serving children at birth through age 8. opportunity for promoting children’s development as well 3rd ed. Washington, DC: National Association for the Education of Young Children. as monitoring developmental milestones and early signs of Dworkin, P. H. 1989. British and American recommendations for 2. delay (1-3). Caregivers/teachers play an essential role in the developmental monitoring: The role of surveillance. Pediatrics 84:1000- early identification and treatment of children with develop - 1010. 3. Brothers, K. l., F. Glascoe, N. Robertshaw. 2008. PEDS: Developmental mental concerns and disabilities (6-8) because of their milestones - An accurate brief tool for surveillance and screening. Clinical knowledge in child development principles and milestones Pediatrics 47:271-79. and relationship with families (4). Coordination of obser- 4. Kostelnik, M. J., A. K. Soderman, A. P. Whiren. 2006. Developmentally appropriate curriculum best practices in early childhood education. Upper vation findings and services with children’s primary care Saddle River, NJ: Prentice Hall. providers in collaboration with families will enhance 5. Squires, J., D. Bricker. 2009. Ages and stages questionnaires. Baltimore: children’s outcomes (6). Brookes Publishing. Centers for Disease Control and Prevention. Learn the signs. Act early. 6. COMMENTS http://www.cdc.gov/ncbddd/actearly/. 7. American Academy of Pediatrics, Council on Children With Disabilities, Parents/guardians need to be included in the process of Section on Developmental Behavioral Pediatrics, Bright Futures Steering considering, identifying and shaping decisions about their Committee and Medical Home Initiatives for Children With Special Needs children, (e.g., adding, deleting, or changing a service). Project Advisory Committee. 2006. Identifying infants and young children with developmental disorders in the medical home: An alogorithm for To provide services effectively, facilities must recognize developmental surveillance and screening. Pediatrics 118:405-20. parents’/guardians’ observations and reports about the 8. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines child and their expectations for the child, as well as the for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. family’s need of child care services. A marked discrepancy 9. Gilliam, W. S., S. Meisels, L. Mayes. 2005. Screening and surveillance in between professional and parent/guardian observations early intervention systems. In A developmental systems approach to early of, or expectations for, a child necessitates further dis- intervention: National and international perspectives, ed. M. J. Guralnick, 73-98. Baltimore, MD: Brookes Publishing. cussion and development of a consensus on a plan of 10. Glascoe, F. P. 2005. Screening for developmental and behavioral problems. action. Consideration should be given to utilizing parent/ Mental Retardation Develop Disabilities 11:173-79. guardian- completed screening tools, such as the Ages and O’Connor, S., et al. 1996. ASQ: Assessing school age child care quality. 11. Wellesly, MA: Center for Research on Women. Stages Questionnaire (ASQ) (for a list of validated develop mental screening tools, see the American Academy of

83 56 Caring for Our Children: National Health and Safety Performance Standards - Where a family is experiencing separation due to a mili f. 2 .1.1. 5 tary deployment, collaborate with the parent/guardian Helping Families Cope with Separation at home to address changes in children’s behavior that The staff of the facility should engage strategies to help a may be related to the deployment, providing parents/ child and parents/guardians cope with the experience of guardians with information about activities in care and separation and reunion, such as death of family members, - at home may help promote their child’s positive adjust divorce, or placement in foster care. ment throughout the deployment cycle (connect parents/ For the child, this should be accomplished by: guardians with services/resources in the community Encouraging parents/guardians to spend time in the a. that can help to support them); facility with the child and supporting the separation Requesting assistance from early childhood mental health g. transition; consultants, mental health professionals, developmental- Providing a comfortable setting both indoors and b. behavioral pediatricians, parent/guardian counselors, outdoors for parents/guardians to be with their children etc. when a child’s adjustment continues to be problem - to transition or to have conversation with staff; atic over time. Having established routines for drop-off and pick-up c. RATIONALE times to assist with transition; Enabling the child to bring to child care tangible d. In childhood, some separation experiences facilitate reminders of home/family (such as a favorite toy or a psychological growth by mobilizing new approaches for picture of self and parent/guardian); learning and adaptation. Other separations are painful e. Encouraging parents/guardians to reassure the child of and traumatic. The way in which influential adults provide their return and to calmly say “goodbye”; support and understanding, or fail to do so, will shape f. Helping the child play out themes of separation and the child’s experience (1). reunion; Many parents/guardians who prefer to care for their young Frequently exchanging information between the child’s g. children only at home may have no other option than to parents/guardians and caregivers/teachers, including place their children in out-of-home child care before three activities and routine care information particularly months of age. Some parents/guardians prefer combining during greeting and departing; out-of-home child care with parental/guardian care to pro- Reassuring the child about the parent’s/guardian’s return; h. vide good experiences for their children and support for i. Ensuring the caregivers/teachers are consistent both other family members to function most effectively. Whether within the parts of a day and across days; - parents/guardians view out-of-home child care as a neces j. Requesting assistance from early childhood mental sary accommodation to undesired circumstances or a bene - health consultants, mental health professionals, fit for their family, parents/guardians and their children developmental-behavioral pediatricians, parent/ need help from the caregivers/teachers to accommodate guardian counselors, etc. when a child’s adjustment the transitions between home and out-of-home settings (2). continues to be problematic over time; Many parents/guardians experience distress at separation. When a family is experiencing separation due to a mili k. - For most parents/guardians, the younger their child and tary deployment, explore changes in children’s behavior the less experience they have had with sharing the care of that may be related to feelings of anger, fear, sadness, or their children with others, the more intense their distress uncertainty related to changes in family structure as a at separation (3). result of deployment. Work with the parent/guardian at home to help the child adjust to these changes, including Although children’s responses to deployment separation will providing activities that help the child remain connected vary depending on age, personality, and support received, to the deployed parent/guardian and manage their children will be aware of a parent’s/guardian’s long-term emotions throughout the deployment cycle. absence and may mourn. Children may feel uncertain, sad, afraid, or angry. These feelings can manifest as increased For the parents/guardians, this should be accomplished by: clinginess, aggression, withdrawal, changes in sleeping Validating their feelings as a universal human a. or eating patterns, regression or other behaviors. Young experience; children don’t often have the vocabulary to express their b. Providing parents/guardians with information about emotions, and may need support to express their feelings in the positive effects for children of high quality facilities healthy and safe ways (2). Additionally, the parent/guardian with strong parent/guardian participation; at home may be experiencing stress, anxiety, depression, or Encouraging parents/guardians to discuss their feelings; c. fear. These parents/guardians may benefit from additional d. Providing parents/guardians with evidence, such as outreach from caregivers/teachers, who are part of their photographs, that their child is being cared for and is - community support system, and can help them with strate enjoying the activities of the facility; gies to promote children’s adjustment and connect them e. Ask parents/guardians to bring pictures from home with resources in the community (3). that may be placed in the room or cubby and displayed throughout the indoor and outdoor learning/play environment at the child’s eye level;

84 57 Chapter 2: Program Activities for Healthy Development COMMENTS 2 .1.1. 6 Depending on the child’s developmental stage, the impact Transitioning within Programs and Indoor of separation on the child and parent/guardian will vary. and Outdoor Learning/Play Environments Child care facilities should understand and communicate Caregivers/teachers should take into consideration the this variation to parents/guardians and work with parents/ individual needs of children when transitioning them to a guardians to plan developmentally appropriate coping new indoor and outdoor learning/play environment. The strategies for use at home and in the child care setting. For - transitioning child/children should be offered the opportu example, a child at eighteen to twenty-four months of age nity to visit the new space with a familiar caregiver/teacher is particularly vulnerable to separation issues and may with enough time to allow them to display comfort in the show visible distress when experiencing separation from - new space. The program should allow time for communica parents/guardians. Entry into child care at this age may tion with the families regarding the process and for each trigger behavior problems, such as difficulty sleeping. child to follow through a comfortable time line of adaptation Even for the child who has adapted well to a child care to the new indoor and outdoor learning/play environment, arrangement before this developmental stage, such diffi- caregiver/teachers, and peers. culties can occur as the child continues in care and enters Children need time to manipulate, explore and familiarize this developmental stage. For younger children, who are themselves with the new space and caregivers/teachers. This working on understanding object permanence (usually should be done before they are part of a new group to allow around nine to twelve months of age), parents/guardians them time to explore to their personal satisfaction. Eating who sneak out after bringing their children to the child is a primary reinforcer and need. The opportunity to share care facility may create some level of anxiety in the child food within the new space will help reassure a child and help throughout the day. Sneaking away leaves the child unable adults assess how the transition is going. Toileting involves to discern when someone the child trusts will leave with- - another level of trust. Diapering/toileting should be intro out warning. Parents/guardians and caregivers/teachers duced in the new space with a familiar teacher. reminding a child that the parent/guardian returned as promised reinforces truthfulness and trust. Parents/ New routines should be introduced by the new staff with guardians of children of any age should be encouraged a familiar caregiver/teacher present to support the child/ to visit the facility together before the child care officially children. Transitions to the indoor and outdoor learning/ begins. Parents/guardians of infants may benefit from play environment, especially if the space is different than feeling assured by the caregivers/teachers themselves. the one from which they are familiar, should follow similar Depending on the child’s temperament and prior care procedures as moving to another indoor space. Parents/ experience, several visits may be recommended before guardians should be part of the transition as they too are enrolling as well opportunities to practice the process and in the process of learning to trust a new indoor and outdoor consistency of a separation experience in the first weeks of learning/play environment for their child. Primary needs entering the child care. Using a phasing-in period can also need to be met to support a smooth transition. be helpful (e.g., spend only a part of the day with parents/ Transitions should be planned in advance, based on the guardians on the first day, half-day on the second day, child’s readiness. A written plan should be developed and and parents/guardians leave earlier, etc.) shared with parents/guardians, describing how and when TYPE OF FACILITY the transition will occur. Children should not be moved to Center, Large Family Child Care Home a new indoor and outdoor learning/play environment for the sole purpose of maintaining child: staff ratios. RELATED STANDARDS RATIONALE Minimum Age to Enter Child Care 1.1. 2 .1 Supporting the achievement of developmental tasks for Early Childhood Mental Health Consultants 1.6.0. 3 young children is essential for their social and emotional 2 . 3.1.1 Mutual Responsibility of Parents/Guardians health. Establishing trust with caregivers/teachers and suc- and Staff cessful adaptation to a new indoor and outdoor learning/ References play environment is a critical component of quality care. 1. Blecher-Sass, H. 1997. Good-byes can build trust. Young Child 52:12-14. Young children need predictability and routine. They need Kim, A. M., J. Yeary. 2008. Making long-term separations easier for children 2. and families. Young Children 63:32-37. to feel secure and to understand the expectations of their 3. Gonzalez-Mena, J. 2007. Separation: Helping children and families. In 50 environment. By taking time to allow them to familiarize Early childhood strategies for working and communicating with diverse themselves with their new caregivers/teachers and environ - families, 96-97. Upper Saddle River, NJ: Prentice Hall. ment, they are better able to handle the emotional, cognitive, and social requirements of their new space (1-5). TYPE OF FACILITY Center, Large Family Child Care Home RELATED STANDARD 2.1.2.5 Toilet Learning/Training

85 58 Caring for Our Children: National Health and Safety Performance Standards learning/play environments should have an array of toys, References 1. Erikson, E. H. 1950. Childhood and society. New York: W.W. Norton and Co. materials, posters, etc. that reflect diverse cultures and 2. Gorski, P. A., S. P. Berger. 2005. Emotional health in child care. In Health in ethnicities. Stereotyping of any culture must be avoided. child care: A manual for health professionals, ed. J. R. Murph, S. D. Palmer, D. Glassy, 173-86. Elk Grove Village, IL: American Academy of Pediatrics. RATIONALE 3. Lally, R. L., L. Y. Torres, P. C. Phelps. 1994. Caring for infants and toddlers Children who participate in programs that reflect and show in groups: Necessary considerations for emotional, social, and cognitive development. Zero to Three 14:1-8. respect for the cultural diversity of their communities learn 4. Mahler, M., F. Pine, A. Bergman. 1975. The Psychological birth of the to understand and value cultural diversity. This learning human infant. New York: Basic Books. in early childhood enables their healthy participation in 5. Maslow, A. 1943. A theory of human motivation. Psychological Review 50:370-96 a democratic pluralistic society (peaceful coexistence of different interests, convictions, and lifestyles) throughout life (1-3,11,12). By facilitating the expression of cultural 2 .1.1.7 - development or ethnic identity and by encouraging famil Communication in Native Language iarity with different groups and practices through ordinary Other Than English interaction and activities integrated into a developmentally - At least one member of the staff should be able to commu appropriate curriculum, a facility can foster children’s abil - - nicate with the parents/guardians and children in the fami ity to relate to people who are different from themselves, ly’s native language (sign or spoken), or the facility should their sense of possibility, and their ability to succeed in a work with parents/guardians to arrange for a translator to diverse society, while also promoting feelings of belonging communicate with parents/guardians and children. Efforts and identification with a tradition. should be made to support a child’s and family’s native COMMENTS language while providing resources and opportunities for learning English (2). Children should not be used as trans - Sharing information about the child on a daily basis with lators. They are not developmentally able to understand the children’s families shows respect for the children’s the meaning of all words as used by adults, nor should they cultures by creating an opportunity to learn more about participate in all conversations that may be regarding the families’ background, beliefs, and traditions (5-9). the child. Materials, displays, and learning activities must represent the cultural heritage of the children and the staff to instill RATIONALE a sense of pride and positive feelings of identification in all The future development of the child depends on his/her children and staff members (4). In order to enroll a diverse command of language (1). Richness of language increases as group, the facility should market its services in a culturally a result of experiences as well as through the child’s verbal sensitive way and should make sincere efforts to employ interaction with adults and peers. Basic communication staff members that represent the culture of the children and with parents/guardians and children requires an ability to their families (10). Children need to see members of their speak their language. Learning English while maintaining own community in positions of influence in the services a family’s native language enriches child development and they use. Scholarships and tuition assistance can be used strengthens family cultural traditions. to increase the diversity among enrolled children. COMMENTS TYPE OF FACILITY For resources on bilingual and dual language learning, Center, Large Family Child Care Home see the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics (SODBP) at References http://www.aap.org/sections/dbpeds/. 1. Wardle, F. 1998. Meeting the needs of multicultural and multiethnic children in early childhood settings. Early Child Education J 26:7-11. TYPE OF FACILITY 2. Ramsey, P. G. 1998. Teaching and learning in a diverse world: Multicultural education for young children. 2nd ed. New York: Teachers College Press. Center, Large Family Child Care Home 3. Ramsey, P. G. 1995. Growing up with the contradictions of race and class. Young Child 50:18-22. References 4. Maschinot, B. 2008. The changing face of the United States: The influence of 1. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances ht tp:// culture on early child development. Washington, DC: Zero to Three. Applied Dev Psychol 20:248. www.zerotothree.org/site/DocServer/Culture_book.pdf?docID=6921. Olsen, L. 2006. Ensuring academic success of English learners. 2006. U.C. 2. 5. Williams, K. C., M. H. Cooney. 2006. Young children and social justice. Linguistic Minority Research Institute 15:1-7. Young Children 61:75-82. 6. Gonzalex-Mena, J. 2008. Diversity in early care and education: Honoring differences. 5th ed. Boston: McGraw-Hill. 2 .1.1. 8 7. Gonzalez-Mena, J. 2007. 50 early childhood strategies for working and Diversity in Enrollment and Curriculum communicating with diverse families. Upper Saddle River, NJ: Pearson Merrill Prentice Hall. Programs should work to increase understanding of cul- Bradely, J., P. Kibera. 2006. Closing the gap: Culture and promotion of 8. tural, ethnic, and other similarities and differences by inclusion in child care. Young Children 61:34-40. enrolling children who reflect the cultural and ethnic 9. Romero, M. 2008. Promoting tolerance and respect for diversity in early childhood: Toward a research and practice agenda. Report of the Promoting diversity of the community. Programs should provide Tolerance and Respect for Diversity in Early Childhood Meeting, Brooklyn, cultural curricula that engage children and families and http://www.nccp.org/publications/pdf/text_812.pdf. NY, June 25, 2007. teach multicultural learning activities. Indoor and outdoor

86 59 Chapter 2: Program Activities for Healthy Development 10. Matthews, H. 2008. Supporting a diverse and culturally competent impact on future school success (6). Richness of the child’s workforce: Charting progress for babies in child care. Charting Progress language increases as it is nurtured by verbal interactions for Babies in Child Care: A CLASP Child Care and Early Education and learning experiences with adults and peers. Basic com- Project, Washington, DC. http://www.clasp.org/babiesinchildcare/ recommendations?id=0005. munication with parents/guardians and children requires 11. Parent Services Project (PSP). Making room in the circle. Training an ability to speak their language. Discussing the impact Curriculum, PSP, San Rafael, CA. of actions on feelings for the child and others helps to 12. Fox, R. K. 2007. One of the hidden diversities in schools: Families with parents who are Lesbian or Gay. Childhood Education 83:277-81. develop empathy. TYPE OF FACILITY 2 .1.1. 9 Center, Large Family Child Care Home Verbal Interaction References - The child care facility should assure that a rich environ 1. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An ment of spoken language by caregivers/teachers surrounds exploratory empirical study. Int J Early Years Education 7:229-39. and includes all children with opportunities to expand their 2. Baron, N., L. W. Schrank. 1997. Children learning language: How adults can help. Lake Zurich, IL: Learning Seed. language communication skills. Each child should have at 3. Szanton, E. S., ed. 1997. Creating child-centered programs for infants and least one speaking adult person who engages the child in toddlers, birth to 3 year olds, step by step: A Program for children and - frequent verbal exchanges linked to daily events and expe families. New York: Children’s Resources International, Inc. 4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: riences. To encourage the development of language, the Why are they so important? Young Child 52:4-12. caregiver/teacher should demonstrate skillful verbal 5. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances communication and interaction with the child. in Applied Dev Psychol 20:248. 6. Pikulski, J. J., Templeton, S. 2004. Teaching and developing vocabulary: Key a. For infants, these interactions should include responses to long-term reading success. Geneva, IL: Houghton Mifflin Company. to, and encouragement of, soft infant sounds, as well as http://www.eduplace.com/state/author/pik_temp.pdf. identifying objects, feelings, and desires by the care - giver/teacher. For toddlers, the interactions should include naming of b. 2 .1. 2 objects, feelings, listening to the child and responding, PROGRAM ACTIVITIES FOR INFANTS AND along with actions and supporting, but not forcing, the TODDLERS FROM THREE MONTHS TO child to do the same. LESS THAN THIRTY-SIX MONTHS For preschool and school-age children, interactions c. should include respectful listening and responses to what the child has to say, amplifying and clarifying the 2 .1. 2 .1 child’s intent, and not reinforcing mispronunciations Personal Caregiver/Teacher Relationships (e.g., Wambulance instead of Ambulance). for Infants and Toddlers Frequent interchange of questions, comments, and d. The facility should practice a relationship-based philosophy responses to children, including extending children’s that promotes consistency and continuity of caregivers/ utterances with a longer statement, by teaching staff. teachers for infants and toddlers (1-3). Facilities should For children with special needs, alternative methods e. implement continuity of care practices into established of communication should be available, including but policies and procedures as a means to foster strong, positive not limited to: sign language, assistive technology, pic- relationships that will act as a secure basis for exploration ture boards, picture exchange communication systems - and learning in the classroom (1-4). Child–caregiver rela (PECS), FM systems for hearing aids, etc. Communica- tionships based on high-quality care are central to brain - tion through methods other than verbal communica development, emotional regulation, and overall learning tion can result in the same desired outcomes. (5). The facility should encourage practices of continuity of Profanity should not be used at any time. f. care that give infants and toddlers the added benefit of the RATIONALE same caregiver for the first three years of life of the child or during the time of enrollment (6). The facility should limit Conversation with adults is one of the main channels the number of caregivers/teachers who interact with any through which children learn about themselves, others, one infant or toddler (1). and the world in which they live. While adults speaking to children teaches the children facts and relays information, The caregiver/teacher should: the social and emotional communications and the atmos- Use a variety of safe and appropriate individualized a. phere of the exchange are equally important. Reciprocity of soothing methods of holding and comforting infants expression, response, and the initiation and enrichment of and toddlers who are upset (7). - dialogue are hallmarks of the social function and signifi b. Engage in frequent, multiple, and rich social inter - cance of the conversations (1-4). The future development changes, such as smiling, talking, appropriate forms of the child depends on his/her command of language (5). of touch, singing, and eating. Research suggests that language experiences in a child’s c. Be play partners as well as protectors. early years have a profound influence on that child’s lan- guage and vocabulary development, which in turn has an

87 60 Caring for Our Children: National Health and Safety Performance Standards Be attuned to infants’ and toddlers’ feelings and reflect d. Appendix M: Recognizing Child Abuse and Neglect: Signs them back. and Symptoms Communicate consistently with parents/guardians. e. Protective Factors Regarding Child Abuse Appendix N: f. Interact with infants and toddlers and develop a and Neglect relationship in the context of everyday routines References (eg, diapering, feeding). https://www. 1. Zero to Three. Primary caregiving and continuity of care. zerotothree.org/resources/85-primary-caregiving-and-continuity-of-care. Opportunities should be provided for each infant and tod- Published February 8, 2010. Accessed January 11, 2018 dler to develop meaningful relationships with caregivers. National Scientific Council on the Developing Child. The Science of 2. Neglect: The Persistent Absence of Responsive Care Disrupts the The facility’s touch policy should be direct in addressing https://46y5eh11fhgw3ve3ytpwxt9r- Developing Brain: Working Paper 12. that children may be touched when it is appropriate for, wpengine.netdna-ssl.com/wp-content/uploads/2012/05/The-Science-of- Neglect-The-Persistent-Absence-of-Responsive-Care-Disrupts-the- respectful to, and safe for the child. Caregivers/teachers Developing-Brain.pdf. Published December 2012. Accessed January 11, should respect the wishes of children, regardless of their 2018 age, for physical contact and their comfort or discomfort 3. Harvard University Center on the Developing Child. Three principles to improve outcomes for children and families. https://developingchild. with it. Caregivers/teachers should avoid even “friendly” harvard.edu/resources/three-early-childhood-development-principles- contact (eg, touching the shoulder or arm) with a child if improve-child-family-outcomes. Accessed January 11, 2018 the child expresses that he or she is uncomfortable. Recchia SL. Caregiver–child relationships as a context for continuity in 4. child care. Early Years. 2012;32(2):143–157 RATIONALE 5. US Department of Health and Human Services, Child Care State Capacity Building Center. Six essential program practices. Program for infant/ When children trust caregivers and are comfortable in the https://childcareta.acf.hhs.gov/sites/default/files/public/ toddler care. environment that surrounds them, they are allowed to Published January 2017. pitc_rationale_-_continuity_of_care_508_0.pdf. focus on educational discoveries in their physical, social, Accessed January 11, 2018 6. Ruprecht K, Elicker J, Choi J. Continuity of care, caregiver–child and emotional development. interactions, toddler social competence and problem behaviors. Early Educ Dev. 2015;27:221–239 Holding, and hugging, in a positive, respectful, and safe 7. Kim Y. Relationship-based developmentally supportive approach to infant manner is an essential part of providing care for infants childcare practice. Early Child Dev Care. 2015:734-749 and toddlers. Understanding children’s behavior. In: Miller DF. Positive Child 8. Guidance. 8th ed. Boston, MA: Cengage Learning; 2016 Quality caregivers/teachers provide care and learning 9. Sandstrom H, Huerta S. The negative effects of instability on child experiences that play a key role in a child’s development as https://www. development: a research synthesis. Urban Institute Web site. urban.org/research/publication/negative-effects-instability-child- an active, self-knowing, self-respecting, thinking, feeling, Published September 18, 2013. development-research-synthesis. and loving person (8). Limiting the number of adults with Accessed January 11, 2018 whom an infant or a toddler interacts fosters reciprocal Al Odhayani A, Watson WJ, Watson L. Behavioural consequences of child 10. abuse. Can Fam Physician. 2013;59(8):831–836 understanding of communication cues that are unique to each infant or toddler. This leads to a sense of trust of the NOTES adult by the infant or toddler that the infant’s or toddler’s Content in the STANDARD was modified on 05/30/2018. needs will be understood and met promptly (5,6). Studies of infant behavior show that infants have difficulty forming 2.1.2.2 trusting relationships in settings where many adults inter - Interactions with Infants and Toddlers act with infants (eg, in hospitalization of infants when Caregivers/teachers should provide consistent, continuous shifts of adults provide care) (9). and inviting opportunities to talk, listen to, and otherwise Sexual abuse in the form of inappropriate touching is an interact with young infants throughout the day (indoors act that induces or coerces children in a sexually suggestive and outdoors) including feeding, changing, playing with, manner or for the sexual gratification of the adult, such as and cuddling them. sexual penetration and/or overall inappropriate touching RATIONALE or kissing (10). Richness of language increases by nurturing it through TYPE OF FACILITY verbal interactions between the child and adults and peers. Center, Large Family Child Care Home, Small Family Adults’ speech is one of the main channels through which Child Care Home children learn about themselves, others, and the world in RELATED STANDARDS which they live. While adults speaking to children teach the children facts, the social and emotional communications 3.4.4.1 Recognizing and Reporting Suspected and the atmosphere of the exchange are equally important. Child Abuse, Neglect, and Exploitation Reciprocity of expression, response, the initiation and 3.4.4.2 Immunity for Reporters of Child Abuse enrichment of dialogue are hallmarks of the social func- and Neglect tion and significance of the conversations (2-5). Infants 3.4.4.3 Preventing and Identifying Shaken Baby and toddlers learn through meaningful relationships Syndrome/Abusive Head Trauma and interaction with consistent adults and peers. 3.4.4.4 Care for Children Who Have Been Abused/ The future development of the child depends on his/her Neglected command of language (1). Richness of language increases as

88 61 Chapter 2: Program Activities for Healthy Development c. Help the child practice resolving conflicts; it is nurtured by verbal interactions of the child with adults and peers. Basic communication with parents/guardians Use symbols (words, numbers, etc.); d. e. Manipulate objects; and children requires an ability to speak their language. Exercise physical skills; A language-rich environment and warm, responsive inter f. - actions between staff and children are among the elements g. Encourage language development; Foster self-expression; that produce positive impacts (6). h. i. Strengthen the child’s identity as a member of a family COMMENTS and a cultural community; Live, real-time interaction with caregivers/teachers is pre- j. Promote sensory exploration. ferred. For example, caregivers/teachers naming objects in For infants and toddlers the curriculum should be based the indoor and outdoor learning/play environment or sing - on the child’s development at the time and connected to ing rhymes to all children supports language development. a sound understanding as to where they are in their Children’s stories and poems presented on recordings with developmental course. a fixed speed for sing-along can actually interfere with a child’s ability to participate in the singing or recitation. RATIONALE With fixed-speed activities, the pace may be too fast for Opportunities to be an active learner are vitally important some children, and the activity may have to be repeated for the development of motor competence and awareness for some children or the caregiver/teacher will need to of one’s own body and person, the development of sensory try a different method for learning. motor skills, the ability to demonstrate initiative through TYPE OF FACILITY active outdoor and indoor play, and feelings of mastery and successful coping. Coping involves original, imaginative, Center, Large Family Child Care Home and innovative behavior as well as previously learned RELATED STANDARD strategies. 2.2.0.3 Screen Time/Digital Media Use Learning to resolve conflicts constructively in childhood is References essential in preventing violence later in life (1,2). A physical 1. Moerk, E. L. 2000. The guided acquisition of first language skills. Advances and social environment that offers opportunities for active Applied Dev Psychol 20:248. Baron, N., L. W. Schrank. 1997. Children learning language: How adults can 2. mastery and coping enhances the child’s adaptive abilities help. Lake Zurich, Ill: Learning Seed. (3,4,9). The importance of play for developing cognitive skills, 3. Szanton, E. S., ed. 1997. Creating child-centered programs for infants and for maintaining an affective and intellectual equilibrium, toddlers, birth to 3 year olds, step by step: A Program for children and families. New York: Children’s Resources International. and for creating and testing new capacities is well recog - 4. Kontos, S., A. Wilcox-Herzog. 1997. Teachers’ interactions with children: nized (8). Play involves a balance of action and symboliza - Why are they so important? Young Child 52:4-12. tion, and of feeling and thinking (5-7). Children need access 5. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy environments in preschools. ERIC Digest (January). to age-appropriate toys and safe household objects. 6. National Forum on Early Childhood Program Evaluation, National COMMENTS Scientific Council on the Developing Child. 2007. A science-based framework for early childhood policy: Using evidence to improve outcomes For more information regarding appropriate play materials in learning, behavior, and health for vulnerable children. Cambridge, MA: for young children, see “Which Toy for Which Child: A Con- http://developingchild. Center on the Developing Child, Harvard University. harvard.edu/index.php/library/reports_and_working_papers/policy_ sumer’s Guide for Selecting Suitable Toys” from the U.S. framework/. Consumer Product Safety Commission (CPSC) and “The Right Stuff for Children Birth to 8: Selecting Play Materials 2.1.2.3 to Support Development” from the National Association - for the Education of Young Children (NAEYC). For infor Space and Activity to Support Learning mation regarding appropriate materials for outdoor play, of Infants and Toddlers see POEMS: Preschool Outdoor Environment The facility should provide a safe and clean learning envi - Measurement Scale (10). ronment, both indoors and outdoors, colorful materials and equipment arranged to support learning. The indoor TYPE OF FACILITY and outdoor learning/play environment should encourage Center, Large Family Child Care Home - and be comfortable with staff on the floor level when inter RELATED STANDARDS acting with active infant crawlers and toddlers. The indoor Active Opportunities for Physical Activity 3.1. 3.1 and outdoor play and learning settings should provide Space Required per Child 5.1. 2 .1 opportunities for the child to act upon the environment by experiencing age-appropriate obstacles, frustrations, and 5. 2 . 9.14 Shoes in Infant Play Areas risks in order to learn to negotiate environmental challenges. Safety of Equipment, Materials, and Furnishings 5. 3.1.1 The facility should provide opportunities for play that: 5. 3.1. 5 Placement of Equipment and Furnishings Lessen the child’s anxiety and help the child adapt to a. reality and resolve conflicts; b. Enable the child to explore and experience the natural world;

89 62 Caring for Our Children: National Health and Safety Performance Standards References RATIONALE 1. Massey, M. S. 1998. Early childhood violence prevention. ERIC Digest Infants need quiet, calm environments, away from the (October). stimulation of older children. Younger infants should be 2. Levin, D. E. 1994. Teaching young children in violent times: Building a peaceable classroom, A preschool-grade 3 violence prevention and conflict cared for in rooms separate from the more boisterous resolution guide. Cambridge, MA: Educators for Social Responsibility. toddlers. In addition to these developmental needs of 3. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An infants, separation is important for reasons of disease exploratory empirical study. Int J Early Years Education 7:229-39. 4. Cartwright, S. 1998. Group trips: An invitation to cooperative learning. prevention. Rates of hospitalization for all forms of acute Child Care Infor Exch 124:95-97. infectious respiratory tract diseases are highest during the 5. Evaldsson, A., W. A. Corsaro. 1998. Play and games in the peer cultures of first year of life, indicating that respiratory tract illness preschool and preadolescent children: An interpretative approach. Chi ld hood 5:377-402. becomes less severe as the child gets older (1). Therefore, Petersen, E. A. 1998. The amazing benefits of play. Child Family 17:7-8. 6. infants should be a focus for interventions to reduce the 7. Pica, R. 1997. Beyond physical development: Why young children need to incidence of respiratory tract diseases. Handwashing and move. Young Child 52:4-11. Tepperman, J., ed. 2007. Play in the early years: Key to school success, 8. sanitizing practices are key. Depending on the tempera - a policy brief. El Cerrito, CA: Early Childhood Funders. ment of the child, an increase in transitions can increase http://www.4children.org/images/pdf/play07.pdf. anxiety in young children by reducing the opportunity for 9. Torelli, L., C. Durrett. 1996. Landscape for learning: The impact of classroom design on infants and toddlers. Early Childhood News 8 routine and predictability (2), and it increases basic health http://www.spacesforchildren.com/landc1.pdf. (March-April): 12-17. and safety concerns of cross contamination with older 10. DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. 2005. children who have more contact with the environment. Preschool outdoor environment measurement scale. Lewisville, NC: Kaplan Early Learning Co. COMMENTS This separation of younger children from older children 2.1.2.4 ideally should be implemented in all facilities, but may be Separation of Infants and Toddlers less feasible in small or large family child care homes. from Older Children Separation of groups of children by low partitions that Infants and toddlers younger than three years of age should divide a single common space is not acceptable. Without be cared for in a closed room(s) that separates them from sound attenuation, limitation of shared air pollutants older children, except in small family child care homes including airborne infectious disease agents, or control with closed groups of mixed aged children. of interactions among the caregivers/teachers who are working with different groups, the separate smaller In facilities caring for three or more children younger than groups are essentially one large group. three years of age, activities that bring children younger than three years of age in contact with older children should TYPE OF FACILITY be prohibited, unless the younger children already have Center regular contact with the older children as part of a group. RELATED STANDARDS Pooling, as a practice in larger settings where the infants/ 3.2.2.2 Handwashing Procedure toddlers are not part of the group all day—as in home Appendix K: Routine Schedule for Cleaning, Sanitizing, care—should be avoided for the following reasons: and Disinfecting a. Unfamiliarity with caregivers/teachers if not the References primary one during the day; 1. Izurieta, H. S., W. W. Thompson, P. Kramarz, et al. 2000. Influenza and the b. Concerns of noise levels, space ratios, social-emotional rates of hospitalization for respiratory disease among infants and young well-being, etc.; children. New England J Med 342:232-39. Poole, C. 1998. Routine matters. Scholastic Parent Child (August September). 2. c. Occurs at times when children are least able to handle transitions; d. Increases the number of transitions for children, 2.1.2.5 e. Increases the number of adults caring for infants and Toilet Learning/Training toddlers, a practice to be avoided if possible. The facility should develop and implement a plan that teaches each child how and when to use the toilet. Toilet Caregivers/teachers of infants should not be responsible for learning/training, when initiated, should follow a pre- the care of older children who are not a part of the infants’ scribed, sequential plan that is developed and coordinated closed child care group. with the parent’s/guardian’s plan for implementation in Groups of younger infants should receive care in closed the home environment. Toilet learning/training should room(s) that separates them from other groups of toddlers be based on the child’s developmental level rather than and older children. chronological age. When partitions are used, they must control interaction To help children achieve bowel and bladder control, between groups, provide separated ventilation of the spaces caregivers/teachers should enable children to take an active and control sound transmission. The acoustic controls role in using the toilet when they are physically able to do should limit significant transmission of sound from one so and when parents/guardians support their children’s group’s activity into other group environments. learning to use the toilet.

90 63 Chapter 2: Program Activities for Healthy Development Diapering/toilet training should not be used as rationale for COMMENTS not spending time outdoors. Practices and policies should The area of toilet learning/training for children with special be offered to address diapering/toileting needs outdoors health care needs is difficult because there are no age-related, such as providing staff who can address children’s needs, disability-specific rules to follow. As a result, support and or provide outdoor diapering and toileting that meets all counseling for parents/guardians and caregivers/teachers are sanitation requirements. required to help them deal with this issue. Some children with multiple disabilities do not demonstrate any requisite Caregivers/teachers should take into account the prefer - skills other than being dry for a few hours. Establishing a ences and customs of the child’s family. toilet routine may be the first step toward learning to use For children who have not yet learned to use the toilet, the toilet, and at the same time, improving hygiene and skin the facility should defer toilet learning/training until the care. The child care health consultant should be considered child’s family is ready to support this learning and the a resource to assist is supporting special health care needs. child demonstrates: Sometimes children need to increase their fluid intake to a. An understanding of the concept of cause and effect; help a medical condition and this can lead to increased b. An ability to communicate, including sign language; urination. Other conditions can lead to loose stools. Chil- The physical ability to remain dry for up to two hours; c. dren should be given unrestricted access to toileting facilities, An ability to sit on the toilet, to feel/understand the d. especially in these situations. Children who are recovering sense of elimination; - from gastrointestinal illness might temporarily lose conti e. A demonstrated interest in autonomous behavior. nence, especially if they are recently toilet trained, and may need to revert to diapers or training pants for a short period For preschool and school-age children, an emphasis should of time. Children who are experiencing stress (e.g., a new be placed on appropriate handwashing after using the toilet infant in the family) may regress and also return to using and they should be provided frequent and unrestricted diapers for a period of time. opportunities to use the toilet. For more information on toilet learning/training, see Children with special health care needs may require spe- “Toilet Training: Guidelines for Parents,” available from the cific instructions, training techniques, adapted toilets, and/ American Academy of Pediatrics (AAP) at http://www.aap. or supports or precautions. Some children will need to be org and the AAP Section on Developmental and Behavioral taught special techniques like catheterization or care of Pediatrics at http://www.aap.org/sections/dbpeds/. ostomies. This can be provided by trained staff or older children can sometimes learn self-care techniques. Any TYPE OF FACILITY special techniques should be documented in a written care Center, Large Family Child Care Home plan. The child care health consultant can provide training RELATED STANDARDS or coordinate resources necessary to accommodate special 3. 2 .1. 5 Procedure for Changing Children’s Soiled toileting techniques while in child care. Underwear/Pull-Ups and Clothing Cultural expectations of toilet learning/training need to be General Requirements for Toilet and 5. 4 .1.1 recognized and respected. Handwashing Areas RATIONALE 5. 4 .1. 2 Location of Toilets and Privacy Issues - A child’s achievements of motor and cognitive or develop 5. 4 .1. 3 Ability to Open Toilet Room Doors mental skills assist in determining when s/he is ready for 5.4.1.4 Preventing Entry to Toilet Rooms by Infants toilet learning/training (1). Physical ability/neurological a n d To d d l e r s function also includes the ability to sit on the toilet and 5. 4 .1. 5 Chemical Toilets to feel/understand the sense of elimination. 5. 4 .1. 6 Ratios of Toilets, Urinals, and Hand Sinks to Toilet learning/training is achieved more rapidly once Children - expectations from adults across environments are consis Toilet Learning/Training Equipment 5. 4 .1.7 tent (3). The family may not be prepared, at the time, to ex- Cleaning and Disinfecting Toileting Equipment 5. 4 .1. 8 tend this learning/training into the home environment (2). 5. 4 .1. 9 Waste Receptacles in the Child Care Facility and School-age and preschool children may not respond when in Child Care Facility Toilet Room(s) their bodies signal a need to use the toilet because they are involved in activities or embarrassed about needing to use References 1. Mayo Clinic. 2009. Potty training: How to get the job done. http://www. the toilet. Holding back stool or urine can lead to con- mayoclinic.com/health/potty-training/CC00060/. stipation and urinary tract problems (4). Also, unless American Academy of Pediatrics. 2009. When is the right time to start 2. reminded, many children forget to correctly wash their toilet training? http://www.aap.org/publiced/BR_ToiletTrain.htm. 3. Anthony-Pillai, R. 2007. What’s potty about early toilet training? British hands after toileting. Med J 334:1166. 4. Schmitt, B. D. 2004. Toilet training problems: Underachievers, refusers, and stool holders. Contemporary Pediatrics 21:71-77.

91 64 Caring for Our Children: National Health and Safety Performance Standards 2 .1. 3 . 2 2 .1. 3 Opportunities for Learning for Three- to PROGRAM ACTIVITIES FOR Five-Year-Olds THREE- TO FIVE-YEAR-OLDS Programs should provide children a balance of guided and self-initiated play and learning indoors and outdoors. These 2 .1. 3 .1 should include opportunities to observe, explore, order and Personal Caregiver/Teacher Relationships reorder, to make mistakes and find solutions, and to move for Three- to Five-Year-Olds from the concrete to the abstract in learning. Facilities should provide opportunities for each child to RATIONALE build long-term, trusting relationships with a few caring The most meaningful learning has its source in the child’s caregivers/teachers by limiting the number of adults the self-initiated activities. The learning environment that facility permits to care for any one child in child care to a supports individual differences, learning styles, abilities, maximum of eight adults in a given year and no more than and cultural values fosters confidence and curiosity in three primary caregivers/teachers in a day. Children with learners (1,2). special health care needs may require additional specialists to promote health and safety and to support learning; how- TYPE OF FACILITY ever, relationships with primary caregivers/teachers should Center, Large Family Child Care Home be supported. References 1. Rodd, J. 1996. Understanding young children’s behavior: A guide for early RATIONALE childhood professionals. New York: Teacher’s College Press. Children learn best from adults who know and respect Ritchie, S., B. Willer. 2008. Teaching: A guide to the NAEYC early 2. them; who act as guides, facilitators, and supporters within childhood standard and related accreditation criteria. Washington, DC: National Association for the Education of Young Children. a rich learning environment; and with whom they have established a trusting relationship (1,2). When the facility allows too many adults to be involved in the child’s care, 2.1.3.3 the child does not develop a reciprocal, sustained, respon - Selection of Equipment for Three- to sive, and trusting relationship with any of them. Children Five-Year-Olds should have continuous friendly and trusting relationships The program should select, for both indoor and outdoor with several caregivers/teachers who are reasonably con- play and learning, developmentally appropriate equipment sistent within the child care facility. Young children can and materials, for safety, for its ability to provide large and extract from these relationships a sense of themselves with a small motor experiences, and for its adaptability to serve capacity for forming trusting relationships and self-esteem. many different ideas, functions, and forms of creative Relationships are fragmented by rapid staff turnover, staffing expression. reassignment, or if the child is frequently moved from one RATIONALE room to another or one child care facility to another. An aesthetic, orderly, appropriately stimulating, child- COMMENTS oriented indoor and outdoor learning/play environment Compliance should be measured by staff and parent/ contributes to the preschooler’s sense of well-being and guardian interviews. Turnover of staff lowers the quality control (1,2,4,5). of the facility. High quality facilities maintain low turnover COMMENTS through their wage policies, training and support for staff (3). “Play and learning settings that motivate children to be TYPE OF FACILITY physically active include pathways, trails, lawns, loose Center, Large Family Child Care Home parts, anchored playground equipment, and layouts that References stimulate all forms of active play” (3). If traditional play - 1. Rodd, J. 1996. Understanding young children’s behavior: A guide for early ground equipment is used, caregivers/teachers may want childhood professionals. New York: Teacher’s College Press. to consult with an early childhood specialist or a certified Greenberg, P. 1991. Character development: Encouraging self-esteem and 2. self-discipline in infants, toddlers, and two-year-olds. Washington, DC: playground inspector for recommendations on develop - National Association for the Education of Young Children. mentally appropriate play equipment. For more informa - 3. Whitebook, M., D. Bellm. 1998. Taking on turnover: An action guide for tion on play equipment also contact the National Program child care center teachers and directors. Washington, DC: Center for the Child Care Workforce. for Playground Safety (http://www.uni.edu/playground/). TYPE OF FACILITY Center, Large Family Child Care Home RELATED STANDARDS 5.2.9.9 Plastic Containers and Toys 5. 2 . 9.12 Treatment of CCA Pressure-Treated Wood

92 65 Chapter 2: Program Activities for Healthy Development References TYPE OF FACILITY 1. Torelli, L., C. Durrett. 1996. Landscape for learning: The impact of Center, Large Family Child Care Home classroom design on infants and toddlers. Early Child News 8:12-17. 2. Center for Environmental Health. The safe playgrounds project. Reference http://www.safe2play.org. 1. Pica, R. 1997. Beyond physical development: Why young children need to 3. DeBord, K., L. Hestenes, R. Moore, N. Cosco, J. McGinnis. 2005. Preschool move. Young Child 52:4-11. outdoor environment measurement scale. Lewisville, NC: Kaplan Early Learning Co. Banning, W., G. Sullivan. 2009. Lens on outdoor learning. St. Paul, MN: 4. 2 .1. 3 . 6 Red Leaf Press. Fostering Language Development of 5. Keeler, R. 2008. Natural playscapes: Creating outdoor play environments for the soul. Redmond, WA: Exchange Press. Three- to Five-Year-Olds The indoor and outdoor learning/play environment should 2 .1. 3 . 4 be rich in first-hand experiences that offer opportunities Expressive Activities for Three- to for language development. They should also have an abun - dance of books of fantasy, fiction, and nonfiction, and pro- Five-Year-Olds vide chances for the children to relate stories. Caregivers/ Caregivers/teachers should encourage and enhance expres- teachers should foster language development by: - sive activities that include play, painting, drawing, storytell ing, sensory play, music, singing, dancing, and dramatic play. Speaking with children rather than at them; a. b. Encouraging children to talk with each other by helping RATIONALE them to listen and respond; Expressive activities are vehicles for socialization, con- c. Giving children models of verbal expression; flict resolution, and language development. They are vital Reading books about the child’s culture and history, which d. energizers and organizers for cognitive development (2). would serve to help the child develop a sense of self; Stifling the preschooler’s need to play damages a natural Reading to children and re-reading their favorite books; e. integration of thinking and feeling (1). Listening respectfully when children speak; f. TYPE OF FACILITY Encouraging interactive storytelling; g. Center, Large Family Child Care Home Using open-ended questions; h. Provide opportunities during indoor and outdoor learn - i. References ing/play to use writing supplies and printed materials; 1. Cooney, M., L. Hutchinson, V. Costigan. 1996. From hitting to tattling to communication and negotiation: The young child’s stages of socialization. j. - Provide and read books relevant to their natural environ Early Child Education J 24:23-27. ment outdoors (for example, books about the current 2. Tepperman, J., ed. 2007. Play in the early years: Key to school success, season, local wildlife, etc.); a policy brief. El Cerrito, CA: Early Childhood Funders. http:// www.4children.org/images/pdf/play07.pdf. k. Provide settings that encourage children to observe nature, such as a butterfly garden, bird watching station, etc.; 2 .1. 3 . 5 l. Providing opportunities to explore writing, such as Fostering Cooperation of Three- to through a writing area or individual journals. Five-Year-Olds RATIONALE Programs should foster a cooperative rather than a com- petitive indoor and outdoor learning/play environment. Language reflects and shapes thinking. A curriculum created to match preschoolers’ needs and interests enhances RATIONALE language skills. First-hand experiences encourage children As three-, four-, and five-year-olds play and work together, to talk with each other and with adults, to seek, develop, they shift from almost total dependence on the adult to and use increasingly more complex vocabulary, and to use seeking social opportunities with peers that still require language to express thinking, feeling, and curiosity (1-3). adult monitoring and guidance. The rules and responsibili - COMMENTS ties of a well-functioning group help children of this age to internalize impulse control and to become increasingly Compliance with development should be measured by - responsible for managing their behavior. A dynamic curric structured observation. Examples of verbal encouragement ulum designed to include the ideas and values of a broad of verbal expression are: “ask Johnny if you may play with socioeconomic group of children will promote socialization. him”; “tell him you don’t like being hit”; “tell Sara what you The inevitable clashes and disagreements are more easily saw downtown yesterday;” “can you tell Mommy about what resolved when there is a positive influence of the group you and Johnny played this morning?” These encouraging on each child (1). statements should be followed by respectful listening, without pressuring the child to speak. COMMENTS TYPE OF FACILITY Encouraging communication skills and attentiveness to the needs of individuals and the group as a whole supports a Center, Large Family Child Care Home cooperative atmosphere. Adults need to model cooperation. RELATED STANDARD 2.3.2.3 Support Services for Parents/Guardians

93 66 Caring for Our Children: National Health and Safety Performance Standards References 1. Szanton, E. S., ed. 1997. Creating child-centered programs for infants and 2 .1. 4 toddlers, birth to 3 year olds, step by step: A Program for children and PROGRAM ACTIVITIES FOR families. New York: Children’s Resources International. 2. Snow, C. E., M. S. Burns, P. Griffin. 1999. Language and literacy SCHOOL-AGE CHILDREN environments in preschools. ERIC Digest (January). 3. Maschinot, B. 2008. The changing face of the United States: The influence of culture on early child development. Washington, DC: Zero to Three. http:// 2 .1. 4 .1 www.zerotothree.org/site/DocServer/Culture_book.pdf?docID=6921. Supervised School-Age Activities The facility should have a program of supervised activities 2 .1. 3 .7 designed especially for school-age children, to include: Body Mastery for Three- to Five-Year-Olds a. Free choice of play; The caregivers/teachers should offer children opportunities, b. Opportunities, both indoors and outdoors, for vigorous indoors and outdoors, to learn about their bodies and how physical activity which engages each child daily for at their bodies function in the context of socializing with least sixty minutes and are not limited to opportunities others. Caregivers/teachers should support the children in to develop physical fitness through a program of focused their curiosity and body mastery, consistent with parental/ activity that only engages some of the children in guardian expectations and cultural preferences. Body mas- the group; tery includes feeding oneself, learning how to use the toilet, Opportunities for concentration, alone or in a group, c. running, skipping, climbing, balancing, playing with peers, indoors and/or outdoors; displaying affection, and using and manipulating objects. Time to read or do homework, indoors and/or outdoors; d. RATIONALE Opportunities to be creative, to explore the arts, e. Achieving the pleasure and gratification of feeling physi - sciences, and social studies, and to solve problems, cally competent on a voluntary basis is a basic component indoors and/or outdoors; of developing self-esteem and the ability to socialize with f. Opportunities for community service experience adults and other children inside and outside the family (1-5). (museums, library, leadership development, elderly citizen homes, etc.); COMMENTS g. Opportunities for adult-supervised skill-building and Self-stimulatory behaviors, such as thumb sucking or self-development groups, such as scouts, team sports, masturbation, should be ignored. If the masturbation is and club activities (as transportation, distance, and excessive, interferes with other activities, or is noticed by parental permission allow); other children, the caregiver/teacher should make a brief Opportunities to rest; h. non-judgmental comment that touching of private body i. Opportunities to seek comfort, consolation, and parts is normal, but is usually done in a private place (7,8). understanding from adult caregivers/teachers; After making such a comment, the caregiver/teacher should j. Opportunities for exercise and exploration out of doors. offer friendly assistance in going on to other activities. These RATIONALE behaviors may be signs of stress in the child’s life, or simply a habit. If the child’s sexual play is more explicit or forceful Programs organized for older children after school or toward other children or the child witnessed or was ex- during vacation time should provide indoor and outdoor posed to adult sexuality, the caregiver/teacher may need learning/play environments that meet the needs of these to consider that abuse is possible (6). children for physical activity, recreation, responsible completion of school work, expanding their interests, TYPE OF FACILITY learning cultural sensitivity, exploring community Center, Large Family Child Care Home resources, and practicing pro-social skills (1,2). References COMMENTS 1. Botkin, D., et al. 1991. Children’s affectionate behavior: Gender differences. Early Education Dev 2:270-86. For more information on school-age standards, see [The Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An 2. NAA Standards for Quality School-Age Care,] available exploratory empirical study. Int J Early Years Education 7:229-39. from the National AfterSchool Association (NAA). 3. Cartwright, S. 1998. Group trips: An invitation to cooperative learning. Child Care Infor Exch 124:95-97. TYPE OF FACILITY 4. Rodd, J. 1996. Understanding young children’s behavior: A guide for early childhood professionals. New York: Teacher’s College Press. Center, Large Family Child Care Home 5. Cooney, M., L. Hutchinson, V. Costigan. 1996. From hitting to tattling to communication and negotiation: The young child’s stages of socialization. RELATED STANDARD Early Child Education J 24:23-27. 3.1. 3.1 Active Opportunities for Physical Activity 6. Kellogg, N., American Academy of Pediatrics Committee on Child Abuse and Neglect. 2005. Clinical report: The evaluation of sexual abuse in References children. Pediatrics 116:506-12. 1. Coltin, L. 1999. Enriching children’s out-of-school time. ERIC Digest (May). 7. Johnson, T. C. 2007. Understanding children’s sexual behaviors: What’s Fashola, O. S. 1999. Implementing effective after-school programs. 2. natural and healthy. San Diego: Institute on Violence, Abuse and Trauma. Here’s How 17:1-4 Friedrich, W. N., J. Fisher, D. Broughton, M. Houston, C. R. Shafran. 1998. 8. Normative sexual behavior in children: A contemporary sample. Pediatrics 101: e9.

94 67 Chapter 2: Program Activities for Healthy Development 2 .1. 4 . 5 2 .1. 4 . 2 Community Outreach for School-Age Children Space for School-Age Activity The facility should provide opportunities for school-age The facility should provide a space for indoor and outdoor - children to participate in community outreach and involve activities for children in school-age child care. ment, such as field trips and community improvement RATIONALE projects. A safe and secure environment that fosters the growing RATIONALE independence of school-age children is essential for their As the world of the school-age child encompasses the larger development (1,2). Active connection with nature promotes children’s sensitivity, confidence, exploration, and community, facility activities should reflect this stage of self-regulation. development. Field trips and other opportunities to explore the community should enrich the child’s experience (1). TYPE OF FACILITY TYPE OF FACILITY Center, Large Family Child Care Home Center, Large Family Child Care Home References 1. Greenspan, S. L. 1997. Building children’s minds: Early childhood Reference development for a better future. Our Child 23:6-10. 1. Taras, H. L. 2005. School-aged child care. In Health in child care: A manual Maxwell, L. E. 1996. Designing early childhood education environments: 2. for health professionals, ed. J. R. Murph, S. D. Palmer, D. Glassy, 411-21. 4th A partnership between architect and educator. Education Facility Planner ed. Elk Grove Village, IL: American Academy of Pediatrics. 33 :15 -17. 2 .1. 4 . 6 2 .1. 4 . 3 Communication Between Developing Relationships for School-Age Child Care and School Children Facilities that accept school-age children directly from school The facility should offer opportunities to school-age should arrange a system of communication with children for developing trusting, supportive relationships the child’s school teacher. Families should be included in this with the staff and with peers. communication loop. RATIONALE RATIONALE Although school-age children need more independent This communication may be facilitated by phone or email experiences, they continue to need the guidance and between the child’s teacher and the school-age child care support of adults. Peer relationships take on increasing facility. School-age child care programs should include importance for this age group. Community service parent/guardian permissions which allow school teachers opportunities can be valuable for this age group. to communicate relevant information to caregivers/teachers. TYPE OF FACILITY Parents/guardians should also be notified of any significant event so that a system of communication is established Center, Large Family Child Care Home between and among family, school, and caregivers/teachers. The child’s school teacher and a staff member from the 2.1.4.4 facility should meet at least once to exchange telephone Planning Activities for School-Age Children numbers and to offer a contact in the event relevant The facility should offer a program based on the needs information needs to be shared. and interests of the age group, as well as of the individuals TYPE OF FACILITY within it. Children should participate in planning the Center, Large Family Child Care Home program activities. Parents/guardians should be engaged and their work commitments should be honored when RELATED STANDARD planning program activities. Written Policy on Confidentiality of Records 9. 4 .1. 3 RATIONALE Reference A child care facility for school-age children should provide 1. National Association of Elementary School Principals, National AfterSchool http://www.naaweb.org/ Association. Leading a new day for learning. an enriching contrast to the formal school program, but downloads/Principal Documents/leading_joint_statement-r3_.pdf. - also offer time for children to complete homework assign ments. Programs that offer a wide range of activities (such as team sports, cooking, dramatics, art, music, crafts, games, open time, quiet time, outdoor play and learning, and use of community resources) allow children to explore new interests and relationships. TYPE OF FACILITY Center, Large Family Child Care Home

95 68 Caring for Our Children: National Health and Safety Performance Standards - The importance of supervision is not only to protect chil 2.2 dren from physical injury, but from harm that can occur SUPERVISION AND DISCIPLINE 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. 2.2.0.1 Children like to test their skills and abilities. This is partic - Methods of Supervision of Children ularly noticeable around playground equipment. Even if the Caregivers/teachers should directly supervise infants, highest safety standards for playground layout, design and toddlers, and preschoolers by sight and hearing at all times, surfacing are met, serious injuries can happen if children even when the children are going to sleep, napping or sleep - are left unsupervised. Adults who are involved, aware, and ing, are beginning to wake up, or are indoors or outdoors. appreciative of young childrens’ behaviors are in the best School-age children should be within sight or hearing at all position to safeguard their well-being. Active and positive times. Caregivers/teachers should not be on one floor level supervision involves: of the building, while children are on another floor or a. Knowing each child’s abilities; room. Ratios should remain the same whether inside Establishing clear and simple safety rules; b. or outside. Being aware of and scanning for potential safety hazards; c. School-age children should be permitted to participate in Placing yourself in a strategic position so you are able d. activities off the premises with appropriate adult supervi - to adapt to the needs of the child; sion and with written approval by a parent/guardian and by Scanning play activities and circulating around the area; e. the caregiver. If parents/guardians give written permission Focusing on the positive rather than the negative to teach f. - for the school-age child to participate in off-premises activi a child what is safe for the child and other children; ties, the facility would no longer be responsible for the child g. Teaching children the developmentally appropriate and during the off-premises activity and not need to provide safe use of each piece of equipment (e.g., using a slide staff for the off-premises activity. correctly—feet first only—and teaching why climbing up a slide can cause injury, possibly a head injury). Caregivers/teachers should regularly count children (name to face on a scheduled basis, at every transition, and Primary caregiving systems, small group sizes, and low whenever leaving one area and arriving at another), going child:staff ratios unique to infant/toddler settings support indoors or outdoors, to confirm the safe whereabouts of staff in properly supervising infants and toddlers. These every child at all times. Additionally, they must be able - practices encourage responsive interactions and under to state how many children are in their care at all times. standing each child’s strengths and challenges. When staff connect deeply with the children in their care, they Developmentally appropriate child:staff ratios should be met are more in tune to children’s needs and whereabouts. during all hours of operation, including indoor and outdoor Ultimately, carefully planned environments; staffing that play and field trips, and safety precautions for specific areas supports nurturing, individualized, and engaged care- and equipment should be followed. No center-based facility giving; and well-planned, responsive care routines support or large family child care home should operate with fewer active supervision in infant and toddler environments. than two staff members if more than six children are in care, even if the group otherwise meets the child:staff ratio. Children are going to be more active in the outdoor learning/ Although centers often downsize the number of staff for play environment and need more supervision rather than the early arrival and late departure times, another adult less outside. Playground supervisors need to be designated must be present to help in the event of an emergency. The and trained to supervise children in play areas (1). Super- supervision policies of centers and large family child care vision of the playground is a strategy of watching all the homes should be written policies. children within a specific territory and not engaging in prolonged dialog with any one child or group of children RATIONALE (or other staff ). Other adults not designated to supervise Supervision is basic to safety and the prevention of injury may facilitate outdoor learning/play activities and engage and maintaining quality child care. Parents/guardians have in conversations with children about their exploration and a contract with caregivers/teachers to supervise their chil - discoveries. Facilitated play is where the adult is engaged in dren. To be available for supervision or rescue in an emer - helping children learn a skill or achieve specific outcome gency, an adult must be able to hear and see the children. of an activity. Facilitated play is not supervision (2). In case of fire, a supervising adult should not need to climb stairs or use a ramp or an elevator to reach the children. Children need spaces, indoors and out, in which they Stairs, ramps, and elevators may become unstable because can withdraw for alone-time or quiet play in small groups. they can be pathways for fire and smoke. Children who are However, program spaces should be designed with visibility presumed to be sleeping might be awake and in need of that allows constant unobtrusive adult supervision. To adult attention. A child’s risk-taking behavior must be protect children from maltreatment, including sexual detected and illness, fear, or other stressful behaviors abuse, the environment layout should limit situations in must be noticed and managed.

96 69 Chapter 2: Program Activities for Healthy Development which an adult or older child is left alone with a child Harms, T., D. Cryer, R. M. Clifford. 2005. Infant/toddler without another adult present (3,4). environment rating scale, revised ed. Frank Porter Graham Child Development Institute, University of North Carolina. Many instances have been reported where a child has hid- http://ers.fpg.unc.edu/node/84/. den when the group was moving to another location, or Chen, X., M. Beran, R. Altkorn, S. Milkovich, K. Gruaz, G. where the child wandered off when a door was opened for another purpose. Regular counting of children (name to Rider, A. Kanti, J. Ochsenhirt. 2006. Frequency of caregiver supervision of young children during play. Intl J Injury face) will alert the staff to begin a search before the child gets too far, into trouble, or slips into an unobserved location. Control and Safety Promotion 14:122-24. Schwebel, D. C., A. L. Summerlin, M. L. Bounds, B. A. Caregivers/teachers should record the count on an atten - Morrongiello. 2006. The stamp-in-safety program: A dance sheet or on a pocket card, along with notations of any behavioral intervention to reduce behaviors that can lead to children joining or leaving the group. Caregivers/teachers unintentional playground injury in a preschool setting. J should do the counts before the group leaves an area and Pediatric Psychology 31:152-62. when the group enters a new area. The facility should assign and reassign counting responsibility as needed to maintain U.S. Consumer Product Safety Commission (CPSC). 2010. a counting routine. Facilities might consider counting sys- Public playground safety handbook. http://www.cpsc.gov/ tems such as using a reminder tone on a watch or musical cpscpub/pubs/325.pdf. clock that sounds at timed intervals (about every fifteen TYPE OF FACILITY minutes) to help the staff remember to count. Center, Large Family Child Care Home Caregivers/teachers should be ready to provide help and RELATED STANDARDS guidance when children are ready to use the toilet correctly and independently. Caregivers/teachers should make sure Ratios for Small Family Child Care Homes 1.1.1.1 children correctly wash their hands after every use of the 1.1.1. 2 Ratios for Large Family Child Care Homes and toilet, as well as monitor the bathroom to make sure that Centers the toilet is flushed, the toilet seat and floor are free from Ratios for Facilities Serving Children with Special 1.1.1. 3 stool or urine, and supplies (toilet paper, soap, and paper Health Care Needs and Disabilities towels) are available. Ratios and Supervision During Transportation 1.1.1.4 Older preschool children and school-age children may use 1.1.1.5 Ratios and Supervision for Swimming, Wading, toilet facilities without direct visual observation but must and Water Play - remain within hearing range in case children need assis 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse tance and to prevent inappropriate behavior. If toilets are and Neglect not on the same floor as the child care area or within sight 5. 4 .1. 2 Location of Toilets and Privacy Issues or hearing of a caregiver/teacher, an adult should accom - pany children younger than five years of age to and from References 1. National Program for Playground Safety. 2006. Playground supervision the toilet area. Younger children who request privacy training for childcare providers. University of Northern Iowa. http://www. and have shown capability to use toilet facilities properly playgroundsafety.org/training/online/childcare/course_supervision.htm. should be given permission to use separate and private National Program for Playground Safety. 2006. NPPS Website. http://www. 2. playgroundsafety.org. toilet facilities. 3. National Association for the Education of Young Children. 1996. Position Planning must include advance assignments, monitoring, Statement. Prevention of child abuse in early childhood programs and the responsibilities of early childhood professionals to prevent child abuse. and contingency plans to maintain appropriate staffing. 4. Fiene, R. 2002. 13 indicators of quality child care: Research update. During times when children are typically being dropped Washington, DC: U.S. Department of Health and Human Services, Office of off and picked up, the number of children present can vary. the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ basic-report/13-indicators-quality-child-care. There should be a plan in place to monitor and address unanticipated changes, allowing for caregivers/teachers to receive additional help when needed. Sufficient staff 2.2.0.2 must be maintained to evacuate the children safely in case Limiting Infant/Toddler Time in Crib, of emergency. Compliance with proper child:staff ratios High Chair, Car Seat, Etc. should be measured by structured observation, by counting A child should not sit in a high chair or other equipment caregivers/teachers and children in each group at varied that constrains his/her movement (1,2) indoors or outdoors times of the day, and by reviewing written policies. for longer than fifteen minutes, other than at meals or COMMENTS snack time. Children should never be left out of the view Additional Readings and attention of adult caregivers/teachers while in these types of equipment/furniture. A least restrictive environ - Harms, T., R. M. Clifford, D. Cryer. 2005. Early childhood ment should be encouraged at all times. Children should environment rating scale, revised ed. Frank Porter Graham not be left to sleep in equipment, such as car seats, swings, Child Development Institute, University of North Carolina. or infant seats that does not meet ASTM International http://ers.fpg.unc.edu/node/82/. (ASTM) product safety standards for sleep equipment.

97 70 Caring for Our Children: National Health and Safety Performance Standards For children of all ages, digital media and devices should RATIONALE not be used during meal or snack time, or during nap/rest Children are continually developing their physical skills. times and in bed. Devices should be turned off at least one They need opportunities to use and build on their physical hour before bedtime. When offered, digital media should abilities. This is especially true for infants and toddlers who be free of advertising and brand placement, violence, and are eagerly using their bodies to explore their environment. sounds that tempt children to overuse the product. Extended periods of time in the crib, high chair, car seat, or other confined space limits their physical growth and also Caregivers/teachers should communicate with parents/ affects their social interactions. Injuries and Sudden Infant guardians about their guidelines for home media use. Death Syndrome (SIDS) have occurred when children have Caregivers/teachers should take this information into been left to sleep in car seats or infant seats when the straps consideration when planning the amount of media use have entrapped body parts, or the children have turned the at the child care program to help in meeting daily seats over while in them. Sleeping in a seated position can recommendations (1). restrict breathing and cause oxygen desaturation in young Programs should prioritize physical activity and increased infants (3). Sleeping should occur in equipment manufac - personal social interactions and engagement during the tured for this activity. When children are awake, restricting program day. It is important for young children to have them to a seat may limit social interactions. These social active social interactions with adults and children. Media interactions are essential for children to gain language use can distract children (and adults), limit conversations skills, develop self-esteem, and build relationships (4). and play, and reduce healthy physical activity, increasing TYPE OF FACILITY the risk for overweight and obesity. Media should be turned Center, Large Family Child Care Home off when not in use since background media can be distrac- ting, and reduce social engagement and learning. Overuse of RELATED STANDARDS media can also be associated with problems with behavior, Active Opportunities for Physical Activity 3.1. 3.1 limit-setting, and emotional and behavioral self-regulation; 3.1. 4 .1 Safe Sleep Practices and Sudden Unexpected therefore, caregivers/teachers should avoid using media to Infant Death (SUID)/SIDS Risk Reduction calm a child down (1). Restrictive Infant Equipment Requirements 5. 3.1.10 Note: The guidance above should not limit digital media Sleeping Equipment and Supplies 5.4.5.1 use for children with special health care needs who require Cribs 5.4.5.2 and consistently use assistive and adaptive computer tech - nology (2). However, the same guidelines apply for enter - References 1. Kornhauser Cerar, L., C.V. Scirica, I. Stucin Gantar, D. Osredkar, D. tainment media use. Consultation with an expert in Neubauer, T.B. Kinane. 2009. A comparison of respiratory patterns in assistive communication may be necessary. healthy term infants placed in care safety seats and beds. Pediatrics 124:e396-e402. * Designed with child psychologists and educators to meet Benjamin, S.E., S.L. Rifas-Shiman, E.M. Taveras, J. Haines, J. Finkelstein, K. 2. specific educational goals Kleinman, M.W. Gillman. 2009. Early child care and adiposity at ages 1 and 3 years. Pediatrics 124:555-62. RATIONALE 3. Bass, J. L., M. Bull. 2008. Oxygen desaturation in term infants in car safety The first two years of life are critical periods of growth and seats. Pediatrics 110:401-2. New York State Office of Children and Family Services. Website. http:// 4. development for children’s brains and bodies, and rapid www.ocfs.state.ny.us/main/. brain development continues through the early childhood years. To best develop their cognitive, language, motor, and 2.2.0.3 social-emotional skills, infants and toddlers need hands-on exploration and social interaction with trusted caregivers Screen Time/Digital Media Use (1). Digital media viewing do not promote such skills Please note: For the purposes of this standard “screen time/ development as well as “real life”. digital media” refers to media content viewed on cell/ mobile phone, tablet, computer, television (TV), video, film, Excessive media use has been associated with lags in and DVD. It does not include video-chatting with family. achievement of knowledge and skills, as well as negative impacts on sleep, weight, and social/emotional health. (1). Screen time/digital media should not be used with children For example, among 2-year-olds, research has shown that ages 2 and younger in early care and education settings. For body mass index (BMI) increases for every hour per week children ages 2 to 5 years, total exposure (in early care and of media consumed (3). education and at home combined) to digital media should be limited to 1 hour per day of high-quality programming,* COMMENTS and viewed with an adult who can help them apply what Digital media is not without benefits, including learning they are learning to the world around them (1). from high-quality content, creative engagement, and social Children ages 5 and older may need to use digital media in interactions. However, especially in young children, real- early care and education to complete homework. However, life social interactions promote greater learning and reten - caregivers/teachers should ensure that entertainment media tion of knowledge and skills. When limited digital media time does not displace healthy activities such as exercise, are used, co-viewing and co-teaching with an engaged adult refreshing sleep, and family time, including meals. promotes more effective learning and development.

98 71 Chapter 2: Program Activities for Healthy Development 4. American Academy of Pediatrics. Council on Early Childhood. Literacy Because children may use digital media before and after promotion: an essential component of primary care pediatric practice. attending early care and education settings, limiting http://pediatrics.aappublications.org/content/ 2014;134(2):1-6. Pediatrics. digital media use in early care and education settings and early/2014/06/19/peds.2014-1384. 5. American Academy of Pediatrics Council on Communications and Media. substituting developmentally appropriate play and other Media use in school-aged children and adolescents. Pediatrics. hands-on activities can better promote learning and skills 2016;138(5):e20162592. http://pediatrics.aappublications.org/content/138/5/ development. Such an activity is reading. Caregivers/ e20162592. teachers should begin reading to children at infancy (4) Additional References and facilities should make age-appropriate books available American Academy of Pediatrics Council on Communica-tions and Media. Children and adolescents and digital media. Pediatrics. for each cognitive stage of development that can be co-read 2016;138(5): e20162593. http://pediatrics.aappublications.org/content/ and discussed with an adult. See the American Academy of pediatrics/early/2016/10/19/peds.2016 -2593.f u l l.pdf. Pediatrics’ “Books Build Connections Toolkit” at https:// American Academy of Pediatrics. Media and children communication toolkit. littoolkit.aap.org/forprofessionals/Pages/home.aspx for Aap.org Web site. https://www.aap.org/en-us/advocacy-and-policy/aap-health- more information. The American Academy of Pediatrics initiatives/pages/media-and-children.aspx. Accessed October 12, 2017. has developed a Family Media Use Plan tool, available at Campaign for a Commercial-Free Childhood. Screenfree.org Web site. http://www.screenfree.org/. Accessed October 12, 2017. https://www.healthychildren.org/English/media/Pages/ default.aspx, which can help parents/guardians, caregivers, Common Sense Education. Commonsense.org Web site. https://www. commonsense.org/education/toolkit/audience/device-free-dinner- and families identify healthy activities for each child, and educator-resources. Accessed October 12, 2017. prioritize them ahead of limited digital media use (5). Fred Rogers Center for Early Learning and Children’s Media at Saint Caregivers/teachers serve as role models for children in Vincent College. How am I doing? A checklist for identifying exemplary uses of technology and interactive media for early care and education settings by not using or being dis- early learning. Fredrogerscenter.org Web site. http://www.fredrogerscenter. tracted by digital media during care hours. In addition, if org/2014/02/25/how-am-i-doing-checklist-exemplary-uses-of-technology- adults view media such as news in the presence of children, early-learning/. Updated February 25, 2014. Accessed October 12, 2017. children may be exposed to inappropriate language or vio- National Association for the Education of Young Children. Technology and interactive media as tools in early childhood programs serving children from lent or frightening images that can cause emotional upset birth through age 8. Position Statement. NAEYC.org Web site. http://www. or increase aggressive thoughts and behavior. Caregivers/ naeyc.org/files/naeyc/PS_technology_WEB.pdf. January 2012. Accessed teachers should be discouraged from using digital media October 12, 2017. for personal use while actively engaging with and super- NOTES vising the children in their care. Instead, opportunities Content in the STANDARD was modified on 10/12/2017. for collaborative activities are preferred. It is important to safeguard privacy for children on the 2.2.0.4 internet and digital media. Pictures and videos of children Supervision Near Bodies of Water should never be posted on social media without parent/ Constant and active supervision should be maintained when guardian consent. Caregivers/teachers should know and any child is in or around water (1). During any swimming/ follow their program’s policy for taking, sharing, or posting wading/water play activities where either an infant or a pictures and videos. toddler is present, the ratio should always be one adult to TYPE OF FACILITY one infant/toddler. Children ages thirteen months to five Center, Large Family Child Care Home years of age should not be permitted to play in areas where RELATED STANDARDS there is any body of water, including swimming pools, ponds and irrigation ditches, built-in wading pools, tubs, 2 .1. 2 .1 Personal Caregiver/Teacher Relationships for pails, sinks, or toilets unless the supervising adult is within Infants and Toddlers an arm’s length providing “touch supervision”. 2 .1. 3.1 Personal Caregiver/Teacher Relationships for Three- to Five-Year-Olds Caregivers/teachers should ensure that all pools meet the Virginia Graeme Baker Pool and Spa Safety Act, requiring 2 .1. 4 . 3 Developing Relationships for School-Age the retrofitting of safe suction-type devices for pools and Children spas to prevent underwater entrapment of children in such 2.2.0.1 Methods of Supervision of Children locations with strong suction devices that have led to deaths 3.1. 3.1 Active Opportunities for Physical Activity of children of varying ages (2). Physical Activity: How Much Is Needed? Appendix S: RATIONALE References Small children can drown within thirty seconds, in as little 1. American Academy of Pediatrics Council on Communications and Media. as two inches of liquid (3). In a comprehensive study of Media and young minds. Pediatrics. 2016;138(5):e20162591. ht tp:// pediatrics.aappublications.org/content/pediatrics/138/5/e20162591.full.pdf drowning and submersion incidents involving children 2. Reid CY, Radesky J, Christakis D, et al., American Academy of Pediatrics under five years of age in Arizona, California, and Florida, Council on Communications and Media. Children and adolescents and the U.S. Consumer Product Safety Commission (CPSC) digital media. Pediatrics. 2016;138(5):e2016593. ht tp://pediatr ic s. aappublications.org/content/early/2016/10/19/peds.2016-2593. found that: 3. Wen LM, Baur LA, Rissel C, Xu H, Simpson, JM. Correlates of body mass index and overweight and obesity of children aged 2 years: finding from the 2014;22(7):1723-1730. Obesity. healthy beginnings trial.

99 72 Caring for Our Children: National Health and Safety Performance Standards Submersion incidents involving children usually happen The Centers for Disease Control (CDC) National Center for a. in familiar surroundings; Injury Prevention and Control recommends that whenever b. Pool submersions involving children happen quickly, young children are swimming, playing, or bathing in water, 77% of the victims had been missing from sight for five - an adult should be watching them constantly. The supervis ing adult should not read, play cards, talk on the telephone, minutes or less; mow the lawn, or do any other distracting activity while Child drowning is a silent death, and splashing may not c. occur to alert someone that the child is in trouble (4). watching children (1,9). Drowning is the second leading cause of unintentional COMMENTS injury-related death for children ages one to fourteen (5). “Touch supervision” means keeping swimming children within arm’s reach and in sight at all times. Flotation devices In 2006, approximately 1,100 children under the age of should never be used as a substitute for supervision.Know- twenty in the U.S. died from drowning (11). A national ing how to swim does not make a child drown-proof. The study that examined where drowning most commonly need for constant supervision is of particular concern in takes place concluded that infants are most likely to drown dealing with very young children and children with sig- in bathtubs, toddlers are most likely to drown in swimming nificant motor dysfunction or developmental delays. pools and older children and adolescents are most likely to Supervising adults should be CPR-trained and should drown in freshwater (rivers, lakes, ponds) (11). have a telephone accessible to the pool and water area While swimming pools pose the greatest risk for toddlers, at all times should emergency services be required. about one-quarter of drowning among toddlers are in TYPE OF FACILITY freshwater sites, such as ponds or lakes. Center, Large Family Child Care Home The American Academy of Pediatrics (AAP) recommends: RELATED STANDARDS Swimming lessons for children based on the child’s a. 1.1.1.5 Ratios and Supervision for Swimming, Wading, frequency of exposure to water, emotional maturity, and Water Play physical limitations, and health concerns related to CPR Training for Swimming and Water Play 1.4.3.3 swimming pools; “Touch supervision” of infants and young children b. 6 . 3.1.1 Enclosure of Bodies of Water through age four when they are in the bathtub or Pool Safety Rules 6 . 3.1.7 around other bodies of water; References c. Installation of four-sided fencing that completely 1. U.S. Consumer Product Safety Commission. 2009. CPSC warns of in- separates homes from residential pools; home drowning dangers with bathtubs, bath seats, buckets. Release http://www.cpsc.gov/cpscpub/prerel/ #10-008. Washington, DC: CPSC. d. Use of approved personal flotation devices (PFDs) when prhtml10/10008.html. riding on a boat or playing near a river, lake, pond, U.S. Congress. 2007. Virginia Graeme Baker Pool and Spa Safety Act. 15 2. or ocean; http://www.cpsc.gov/businfo/vgb/pssa.pdf. USC 8001. 3. American Academy of Pediatrics, Committee on Injury, Violence, and e. Teaching children never to swim alone or without adult Poison Prevention. 2010. Policy statement-prevention of drowning. supervision; Pediatrics 126: 178-85. f. Stressing the need for parents/guardians and teens to U.S. Consumer Product Safety Commission. 2002. How to plan for the 4. unexpected: Preventing child drownings. Publication #359. Washington, learn first aid and cardiopulmonary resuscitation DC: CPSC. http://www.cpsc.gov/CPSCPUB/PUBS/359.pdf. (CPR) (3). 5. Centers for Disease Control and Prevention (CDC). 2010. Unintentional drowning: Fact sheet. http://www.cdc.gov/HomeandRecreationalSafety/ Deaths and nonfatal injuries have been associated with Water-Safety/waterinjuries-factsheet.html. infant bathtub “supporting ring” devices that are supposed U.S. Consumer Product Safety Commission. 1994. Drowning hazard 6. with baby “supporting ring” devices. Document #5084. Washington, DC: to keep an infant safe in the tub. These rings usually con- CPSC. http://www.cpsc.gov/cpscpub/pubs/5084.html. tain three or four legs with suction cups that attach to the 7. Rauchschwalbe, R., R. A. Brenner, S. Gordon. 1997. The role of bathtub bottom of the tub. The suction cups, however, may release seats and rings in infant drowning deaths. Pediatrics 100:e1. U.S. Consumer Product Safety Commission. 1994. Infants and toddlers can 8. suddenly, allowing the bath ring and infant to tip over. An drown in 5-gallon buckets: A hidden hazard in the home. Document #5006. infant also may slip between the legs of the bath ring and http://www.cpsc.gov/cpscpub/pubs/5006.html. Washington, DC: CPSC. become trapped under it. Caregivers/teachers must not 9. U.S. Consumer Product Safety Commission. 1997. CPSC reminds pool owners that barriers, supervision prevent drowning. Release #97-152. rely on these devices to keep an infant safe in the bath and http://www.cpsc.gov/CPSCPUB/PREREL/ Washington, DC: CPSC. must never leave an infant alone in these bath support PRHTML97/97152.html. rings (1,6,7). Gipson, K. 2008. Submersions related to non-pool and non-spa products, 10. 2008 report. Washington, DC: U.S. Consumer Product Safety Commission. Thirty children under five years of age died from drowning http://www.cpsc.gov/library/FOIA/FOIA09/OS/nonpoolsub2008.pdf. in buckets, pails, and containers from 2003-2005 (10). Of 11. American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, J. Weiss. 2010. Technical report: Prevention of all buckets, the five-gallon size presents the greatest hazard drowning. Pediatrics 126: e253-62. 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).

100 73 Chapter 2: Program Activities for Healthy Development child’s lead, playing with the child, and responding to 2.2.0.5 the child’s needs; Behavior Around a Pool b. Basing expectations on children’s developmental level; When children are in or around a pool, caregivers/teachers Establishing simple rules children can understand c. should teach age-appropriate behavior and safety skills (e.g., you can’t hurt others, our things, or yourself) and including not pushing each other, holding each other under being proactive in teaching and supporting children in water, or running at the poolside. Children should be learning the rules; shown the depth of the water at different part of the pool. d. Adapting the physical indoor and outdoor learning/ They should be taught that when going into a body of water, - play environment or family child care home to encour they should go in feet first the first time to check the depth. age positive behavior and self regulation by providing Children should be instructed what an emergency would be engag- ing materials based on children’s interests and and to only call for help only in a real/genuine emergency. ensuring that the learning environment promotes active They should be taught to never dive in shallow water. participation of each child. Well-designed child care RATIONALE - environments are ones that are supportive of appropri Caregivers/teachers should take the opportunities to ate behavior in children, and are designed to help chil - explain how certain behaviors could injure other children. dren learn about what to expect in that environment Also, such behavior can distract caregivers/teachers from and to promote positive interactions and engagement supervising other children, thereby placing the other with others; children at risk (1). e. Modifying the learning/play environment (e.g., schedule, routine, activities, transitions) to support the child’s TYPE OF FACILITY appropriate behavior; Center, Large Family Child Care Home Creating a predictable daily routine and schedule. f. When a routine is predictable, children are more likely Reference 1. U.S. Department of Health and Human Services, Maternal and Child to know what to do and what is expected of them. This Health Bureau. 1999. Basic emergency lifesaving skills (BELS): A framework may decrease anxiety in the child. When there is less for teaching emergency lifesaving skills to children and adolescents. anxiety, there may be less acting out. Reminders need Newton, MA: Children’s Safety Network, Education Development Center. http://bolivia.hrsa.gov/emsc/Downloads/BELS/BELS.htm. 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 2.2.0.6 child understands and anticipates the transition; Discipline Measures Using encouragement and descriptive praise. When g. Re a der ’s Note : The word discipline means to teach and clear encouragement and descriptive praise are used to guide. Discipline is not punishment. The discipline stan - give attention to appropriate behaviors, those behaviors - dard therefore reflects an approach that focuses on prevent are likely to be repeated. Encouragement and praise ing behavior problems by supporting children in learning should be stated positively and descriptively. Encourage- appropriate social skills and emotional responses. ment and praise should provide information that the Caregivers/teachers should guide children to develop behavior the child engaged in was appropriate.Examples: self-control and appropriate behaviors in the context of “I can tell you are ready for circle time because you are relationships with peers and adults. Caregivers/teachers sitting on your name and looking at me.” “Your friend should care for children without ever resorting to physical looked so happy when you helped him clean up his - punishment or abusive language. When a child needs assis toys.” “You must be so proud of yourself for putting on tance to resolve a conflict, manage a transition, engage in a your coat all by yourself.” Encouragement and praise challenging situation, or express feelings, needs, and wants, should label the behaviors, not the child (e.g., good the adult should help the child learn strategies for dealing listening, good eating, instead of good boy); with the situation. Discipline should be an ongoing process Using clear, direct, and simple commands. When clear h. to help children learn to manage their own behavior in a commands are used with children, they are more likely socially acceptable manner, and should not just occur in to follow them. The caregiver/teacher should tell the - response to a problem behavior. Rather, the adult’s guid child what to do rather than what NOT to do. The ance helps children respond to difficult situations using caregiver/teacher should limit the number of commands. socially appropriate strategies. To develop self-control, The caregiver/teacher should use if/then and when/then children should receive adult support that is individual statements with logical and natural consequences. These to the child and adapts as the child develops internal practices help children understand they can make controls. This process should include: choices and that choices have consequences; i. Showing children positive alternatives rather than just Forming a positive relationship with the child. When a. telling children “no”; children have a positive relationship with the adult, they Modeling desired behavior; j. 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

101 74 Caring for Our Children: National Health and Safety Performance Standards - Using planned ignoring and redirection. Certain behav k. A comprehensive behavior plan is often based first on a iors can be ignored while at the same time the adult is positive, affectionate relationship between the child and the able to redirect the children to another activity. If the caregiver/teacher. Measures that prevent behavior problems behavior cannot be ignored, the adult should prompt often include developmentally appropriate environments, the child to use a more appropriate behavior and provide supervision, routines, and transitions. Children can benefit positive feedback when the child engages in the behavior; from receiving guidance and repeated instructions for navi - Individualizing discipline based on the individual needs l. gating the various social interactions that take place in the - of children. For example, if a child has a hard time tran child care setting such as friendship development, problem- sitioning, the caregiver/teacher can identify strategies to solving, and conflict-resolution. - help the child with the transition (individualized warn Time-out (also known as temporary separation) is one ing, job during transition, individual schedule, peer strategy to help children change their behavior and should buddy to help, etc.) If a child has a difficult time during be used in the context of a positive behavioral support a large group activity, the child might be taught to ask approach which works to understand undesired behaviors for a break; and teach new skills to replace the behavior. Listed below Using time-out for behaviors that are persistent and m. are guidelines when using time-out (8): unacceptable. Time-out should only be used in com- Time-outs should be used for behaviors that are persis- a. bination with instructional approaches that teach tent and unacceptable, used infrequently and used only children what to do in place of the behavior problem. for children who are at least two years of age. Time-outs (See guidance for time-outs below.) can be considered an extended ignore or a time-out Expectations for children’s behavior and the facility’s from positive enforcement; policies regarding their response to behaviors should be The caregiver/teacher should explain how time-out works b. written and shared with families and children of appro- to the child BEFORE s/he uses it the first time. The adult priate age. Further, the policies should address proactive should be clear about the behavior that will lead to as well as reactive strategies. Programs should work with time-out; families to support their children’s appropriate behaviors c. When placing the child in time-out, the caregiver/teacher before it becomes a problem. should stay calm; While the child is in time-out, the caregiver/teacher d. RATIONALE should not talk to or look at the child (as an extended Common usage of the word “discipline” has corrupted ignore). However, the adult should keep the child in sight. the word so that many consider discipline as synonymous The child could 1) remain sitting quietly in a chair or on a with punishment, most particularly corporal punishment pillow within the room or 2) participate in some activity (2,3). Discipline is most effective when it is consistent, that requires solitary pursuit (painting, coloring, puzzle, reinforces desired behaviors, and offers natural and logical etc.) If the child cannot remain in the room, s/he will consequences for negative behaviors. Research studies find spend time in an alternate space, with supervision; that corporal punishment has limited effectiveness and e. Time-outs do not need to be long. The caregiver/teacher potentially harmful side effects (4-9). Children have to be should use the one minute of time-out for each year of taught expectations for their behavior if they are to develop the child’s age (e.g., three-years-old = three minutes of internal control of their actions. The goal is to help children time-out); learn to control their own behavior. f. The caregiver/teacher should end the time-out on a COMMENTS positive note and allow the child to feel good again. Discussions with the child to “explain WHY you were in Children respond well when they receive descriptive praise/ time-out” are not usually effective; attention for behaviors that the caregiver/teacher wants If the child is unable to be distracted or consoled, parents/ g. to see again. It is best if caregivers/teachers are sincere guardians should be contacted. and enthusiastic when using descriptive praise. On the contrary, children should not receive praise for undesirable How to respond to failure to cooperate during time-out: behaviors, but instead be praised for honest efforts towards Caregivers/teachers should expect resistance from children the behaviors the caregivers/teachers want to see repeated who are new to the time-out procedure. If a child has never (1). Discipline is best received when it includes positive experienced time-out, s/he may respond by becoming very guidance, redirection, and setting clear-cut limits that emotional. Time-out should not turn into a power struggle foster the child’s ability to become self-disciplined. In order with the child. If the child is refusing to stay on time-out, the to respond effectively when children display challenging caregiver/teacher should give the child an if/then statement. behavior, it is beneficial for caregivers/teachers to under - For example, “if you cannot take your time-out, then you stand typical social and emotional development and cannot join story time.” If the child continues to refuse the behaviors. Discipline is an ongoing process to help time-out, then the child cannot join story time. Note that children develop inner control so they can manage children should not be restrained to keep them in time-out. their own behavior in a socially approved manner. More resources for caregivers/teachers on discipline can be found at the following organizations’ Websites: a) Center on

102 75 Chapter 2: Program Activities for Healthy Development Gartrell, D. 2007. He did it on purpose! Young Children 62:62-64. the Social and Emotional Foundations for Early Learning Gartrell, D. 2004. The power of guidance: Teaching social-emotional skills in (CSEFEL) at http://csefel.vanderbilt.edu and b) Technical early childhood classrooms. Clifton Park, NY: Thomson Delmar Learning; Assistance Center on Social Emotional Intervention Washington, DC: NAEYC. http://challengingbehavior.fmhi.usf.edu/. (TACSEI) at Gartrell, D., K. Sonsteng. 2008. Promoting physical activity: It’s pro-active 63:51-53. Young Children guidance. TYPE OF FACILITY Shiller, V. M., J. C. O’Flynn. 2008. Using rewards in the early childhood Center, Large Family Child Care Home classroom: A reexamination of the issues. Young Children 63:88, 90-93. RELATED STANDARDS Reineke, J., K. Sonsteng, D. Gartrell. 2008. Nurturing mastery motivation: No 2 .1.1. 6 Transitioning within Programs and Indoor and need for rewards. Young Children 63:89, 93-97. Outdoor Learning/Play Environments Ryan, R. M., E. L. Deci. 2000. When rewards compete with nature: The undermining of intrinsic motivation and self-regulation. In Intrinsic and 2.2.0.7 Handling Physical Aggression, Biting, and Hitting extrinsic motivation: The search for optimal motivation and performance, Preventing Expulsions, Suspensions, and Other 2.2.0.8 ed. C. Sanstone, J. M. Harackiewicz, 13-54. San Diego, CA: Academic Press. Limitations in Services 3.4.4.1 Recognizing and Reporting Suspected Child 2.2.0.7 Abuse, Neglect, and Exploitation Handling Physical Aggression, Biting, 3.4.4.2 Immunity for Reporters of Child Abuse and and Hitting Neglect Caregivers/teachers should intervene immediately when a 3.4.4.3 Preventing and Identifying Shaken Baby child’s behavior is aggressive and endangers the safety of Syndrome/Abusive Head Trauma others. It is important that the child be clearly told verbally, “no hitting” or “no biting.” The caregiver/teacher should use 3.4.4.4 Care for Children Who Have Been Abused/ age–appropriate interventions. For example, a toddler can Neglected be picked up and moved to another location in the room if 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse s/he bites other children or adults. A preschool child can be and Neglect invited to walk with you first but, if not compliant, taken by Enrollment Information to Parents/Guardians and 9. 2 .1. 3 the hand and walked to another location in the room. The Caregivers/Teachers caregiver/teacher should remain calm and make eye contact Written Discipline Policies 9. 2 .1. 6 with the child telling him/her the behavior is unacceptable. 9. 4 .1. 6 Availability of Documents to Parents/Guardians If the behavior persists, parents/guardians, caregivers/ teachers, the child care health consultant and the early References 1. Henderlong, J., M. Lepper. 2002 The effects of praise on children’s intrinsic childhood mental health consultant should be involved to motivation: A review and synthesis. Psychological Bulletin 128:774 -95. create a plan targeting this behavior. For example, a plan 2. Hodgkin, R. 1997. Why the “gentle smack” should go: Policy review. may be developed to recognize non-aggressive behavior. Child Soc 11:201- 4. 3. Fraiberg, S. H. 1959. New York: Charles Scribner’s Sons. The Magic Years. Children who might not have the social skills or language 4. Straus, M. A., et al. 1997. Spanking by parents and subsequent antisocial to communicate appropriately may use physical aggression Arch Pediatric Adolescent Medicine 151:761-67. behavior of children. to express themselves and the reason for and antecedents 5. Deater-Deckard, K., et al. 1996. Physical discipline among African American and European American mothers: Links to children’s of the behavior must be considered when developing a 32:1065-72. Dev Psychol externalizing behaviors. plan for addressing the behavior. 6. Weiss, B., et al. 1992. Some consequences of early harsh discipline: Child aggression and a maladaptive social information processing style. Child Dev RATIONALE 63:1321-35. Caregiver/teacher intervention protects children and 7. American Academy of Pediatrics, Committee on School Health. 2006. Policy statement: Corporal punishment in schools. Pediatrics 118:1266. encourages children to exhibit more acceptable behavior (1). 8. Dunlap, S., L. Fox, M. L. Hemmeter, P. Strain. 2004. The role of time-out in COMMENTS a comprehensive approach for addressing challenging behaviors of http://csefel.vanderbilt. preschool children. CSEFEL What Works Series. Biting is a phase. Here are some specific steps to deal edu/briefs/wwb14.pdf. with biting: 9. Fiene, R. 2002. 13 indicators of quality child care: Research update. Washington, DC: U.S. Department of Health and Human Services, Office of Step 1: If a child bites another child, the caregiver/teacher http://aspe.hhs.gov/ the Assistant Secretary for Planning and Evaluation. should comfort the child who was bitten and remind the basic-report/13-indicators-quality-child-care. biter that biting hurts and we do not bite. Children should Additional References be given some space from each other for an appropriate 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 amount of time. 10:54-65. children. Preventions Science - The caregiver/teacher should follow first aid instruc Step 2: Breitenstein, S., D. Gross, I. Ordaz, W. Julion, C. Garvey, A. Ridge. 2007. tions (available from the American Academy of Pediatrics Promoting mental health in early childhood programs serving families from J Am Psychiatric Nurses Assoc low income neighborhoods. 13:313-20. [AAP] and the American Red Cross) and use the Center for Disease Control and Prevention’s (CDC’s) Standard Gross, D., C. Garvey, W. Julion, L. Fogg. 2007. Preventive parent training with low-income ethnic minority parents of preschoolers. In Handbook of parent Precautions to handle potential exposure to blood. Ed. J. M. training: Helping parents prevent and solve problem behaviors. Briesmeister, C. E. Schaefer. 3rd ed. Hoboken, NJ: Wiley.

103 76 Caring for Our Children: National Health and Safety Performance Standards actions, briefly removes the child from other activities The caregiver/teacher should allow for “dignity of Step 3: and also lets the child experience success as a helper. risk,” and let the children back in the same space with in- creased supervision. Interactions should be structured Discussing aggressive behavior in group time with the between children such that the child learns to use more - children can be an effective way to gain and share under appropriate social skills or language rather than biting. If - standing among the children about how it feels when aggres there is another incident, caregivers/teachers should repeat sive behavior occurs. Although bullying has not been studied step one. The biter can play with children they have not in the preschool population, it is a form of aggression (2). bitten. Here are some helpful Websites: http://stopbullying.gov and http://www.eyesonbullying.org/preschool.html. The adult needs to shadow the biter to ensure safety Step 4: of the other children. This can be challenging but impera- For more helpful strategies for handling aggression, see tive for the biter. Center on the Social and Emotional Foundations for Early Learning Website at http://csefel.vanderbilt.edu. In addition, For all transitions when the biter would be in close Step 5: a child care health consultant or child care mental health contact, the caregiver/teacher should hold him/her on her/ consultant can help when the biting behavior continues. his hip or if possible hold hands, keep a close watch, and keep the biter from close proximity with peers. TYPE OF FACILITY Step 6: The child (biter) should play with one or two other Center, Large Family Child Care Home children whom they have not bitten with a favored adult in RELATED STANDARDS a section separate from the other children. Sometimes, until Discipline Measures 2.2.0.6 a phase (biting is a phase) passes, the caregiver/teacher needs 2.2.0.8 Preventing Expulsions, Suspensions, and Other to extinguish the behavior by not allowing it to happen and Limitations in Services thereby reducing the attention given to the behavior. 2 . 3.1.1 Mutual Responsibility of Parents/Guardians Parents/guardians of both children of the incident Step 7: and Staff should be informed. 3.2.3.3 Cuts and Scrapes The caregiver/teacher should determine whether the Step 8: 3.2.3.4 Prevention of Exposure to Blood and Body Fluids incident necessitates documentation (see Standard 9.4.1.9). 9. 4 .1. 9 Records of Injury If so, s/he should complete a report form. References Caregivers/teachers need to consider why the child is biting 1. Rush, K. L. 1999. Caregiver-child interactions and early literacy development and teach the child a more appropriate way to communi- of preschool children from low-income environments. Topics Early Child cate the same need. Possible reasons why a child would Special Education 19:3-14. 2. Ross, Scott W., Horner, Robert H. 2009. Bully prevention in positive behavior bite include: support. J Applied Behavior Analysis 42:747-59. Lack of words (desire to stop the behavior of another a. child); 2.2.0.8 Te e t h i n g ; b. Preventing Expulsions, Suspensions, c. Tired (is nap time too late?); and Other Limitations in Services Hungry (is lunch time too late?); d. Child care programs should not expel, suspend, or otherwise Lack of toys—consider buying duplicates of popular items; e. limit the amount of services (including denying out- door f. Lack of supervision—more staff should be added, staff - time, withholding food, or using food as a reward/punish are near children during transitions, and room is set ment) provided to a child or family on the basis up to ensure visibility; - of challenging behaviors or a health/safety condition or situ g. Child is bored—too much sitting, activities are too ation unless the condition or situation meets one of frustrating; the two exceptions listed in this standard. Child has oral motor needs—teethers are offered; h. i. Child is avoiding something, and biting gets him/her Expulsion refers to terminating the enrollment of a child out of it; or family in the regular group setting because of a challeng - j. Lack of attention—child receives attention when biting. ing behavior or a health condition. Suspension and other limitations in services include all other reductions in the Other important strategies to consider: amount of time a child may be in attendance of the regular The caregiver/teacher should point out the effect of a. - group setting, either by requiring the child to cease atten the child’s biting on the victim: “Emma is crying. dance for a particular period of time or reducing the num- Biting hurts. Look at her face. See how sad she is?” ber of days or amount of time that a child may attend. Label feelings and give victims the words to respond. Requiring a child to attend the program in a special “Emma, you can say ‘No biting!’ to Josh”; place away from the other children in the regular group The child should help the victim feel better. He can get a b. setting is included in this definition. wet paper towel, a blankie or favorite toy for the victim Child care programs should have a comprehensive dis- and sit near them until the other child is feeling better. cipline policy that includes an explicit description of This encourages children to take responsibility for their

104 77 Chapter 2: Program Activities for Healthy Development possible interventions and supports recommended by a alternatives to expulsion for children exhibiting extreme levels of challenging behaviors, and should include the qualified early childhood mental health consultant aimed program’s protocol for preventing challenging behaviors. at providing a physically safe environment have been These policies should be in writing and clearly articulated exhausted; or and communicated to parents/guardians, staff and others. The family is unwilling to participate in mental health b. consultation that has been provided through the child These policies should also explicitly state how the program care program or independently obtain and participate plans to use any available internal mental health and other support staff during behavioral crises to eliminate to the in child mental health assistance available in the community; or degree possible any need for external supports (e.g., local Continued placement in this class and/or program clearly c. police departments) during crises. fails to meet the mental health and/or social-emotional Staff should have access to in-service training on both a needs of the child as agreed by both the staff and the proactive and as-needed basis on how to reduce the like- family AND a different program that is better able to lihood of problem behaviors escalating to the level of risk meet these needs has been identified and can immedi - for expulsion and how to more effectively manage behav- ately provide services to the child. iors throughout the entire class/group. Staff should also have access to in-service training, resources, and child care In either of the above three cases, a qualified early childhood mental health consultant, qualified special education staff, health consultation to manage children’s health conditions and/or qualified community-based mental health care pro- in collaboration with parents/guardians and the child’s vider should be consulted, referrals for special education primary care provider. Programs should attempt to obtain services and other community-based services should be access to behavioral or mental health consultation to help facilitated, and a detailed transition plan from this program establish and maintain environments that will support to a more appropriate setting should be developed with the children’s mental well-being and social-emotional health, family and followed. This transition could include a different and have access to such a consultant when more targeted private or public-funded child care or early education pro- child-specific interventions are needed. Mental health gram in the community that is better equipped to address the consultation may be obtained from a variety of sources, behavioral concerns (e.g., therapeutic preschool programs, as described in Standard 1.6.0.3. Head Start or Early Head Start, prekindergarten programs When children exhibit or engage in challenging behaviors in the public schools that have access to additional support that cannot be resolved easily, as above, staff should: staff, etc.), or public-funded special education services for Assess the health of the child and the adequacy of the a. infants and toddlers (i.e., Part C early intervention) or - curriculum in meeting the developmental and educa preschoolers (i.e., Part B preschool special education). tional needs of the child; To the degree that safety can be maintained, the child b. Immediately engage the parents/guardians/family in a should be transitioned directly to the receiving program. spirit of collaboration regarding how the child’s behav - The program should assist parents/guardians in securing the iors may be best handled, including appropriate solutions more appropriate placement, perhaps using the services of a that have worked at home or in other settings; local child care resource and referral agency. With parent/ Access an early childhood mental health consultant c. guardian permission, the child’s primary care pro- vider to assist in developing an effective plan to address the should be consulted and a referral for a comprehensive child’s challenging behaviors and to assist the child in assessment by qualified mental health provider and the developing age-appropriate, pro-social skills; appropriate special education system should be initiated. If d. Facilitate, with the family’s assistance, a referral for an - abuse or neglect is suspected, then appropriate child protec evaluation for either Part C (early intervention) or Part tion services should be informed. Finally, no child should B (preschool special education), as well as any other ever be expelled or suspended from care without first con- appropriate community-based services (e.g., child - ducting an assessment of the safety of alternative arrange mental health clinic); ments (e.g., Who will care for the child? Will the child be Facilitate with the family communication with the e. adequately and safely supervised at all times?) (1). child’s primary care provider (e.g., pediatrician, family medicine provider, etc.), so that the primary care pro- RATIONALE vider can assess for any related health concerns and The rate of expulsion in child care programs has been help facilitate appropriate referrals. estimated to be as high as one in every thirty-six children enrolled, with 39% of all child care classes per year expelling The only possible reasons for considering expelling, sus- at least one child. In state-funded prekindergarten pend- ing or otherwise limiting services to a child on the programs, the rate has been estimated as one in every 149 basis of challenging behaviors are: children enrolled, with 10% of prekindergarten classes per Continued placement in the class and/or program a. year expelling at least one child. These expulsions prevent clearly jeopardizes the physical safety of the child children from receiving potentially beneficial mental health and/or his/her classmates as assessed by a qualified services and deny the child the benefit of continuity of early childhood mental health consultant AND all quality early education and child care services. Mental

105 78 Caring for Our Children: National Health and Safety Performance Standards health consultation has been shown in rigorous research to 2.2.0.9 help reduce the likelihood of behaviors leading to expulsion Prohibited Caregiver/Teacher Behaviors decisions. Also, research suggests that expulsion decisions Child care programs must not tolerate, or in any manner may be related to teacher job stress and depression, large condone, an act of abuse or neglect of a child. The following group sizes, and high child:staff ratios (1-6). behaviors by an older child, caregiver/teacher, substitute or Mental health services should be available to staff to help any other person employed by the facility, volunteer, or address challenging behaviors in the program, to help visitor should be prohibited in all child care settings: improve the mental health climate of indoor and outdoor a. The use of corporal punishment/physical abuse (1) learning/play environments and child care systems, to (punishment inflicted directly on the body), including, better provide mental health services to families, and to but not limited to address job stress and mental health needs of staff. 1. Hitting, spanking (striking a child with an open TYPE OF FACILITY hand or instrument on the buttocks or extremities with the intention of modifying behavior without Center, Large Family Child Care Home causing physical injury), shaking, slapping, twisting, RELATED STANDARDS pulling, squeezing, or biting 1. 6 . 0.1 Child Care Health Consultants 2. Demanding excessive physical exercise, excessive 1.6.0. 3 Early Childhood Mental Health Consultants rest, or strenuous or bizarre postures Specialized Consultation for Facilities Serving 1.6.0.5 3. Forcing and/or demanding physical touch from Children with Disabilities the child 4. Compelling a child to eat or have soap, food, spices, 2.2.0.6 Discipline Measures or foreign substances in his or her mouth 2.2.0.7 Handling Physical Aggression, Biting, and Hitting 5. Exposing a child to extreme temperatures Prohibited Caregiver/Teacher Behaviors 2.2.0.9 Isolating a child in an adjacent room, hallway, closet, b. 2.2.0.10 Using Physical Restraint darkened area, play area, or any other area where the Recognizing and Reporting Suspected Child 3.4.4.1 child cannot be seen or supervised Abuse, Neglect, and Exploitation c. Binding or tying to restrict movement, such as in a car seat (except when traveling) or taping the mouth Immunity for Reporters of Child Abuse and Neglect 3.4.4.2 Using or withholding food as a punishment or reward d. 3.4.4.3 Preventing and Identifying Shaken Baby Toilet learning/training methods that punish, demean, e. Syndrome/Abusive Head Trauma or humiliate a child 3.4.4.4 Care for Children Who Have Been Abused/ f. Any form of emotional abuse, including rejecting, Neglected terrorizing, extended ignoring, isolating, or corrupting 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse a child and Neglect Any form of sexual abuse (Sexual abuse in the form of g. Prohibited Uses of Food 4 . 5 . 0 .11 inappropriate touching is an act that induces or coerces children in a sexually suggestive manner or for the sexual Written Discipline Policies 9. 2 .1. 6 gratification of the adult, such as sexual penetration and/ References or overall inappropriate touching or kissing.) 1. American Academy of Pediatrics, Committee on School Health. 2008. Abusive, profane, or sarcastic language or verbal abuse, h. Policy statement: Out-of-school suspension and expulsion. Pediatrics 122:450. threats, or derogatory remarks about the child or Gilliam, W. S. 2005. Prekindergarteners left behind: Expulsion rates in state 2. child’s family prekindergarten programs. Foundation for Child Development, Policy Brief i. Any form of public or private humiliation, including Series no. 3. http://medicine.yale.edu/childstudy/zigler/Images/ NationalPrekStudy_expulsion brief_tcm350-34775.pdf. threats of physical punishment (2) 3. Gilliam, W. S., G. Shahar. 2006. Preschool and child care expulsion and Physical activity/outdoor time taken away as punishment j. suspension: Rates and predictors in one state. Infants Young Children 19:228-45. Children should not see hitting, ridicule, and/or similar 4. Gilliam, W. S. 2008. Implementing policies to reduce the likelihood of types of behavior among staff members. preschool expulsion. Foundation for Child Development, Policy Brief Series no. 7. http://medicine.yale.edu/childstudy/zigler/Images/ RATIONALE PreKExpulsionBrief2_tcm350-34772.pdf. 5. National Scientific Council on the Developing Child. 2008. Mental health The behaviors mentioned in the standard threaten the safety problems in early childhood can impair learning and behavior for life. and security of children. This would include behaviors that http://developingchild.harvard.edu/library/reports_and_ Working paper #6. occur among or between staff. Even though adults may state working_papers/working_papers/wp6/. Perry, D. F., M. C. Dunne, L. McFadden, D. Campbell. 2008. Reducing the 6. that the behaviors are “playful,” children cannot distinguish risk for preschool expulsion: Mental health consultation for young children this. Corporal punishment may be physical abuse or may with challenging behaviors. J Child Family Studies 17:44-54. easily become abusive. Corporal punishment is clearly pro- hibited 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, antiso - cial and criminal behavior, and learning impairment (3-6).

106 79 Chapter 2: Program Activities for Healthy Development The American Academy of Pediatrics is opposed to the References 1. Gershoff ET, Purtell KM, Holas I. Education and advocacy efforts to reduce use of corporal punishment (7). Factors supporting prohibi - school corporal punishment. In: Corporal Punishment in U.S. Public Schools: tion of certain methods of discipline include current child Legal Precedents, Current Practices, and Future Policy. New York, NY: development theory and practice, legal aspects (namely, Springer International Publishing; 2015:87–98 Centers for Disease Control and Prevention. Violence prevention. Child abuse 2. that a caregiver/teacher does not foster a relationship with https://www.cdc.gov/violenceprevention/ and neglect: definitions. the child in place of the parents/guardians to prevent the childmaltreatment/ definitions.html. Updated April 5, 2016. Accessed development of an inappropriate adult-child relationship), January 11, 2018 3. Fréchette S, Zoratti M, Romano E. What is the link between corporal and increasing liability suits. punishment and child physical abuse? J Fam Violence. 2015;30(2):135–148 4. Zolotor AJ. Corporal punishment. Pediatr Clin North Am. 2014;61(5):971–978 Appropriate alternatives to corporal punishment vary as 5. Hornor G, Bretl D, Chapman E, et al. Corporal punishment: evaluation of an children grow and develop. As infants become more mobile, intervention by PNPs. J Pediatr Health Care. 2015;29(6):526–535 the caregiver/teacher must create a safe space and redirect Afifi TO, Ford D, Gershoff ET, et al. Spanking and adult mental health 6. impairment: The case for the designation of spanking as an adverse childhood children’s difficult or emotional outbursts when necessary. experience. Child Abuse Negl. 2017;(71):24-31 Recognizing a child’s desires and offering a brief explana- 7. American Academy of Pediatrics Councils on Early Childhood and School - tion of the rules to support infants and toddlers in develop Health. The pediatrician’s role in school readiness. Pediatrics. 2016;138(3):1-7 8. Carr A. The Handbook of Child and Adolescent Clinical Psychology. 3rd ed. ing increased understanding over time as developmentally New York, NY: Routledge; 2016 appropriate. Preschoolers can beginning to develop an 9. Ferguson CJ. Spanking, corporal punishment and negative long-term understanding of rules; therefore brief verbal expressions outcomes: a meta-analytic review of longitudinal studies. Clin Psychol Rev. 2013;33(1):196–208 help prepare reasoning skills in infants and toddlers. School- aged children begin to develop a sense of personal responsi - NOTES bility and self-control and can learn using healthy and safe Content in the STANDARD was modified on 5/22/2018 incentives (8). In the wake of well- publicized allegations of child abuse in out-of-home settings and increased concerns 2.2.0.10 about liability, some programs have instituted no-touch poli - Using Physical Restraint cies, either explicitly or implicitly. No-touch policies are Re a der ’s Note : It should never be necessary to physically misguided efforts that fail to recognize the importance of restrain a typically developing child unless his/her safety touch to children’s healthy development. Touch is especially and/or that of others are at risk. important for infants and toddlers. Warm, responsive, safe, and appropriate touches convey regard and concern for chil - When a child with special behavioral or mental health dren of any age. Adults should be sensitive to ensure their issues is enrolled who may frequently need the cautious use touches (eg, pats on the back, hugs, ruffling a child’s hair) are of restraint in the event of behavior that endangers his or her - welcomed by the children and appropriate to their individ safety or the safety of others, a behavioral care plan should be ual characteristics and cultural experience. Careful, open developed with input from the child’s primary care provider, communication between the program and families about mental health provider, parents/guardians, center director/ the value of touch in children’s development can help to family child care home caregiver/teacher, child care health achieve consensus on the acceptable ways for adults to show consultant, and possibly early childhood mental health their respect and support for children in the program (5). consultant in order to address underlying issues and reduce the need for physical restraint. TYPE OF FACILITY Center, Large Family Child Care Home, Small Family That behavioral care plan should include: Child Care Home An indication and documentation of the use of other a. RELATED STANDARDS behavioral strategies before the use of restraint and a 2.2.0.6 Discipline Measures precise definition of when the child could be restrained; b. That the restraint be limited to holding the child as gently Handling Physical Aggression, Biting, and 2.2.0.7 as possible to accomplish the restraint; Hitting c. That such child restraint techniques do not violate the Using Physical Restraint 2.2.0.10 state’s mental health code; 3.4.4.1 Recognizing and Reporting Suspected Child d. That the amount of time the child is physically restrained Abuse, Neglect, and Exploitation should be the minimum necessary to control the situa- 3.4.4.2 Immunity for Reporters of Child Abuse and Neglect tion and be age-appropriate; reevaluation and change Preventing and Identifying Shaken Baby 3.4.4.3 of strategy should be used every few minutes; Syndrome/Abusive Head Trauma That no bonds, ties, blankets, straps, car seats, heavy e. weights (such as adult body sitting on child), or abusive 3.4.4.4 Care for Children Who Have Been Abused/ words should be used; Neglected That a designated and trained staff person, who should f. 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse be on the premises whenever this specific child is present, and Neglect would be the only person to carry out the restraint. 4 . 5 . 0 .11 Prohibited Uses of Food 9. 2 .1. 6 Written Discipline Policies

107 80 Caring for Our Children: National Health and Safety Performance Standards RATIONALE 2.3 A child could be harmed if not restrained properly (1). PARENT/GUARDIAN Therefore, staff who are doing the restraining must be RELATIONSHIPS trained. A clear behavioral care plan needs to be in place. And, clear documentation with parent/guardian notifica - 2 . 3 .1 tion needs to be done after a restraining incident occurs GENERAL in order to conform with the mental health code. COMMENTS 2 . 3 .1.1 If all strategies described in Standard 2.2.0.6 are followed Mutual Responsibility of Parents/Guardians and a child continues to behave in an unsafe manner, staff and Staff need to physically remove the child from the situation to a The quality of the relationship between parents/guardians less stimulating environment. Physical removal of a child is and caregivers/teachers has an influence on the child. There defined according the development of the child. If the child should be a reciprocal responsibility of the family and is able to walk, staff should hold the child’s hand and walk caregivers/teachers to observe, participate, and be trained him/her away from the situation. If the child is not ambula - in the care that each child requires, and they should be tory, staff should pick the child up and remove him/her to encouraged to work together as partners in providing care. a quiet place where s/he cannot hurt themselves or others. Staff need to remain calm and use a calm voice when direct- During the enrollment process, caregivers/teachers should ing the child. Certain procedures described in Standard clarify who is/are the legal guardian(s) of the child. All 2.2.0.6 can be used at this time, including not giving a lot relevant legal documents, court orders, etc., should also of attention to the behavior, distracting the child and/or be collected and filed during the enrollment process (1). giving a time-out to the child. If the behavior persists, a Caregivers/teachers should comply with court orders plan needs to be made with parental/guardian involvement. and written consent from the parent/guardian with This plan could include rewards or a sticker chart and/or legal authority, and not try to make the determination praise and attention for appropriate behavior. Or, loss of themselves regarding the best interests of the child. privileges for inappropriate behavior can be implemented, All aspects of child care programs should be designed to if age-appropriate. Staff should request or agree to step out facilitate parent/guardian input and involvement. Non- of the situation if they sense a loss of their own self-control custodial parents should have access to the same develop - and concern for the child. mental and behavioral information given to the custodial The use of safe physical restraint should occur rarely and parent/guardian, if they have joint legal custody, permission only for brief periods to protect the child and others. Staff by court order, or written consent from the custodial - should be alert to repeated instances of restraint for individ parent/guardian. ual children or within a indoor and outdoor learning/play Caregivers/teachers should also clarify with whom the environment and seek consultation from health and mental child spends significant time and with whom the child has health consultants in collaboration with families primary relationships as they will be key informants for the to develop more appropriate strategies. caregivers/teachers about the child and his/her needs. TYPE OF FACILITY Parent/guardian involvement is needed at all levels of the Center, Large Family Child Care Home program, including program planning for indoors and RELATED STANDARD out- doors, provision of quality care, screening for children 2.2.0.6 Discipline Measures who are ill, and support for other parents/guardians.Com- munication between the administrator, caregiver/teacher Reference and parent/guardian are essential to facilitate the involve - 1. Safe and Responsive Schools. 2003. Effective responses: Physical restraint. http://www.unl.edu/srs/pdfs/physrest.pdf. ment and commitment of parents/guardians. Parents/ guardians should be invited to participate on the program board or planning meetings for the program. Parents/ guardians should meet with their child’s caregiver/teacher or the director annually to discuss how their child is doing in the program. On a daily basis, parents/guardians and caregivers/teachers should share information about the child’s health, changes in drop-off or pick-up times, and changes in family routines or family events. Caregivers/ teachers should communicate regularly with parents/ guardians by providing injury report forms if their child sustains an injury, posting notices of exposures to infec - tious diseases, and greeting the parent/guardian at drop-off each day. Parents/guardians should receive a copy of the

108 81 Chapter 2: Program Activities for Healthy Development child care programs’ written policies, including health RELATED STANDARDS and safety policies. 2 .1.1. 5 Helping Families Cope with Separation 2 .1.1.7 Communication in Native Language Other Than Caregivers/teachers should informally share with parents/ English guardians daily information about their child’s needs and activities. 2 .1.1. 8 Diversity in Enrollment and Curriculum 2 .1.1. 9 Verbal Interaction - Transition reports on any symptoms that the child devel oped, differences in patterns of appetite or urinating, References and activity level should be exchanged to keep parents/ 1. Public Counsel Law Center in California. Guidelines for Releasing Children and Custody Issues. http://www.publiccounsel.org/publications/ guardians informed. release.pdf. Mayr, T., M. Ulich. 1999. Children’s well-being in day care centers: An 2. RATIONALE exploratory empirical study. Int J Early Years Educ 7:229-39. This plan will help achieve the important goal of carryover 3. Marshall, N. L. 1991. Empowering low-income parents: The role of child of facility components from the child care setting to the care. Boston, MA: EDRS. Greenman, J. 1998. Parent partnerships: What they don’t teach you can 4. child’s home environment. The child’s learning of new skills hurt. Child Care Infor Exch 124:78-82. is a continuous process occurring both at home and in child 5. Shores, E. J. 1998. A call to action: Family involvement as a critical care. Research, practice, and accumulated wisdom attest to component of teacher education programs. Tallahassee, FL: Southeastern Regional Vision for Education. the crucially important influence of children’s relationships Massachusetts State Office for Children. Establishing a successful family 6. with those closest to them. Children’s experience in child daycare home: A resource guide for providers. 1990. Boston: MA State care will be most beneficial when parents/guardians and Office for Children. 7. Tijus, C. A., et al. 1997. The impact of parental involvement on the quality caregivers/teachers develop feelings of mutual respect and of day care centers. Int J Early Years Educ 5:7-20. - trust. In such a situation, children feel a continuity of affec Jones, R. 1996. Producing a school newsletter parents will read. Child 8. tion and concern, which facilitates their adjustment to Care Infor Exch 107:91-3. 9. O’Connor, S., et al. 1996. ASQ: Assessing school age child care quality. separation and use of the facility. Especially for infants and Wellesly, MA: Center for Research on Women. toddlers, attention to consistency across settings will help Powell, D. R. 1998. Reweaving parents back into the fabric of early 10. minimize stress that can result from notable differences childhood programs: Research in review. Young Child 53:60-67. 11. Miller, S. H., et al. 1995. Family support in early education and child care in routines across caregivers/teachers and settings. settings: Making a case for both principles and practices. Child Today 23:26-29. Another ongoing source of stress for an infant or a young 12. Dombro, A. L. 1995. Sharing the care: What every provider and parent child is the separation from those they love and depend needs to know. Child Today 23:22-5. upon. Of the various programmatic elements in the facility Larner, M. 1995. Linking family support and early childhood programs: 13. Issues, experiences, opportunities: Best practices project, 1-40. Chicago, - that can help to alleviate that stress, by far the most import IL: Family Resource Coalition. ant is the comfort in knowing that parents/guardians and Endsley, R. C., et al. 1993. Parent involvement and quality day care in 14. caregivers/teachers know the children and their needs and proprietary centers. J Res Child Educ 7:53-61. 15. Fagan, J. 1994. Mother and father involvement in day care centers serving wishes, are in close contact with each other, and can respond infants and young toddlers. Early Child Dev Care 103:95-101. in ways that enable children to deal with separation. Seibel, N. L., L. G. Gillespie, and T. Temple. 2008. The role of child care 16. providers in child abuse prevention. Zero to Three 28:33-40. The encouragement and involvement of parents/guardians in the social and cognitive leaps of the child provides parents/guardians with the confidence vital to their sense 2 . 3 .1. 2 of competence. Caregivers/teachers should be able to direct Parent/Guardian Visits parents/guardians to sources of information and activities Parents/guardians are welcome any time their child is that support child’s development and learning and be able to in attendance. assist them to obtain appropriate screening and assessment Caregivers/teachers should inform all parents/guardians when there are concerns. Communication should that they may visit the site at any time when their child is be sensitive to ethnic and cultural practices. The parent/ there, and that, under normal circumstances, they will guardian/caregiver/teacher partnership models positive be admitted without delay. This open-door policy should adult behavior for school-age children and demonstrates be part of the “admission agreement” or other contract a mutual concern for the child’s well-being (2-16). between the parent/guardian and the facility/caregiver/ In families where the parents/guardians are separated, it is teacher. Parents/guardians should be welcomed and en- usually in the child’s best interest for both parents/guardians couraged to speak freely to staff about concerns and to be involved in the child’s care, and informed about the suggestions. Parents/guardians must be informed what child’s progress and problems in care. However, it is up to appropriate and inappropriate parental/guardian behavior the courts to decide who has legal custody of the child. is and the consequences for inappropriate behavior. TYPE OF FACILITY Authorized family members and parents/guardians should Center, Large Family Child Care Home check in with the facility staff every visit to ensure safety of the children in the facility.

109 82 Caring for Our Children: National Health and Safety Performance Standards To reach agreement on appropriate disciplinary b. RATIONALE measures; Requiring unrestricted access of parents/guardians to their c. To discuss the child’s strengths, specific health issues, children is essential to preventing the abuse and neglect of special needs, and concerns; children in child care (1,2). When access is restricted, areas To stay informed of family issues that may affect the d. observable by the parents/guardians may not reflect the child’s behavior in care; care the children actually receive. e. To identify goals for the child; COMMENTS f. To discuss resources that parents/guardians can access; Caregivers/teachers should not release a child to a parent/ g. To discuss the results of developmental screening. guardian who appears impaired (see Standard 9.2.4.1). At these planned conferences a caregiver/teacher should Caregivers/teachers should not attempt on their own to review with the parent/guardian the child’s health report, handle an unstable (e.g., intoxicated) parent/guardian who and the health record and assessments of development and wants to be admitted but whose behavior poses a risk to the learning that the program may do to identify medical and children. Caregivers/teachers should consult local police or developmental issues that require follow-up or adjustment the local child protection agency about their recommenda - by the facility. - tions for how staff can obtain support from law enforce ment authorities. Parents/guardians can be interviewed to Each review should be documented in the child’s health see if the open-door policy is consistently implemented. record with the signature of the parent/guardian and the staff reviewer. These planned conferences should occur: TYPE OF FACILITY a. As part of the intake process; Center, Large Family Child Care Home b. At each health update interval; RELATED STANDARDS On a calendar basis, scheduled according to the c. 2 .1.1.7 Communication in Native Language Other ch i ld ’s a ge: Than English 1. Every six months for children under six years of age 2.3.2.1 Parent/Guardian Conferences and for children with special health care needs; Seeking Parent/Guardian Input 2.3.2.2 Every year for children six years of age and older; 2. Whenever new information is added to the child’s d. 2.3.2.3 Support Services for Parents/Guardians facility health record. Parent/Guardian Complaint Procedures 2.3.2.4 Additional conferences should be scheduled if the parent/ 2.3.3.1 Parents’/Guardians’ Provision of Information on guardian or caregiver/teacher has a concern at any time Their Child’s Health and Behavior about a particular child. Any concern about a child’s health 9. 2 .1.1 Content of Policies or development should not be delayed until a scheduled Enrollment Information to Parents/Guardians 9. 2 .1. 3 conference date. and Caregivers/Teachers Notes about these planned communications should be 9. 2 . 4 .1 Written Plan and Training for Handling Urgent maintained in each child’s record at the facility and should Medical Care or Threatening Incidents be available for review. References RATIONALE 1. Koralek, D., U.S. Department of Health and Human Services. 1992. Caregivers of young children: Preventing and responding to child Parents/guardians and caregivers/teachers alike should maltreatment. Rev ed. The user manual series. McLean, VA: Circle, Inc. be aware of, and should have arrived at, an agreement con- 2. Baglin, C. A., M. Bender, eds. 1994. Handbook on quality child care for young children: Settings standards and resources. San Diego, CA: Singular cerning each other’s beliefs and knowledge about how to Publishing Group. care for children. Reviewing the health record with parents/ guardians ensures correct information and can be a valu - able teaching and motivational tool (1). It can also be a staff learning experience, through insight gained from parents/ 2.3.2 guardians on a child’s special circumstances. REGULAR COMMUNICATION - Studies have shown that parent–child interactions charac terized as structured and responsive to the child’s needs 2.3.2.1 and emotions were positively related to school readiness, Parent/Guardian Conferences social skills, and receptive communication skills Along with short informal daily conversations between development (2). parents/guardians and caregivers/teachers, and as a supple - A health history is the basis for meeting the child’s health, ment to the collaborative relationships caregivers/teachers mental, safety, and social needs in the child care setting (1). and parents/guardians form specifically to support infants Review of the health record can be a valuable educational and toddlers, periodic and regular planned communication tool for parents/guardians, through better understanding (e.g., parent/guardian conferences) should be scheduled of the health report and immunization requirements (1). with at least one parent/guardian of every child in care: A goal of out-of-home care of infants and children is to a. To review the child’s adjustment to care and development over time;

110 83 Chapter 2: Program Activities for Healthy Development identify parents/guardians who are in need of instruction References 1. Aronson, S. 2002. Model Child Care Health Policies. 4th ed. Bryn Mawr, so they can provide preventive health/nutrition/physical PA: American Academy of Pediatrics, Pennsylvania Chapter. activity care at a critical time during the child’s growth Connell, C. M., R. J. Prinz. 2002. The impact of childcare and parent– 2. and development. It is in the child’s best interest that the child interactions on school readiness and social skills development for low-income African American children. J of School Psychology 40:177-93. staff communicates with parents/guardians about the child’s needs and progress. Parent/guardian support groups and parent/guardian involvement at every level of 2.3.2.2 facility planning and delivery are usually beneficial to the Seeking Parent/Guardian Input children, parents/guardians, and staff. Communication At least twice a year, each caregiver/teacher should seek the among parents/guardians whose children attend the same views of parents/guardians about the strengths and needs - facility helps the parents/guardians to share useful informa of the indoor and outdoor learning/play environment and tion and to be mutually supportive. their satisfaction with the services offered. Caregivers/ teachers should honor parents’/guardians’ requests for COMMENTS more frequent reviews. Anonymous surveys can be offered The need for follow-up on needed intervention increases as a way to receive parent/guardian input without parents/ when an understanding of the need and motivation for the guardians feeling concerned if they have negative com- intervention has been achieved through personal contact. A ments or concerns about the facility or practices within health history ensures that all information needed to care a facility. for the child is available to the appropriate staff member. - Special instructions, such as diet, can be copied for every RATIONALE day use. Compliance can be assessed by reviewing the Parents/guardians and caregiver/teacher alike recognize that records of these planned communications. parents/guardians have essential rights in helping to shape the kind of child care service their children receive (1). Parents/guardians who use child care services should be regarded as active participants and partners in facilities that COMMENTS meet their needs as well as their children’s. Especially for Asking parents/guardians about their concerns and infants and toddlers, authentic relationships are crucial to observations is essential so they can share issues and the optimal development of the child. Compliance can be engage with staff in collaborative problem-solving. Small measured by interviewing parents/guardians and staff. and large family child care homes should have group meet - TYPE OF FACILITY - ings of all parents/guardians once or twice a year. This stan dard avoids mention of procedures that are inappropriate Center, Large Family Child Care Home to small family child care, as it does not require any explicit RELATED STANDARDS mechanism (such as a parent/guardian advisory council) Qualifications and Responsibilities for Health 1. 3. 2.7 for obtaining or offering parental/guardian input. Indivi- Advocates dual or group meetings with parents/guardians would 4.2.0.2 Assessment and Planning of Nutrition for suffice to meet this standard. Seeking consumer input is a Individual Children cornerstone of facility planning and evaluation. Centers can 9.2.3.4 Written Policy for Obtaining Preventive Health offer parents/guardians the chance to respond in writing. Service Information Accreditation organizations such as the National Asso- ciation for the Education of Young Children (NAEYC) or Documentation of Exemptions and Exclusion of 9.2.3.5 the National Association for Family Child Care (NAFCC) Children Who Lack Immunizations have guidance on conducting parent/guardian surveys. Identification of Child’s Medical Home and 9.2.3.6 Parental Consent for Information Exchange TYPE OF FACILITY Center, Large Family Child Care Home Information Sharing on Therapies and Treatments 9.2.3.7 Needed Reference 1. National Association of Child Care Resource and Referral Agencies. It’s a 9.2.3.8 Information Sharing on Family Health win-win situation: When parents and providers work together. Child Care 9. 4 . 2 .1 Contents of Child’s Records http://ccaapps.childcareaware.org/en/subscriptions/dailyparent/ Awa re. volume.php?id=29. 9.4.2.2 Pre-Admission Enrollment Information for Each Child 2.3.2.3 9.4.2.3 Contents of Admission Agreement Between Child Care Program and Parent/Guardian Support Services for Parents/Guardians Caregivers/teachers should establish parent/guardian 9.4.2.4 Contents of Child’s Primary Care Provider’s groups and parent/guardian support services. Caregivers/ Assessment teachers should have a regularly established means of com- Health History 9.4.2.5 municating to parents/guardians the existence of these Contents of Medication Record 9.4.2.6 groups and support services. Caregivers/teachers should 9.4.2.7 Contents of Facility Health Log for Each Child document these services and should include intra-agency Release of Child’s Records 9.4.2.8 activities or other community support group offerings.

111 84 Caring for Our Children: National Health and Safety Performance Standards The caregiver/teacher should record parental/guardian par- RATIONALE ticipation in these on-site activities in the facility record. Coordination between the facility and the parents/guardians is essential to promote their respective child care roles and One strategy for supporting parents/guardians is to facili - - to avoid confusion or conflicts surrounding values. In addi tate communication among parents/guardians. The facility tion to routine meetings, special meetings can deal with should give consenting parents/guardians a list of names crises and unique problems. Complaint and resolution and phone numbers of other consenting parents/guardians documentation records can help program directors assess whose children attend the same facility. The list should problem areas of the facility, staff, and services. include an annotation encouraging parents/guardians whose children attend the same facility to communicate COMMENTS with one another about the service. The facility should Special meetings could identify facility needs, assist in update the list at least annually. developing resources, and recommend facility and policy - changes to the governing body. It is most helpful to docu RATIONALE ment the proceedings of these meetings to facilitate future Parental/guardian involvement at every level of program - communications and to ensure continuity of service deliv planning and delivery and parent/guardian support groups ery. Facility-sponsored activities could take place outside are elements that are usually beneficial to the children, facility hours and at other venues. parents/guardians, and staff of the facility (1). The parent/ - guardian association group facilitates mutual understand TYPE OF FACILITY ing between the program and parents/guardians. Parental/ Center, Large Family Child Care Home guardian involvement also helps to broaden parents’/ RELATED STANDARDS guardians’ knowledge of administration of the facility Handling Complaints About Caregivers/Teachers 1.8. 2.5 and develops and enhances advocacy efforts (1). Encourag- Governing Body of the Facility 9.1. 0.1 - ing parents’/guardians’ communication is simple, inexpen sive, and beneficial. Such communication may include the 9.1. 0. 2 Written Delegation of Administrative Authority exchange of positive aspects of the facility and positive Access to Facility Records 9.4.1.4 knowledge about children’s peers. If parents/guardians Procedure for Receiving Complaints 10. 4 . 3.1 communicate with each other, they can share concerns about the behavior of a specific caregiver/teacher and can identify patterns of action suggestive of abuse/neglect. 2.3.3 Parents/guardians can encourage each other to report all HEALTH INFORMATION SHARING concerns to the director or owner of the program. COMMENTS 2.3.3.1 Parent/guardian meetings within a facility are useful means Parents’/Guardians’ Provision of Information of communication that supplement mailings and indirect on Their Child’s Health and Behavior contacts. The facility should ask parents/guardians for information TYPE OF FACILITY regarding the child’s health, nutrition, level of physical Center, Large Family Child Care Home activity, and behavioral status upon registration or when there has been an extended gap in the child’s attendance Reference 1. National Association of Child Care Resource and Referral Agencies. It’s a at the facility. The child’s health record should be updated if win-win situation: When parents and providers work together. Child Care s/he have had any changes in their health or immunization http://ccaapps.childcareaware.org/en/subscriptions/dailyparent/ Awa re. status. Parents/guardians should be encouraged to sign a volume.php?id=29. release of information/agreement so that child care workers can communicate directly with the child’s medical home/ 2.3.2.4 primary care provider. Parent/Guardian Complaint Procedures RATIONALE Facilities should have in place complaint resolution Admission of children without this information will leave procedures to jointly resolve with parents/guardians any the center unprepared to deal with daily and emergent problems that may arise. Arrangements for hearing (or health needs of the child, other children, and staff if receiving) the complaint and the actions (or discussion) there is a question of communicability of disease. resulting in resolution should be documented along with - dates and people involved. Facilities should develop mecha COMMENTS nisms for holding formal and informal meetings between It would be helpful to also have updated information about staff and groups of parents/guardians. Substantiated com- the health status of parents/guardians and siblings, noting plaints and their resolution(s) should be posted in a promi - any special conditions, circumstances, or stress that may nent location. Facilities should post the complaint and be affecting the child in care. Some parents/guardians resolution procedure where parents/guardians can easily may resist providing this information. If so, the caregiver/ see (or view) them. teacher should invite them to view this exchange of

112 85 Chapter 2: Program Activities for Healthy Development information as an opportunity to express their own 9.4.2.4 Contents of Child’s Primary Care Provider’s concerns about the facility (1). Assessment 9.4.2.5 Health History TYPE OF FACILITY 9.4.2.6 Contents of Medication Record Center, Large Family Child Care Home 9.4.2.7 Contents of Facility Health Log for Each Child RELATED STANDARDS 9.4.2.8 Release of Child’s Records Inclusion/Exclusion/Dismissal of Children 3. 6 .1.1 Staff Exclusion for Illness 3. 6 .1. 2 2.4 Enrollment Information to Parents/Guardians and 9. 2 .1. 3 Caregivers/Teachers HEALTH EDUCATION Contents of Child’s Records 9. 4 . 2 .1 2.4.1 Reference HEALTH EDUCATION FOR CHILDREN 1. Crowley, A. A., G. C. Whitney. 2005. Connecticut’s new comprehensive and universal early childhood health assessment form. J School Health 75:281-85. 2 . 4 .1.1 Health and Safety Education Topics 2.3.3.2 for Children Communication from Specialists Health and safety education topics for children should Health and safety, education, and other specialists/ include physical, oral, mental, nutritional, and social and professionals who come into the facility to furnish spe- emotional health, and physical activity. These topics should cial services to a child should communicate at each visit be integrated daily into the program of age-appropriate with the caregiver/teacher at the facility. The specialist/ activities, to include: professional must also be certain that all communication Body awareness and use of appropriate terms for body parts a. shared with caregivers/teachers is shared directly with the Families, including that families have varying composi b. - parent/guardian. These specialists may include, but are not tions, beliefs, and cultures limited to, physicians, registered nurses, child care health c. Personal social skills, such as sharing, being kind, helping consultants, behavioral consultants (e.g., psychologists, others, and communicating appropriately counselors, clinical social workers), occupational thera- Expression and identification of feelings d. pists, physical therapists, speech therapists, educational Self-esteem and self-awareness e. therapists, registered dietitians, and play facilitator. The Nutrition and healthy eating, drinking water, including f. discussions should be documented in the child’s Care Plan. healthy habits and preventing obesity Specialists should use the facility’s sign in/sign out system Healthy sleep habits g. for accurate tracking of their interactions with or on behalf h. Outdoor learning/play of the child. i. Fitness and age-appropriate physical activity RATIONALE j. Personal and dental hygiene, including wiping, flushing, handwashing, cough and sneezing etiquette, and tooth Therapeutic services must be coordinated with the child’s brushing general education program and with the parents/guardians k. Safety, such as home, vehicular car seats and safety belts, and caregivers/teachers so everyone understands the child’s playground, bicycle, fire, firearms, water, and hat to do needs. To be most useful, the service providers must share in an emergency, getting help, and/or dialing 911 for the therapeutic techniques with the caregivers/teachers and emergencies parents/guardians and integrate them into the child’s daily Conflict management, violence prevention, and l. routines, not just at therapy sessions. Parent/guardian bullying prevention consent to share information may be necessary. A child Age-appropriate first aid concepts m. care health consultant can be helpful in coordinating Healthy and safe behaviors n. these techniques and treatments. Poisoning prevention and poison safety o. TYPE OF FACILITY Awareness of routine preventive care p. Center, Large Family Child Care Home q. Care of children with special health care needs RELATED STANDARDS Health risks of secondhand and third-hand smoke r. s. Appropriate use of medications 9.2.4.7 Sign-In/Sign-Out System Handling food safely t. 9. 4 . 2 .1 Contents of Child’s Records Preventing choking and falls u. 9.4.2.2 Pre-Admission Enrollment Information for RATIONALE Each Child For young children, health education and safety education 9.4.2.3 Contents of Admission Agreement Between Child are inseparable from one another. Children learn about Care Program and Parent/Guardian health and safety by experiencing risk-taking and risk

113 86 Caring for Our Children: National Health and Safety Performance Standards control, fostered and modeled by adults who are involved 3.1.3.4 Caregivers’/Teachers’ Encouragement of Physical with them. Whenever opportunities for learning arise, Activity caregivers/teachers should integrate education to promote Scheduled Rest Periods and Sleep Arrangements 3.1.4.4 healthy and safe behaviors.1 Health and safety education 3.1. 5. 3 Oral Health Education does not have to be seen as a structured curriculum but as Handwashing Procedure 3.2.2.2 a daily component of the planned program that is part of a Cough and Sneeze Etiquette 3.2.3.2 child’s development and habit. Health and safety education 4 . 5. 0.10 Foods that Are Choking Hazards supports and reinforces a healthy and safe lifestyle (1,2). Nutrition Learning Experiences for Children 4.7.0.1 COMMENTS Nutrition Education for Parents/Guardians 4.7.0.2 Teaching children the appropriate names for their body parts is a good way to increase body awareness and per- References 1. Sharma M. Health education and health promotion. In: Theoretical sonal safety. Learning about routine health maintenance Foundations of Health Education and Health Promotion. Burlington, - practices, such as vaccination, vision screening, blood pres MA: Jones & Bartlett Learning; 2017:4–7 sure screening, oral health examinations, and blood tests, Lyn R, Evers S, Davis J, Maalouf J, Griffin M. Barriers and supports to 2. implementing a nutrition and physical activity intervention in child care: helps children understand these activities and appreciate directors’ perspectives. J Nutr Educ Behav. 2014;46(3);171–180 their value rather than fearing them. Similarly, learning 3. Anderson SE, Andridge R, Whitaker RC. Bedtime in preschool-aged about the importance of nutrition, drinking water, fitness, children and risk for adolescent obesity. J Pediatr. 2016;176:17–22 Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus statement of the 4. and healthy sleeping habits helps children make responsible American Academy of Sleep Medicine on the recommended amount of healthful decisions. Good sleep hygiene (3) (e.g., early and sleep for healthy children: methodology and discussion. J Clin Sleep Med. routine bedtimes) and obtaining a sufficient amount of 2016;12(11):1549–1561 5. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, sleep in early childhood4 are associated with improved Hysing M. Later emotional and behavioral problems associated with sleep social and emotional (5,6) cognitive, and weight outcomes problems in toddlers: a longitudinal study. JAMA Pediatr. (7-10). 2015;169(6):575–582 Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a 6. Child care health consultants and certified health educa- population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. tion specialists are good resources for this instruction. The 2012;129(4):e857–e865 7. Institute of Medicine. Early Childhood Obesity Prevention Policies: National Commission for Health Education Credentialing Goals, Recommendations, and Potential Actions. Washington, DC: provides information on certified health education Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/ specialists. media/Files/Report%20Files/2011/Early-Childhood-Obesity-Prevention- Policies/Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017 Additional Resources 8. Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on American Academy of Pediatrics. Healthy sleep habits: how many hours does overweight and obesity in children and adolescents: a systematic review your child need? HealthyChildren.org Web site. https://www.healthychildren. and bias-adjusted meta-analysis. Obes Rev. 2015;16(2):137–149 org/English/healthy-living/sleep/Pages/Healthy-Sleep-Habits-How-Many- 9. Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a Hours-Does-Your-Child-Need.aspx. Updated March 23, 2017. Accessed systematic review and meta-analysis of prospective cohort studies. November 14, 2017 J Paediatr Child Health. 2017;53(4):378–385 Bonuck KA, Schwartz B, Schechter C. Sleep health literacy in Head Start Bonuck K, Chervin RD, Howe LD. Sleep-disordered breathing, sleep 10. families and staff: exploratory study of knowledge, motivation, and duration, and childhood overweight: a longitudinal cohort study. competencies to promote healthy sleep. Sleep Health. 2016;2(1):19–24 J Pediatr. 2015;166(3):632–639 Kobayashi K, Yorifuji T, Yamakawa M, et al. Poor toddler-age sleep schedules NOTES predict school-age behavioral disorders in a longitudinal survey. Brain Dev. 2015;37(6):572–578 Content in the STANDARD was modified on 1/10/2017 Owens JA, Witmans M. Sleep problems. Curr Probl Pediatr Adolesc Health and 5/30/2018 Care. 2004;34(4):154–179 TYPE OF FACILITY 2 . 4 .1. 2 Center, Large Family Child Care Home, Small Family Staff Modeling of Healthy and Safe Behavior Child Care Home and Health and Safety Education Activities RELATED STANDARDS The program should strongly encourage all staff members to model healthy and safe behaviors and attitudes in their 1. 6 . 0.1 Child Care Health Consultants contact with children in the indoor and outdoor learning/ 1.6.0. 3 Early Childhood Mental Health Consultants play environment, including, eating nutritious foods, drink- 2 .1.1.1 Written Daily Activity Program and Statement of ing water or nutritious beverages when with the children, Principles sitting with children during mealtime, and eating some of Health, Nutrition, Physical Activity, and Safety 2 .1.1. 2 the same foods as the children. Caregivers/teachers should Awareness engage in daily movement and physical activity; limit seden- 2 .1.1. 6 Transitioning within Programs and Indoor and tary behaviors when in the outdoor learning/play environ - Outdoor Learning/Play Environments ment (e.g., not sitting in structured chairs); not watch TV; and comply with handwashing protocols, and tobacco, Handling Physical Aggression, Biting, and Hitting 2.2.0.7 electronic cigarettes (e-cigarettes), and drug use policies. 2 . 4 .1. 3 Gender and Body Awareness

114 87 Chapter 2: Program Activities for Healthy Development - in their care. Compliance should be documented by obser Caregivers/teachers should talk about and model healthy vation. Consultation can be sought from a child care health and safe behaviors while they carry out routine daily activities. Activities should be accompanied by words consultant or certified health education specialist. The of encouragement and praise for achievement. American Association for Health Education (AAHE) and the National Commission for Health Education Facilities should encourage and support staff who wish Credentialing (NCHEC) provide information on to breastfeed their own infants and those who engage in certified health education specialists. gardening to enhance interest in healthy food, science, An extensive education program to make such experiential inquiries and learning. Staff are consistently a model for learning possible indoors and outdoors should be supported children and should be cognizant of the environmental by strong community resources in the form of both con- information and print messages they bring into the indoor and outdoor learning/play environment. The labels and sultation and materials from sources such as the health print messages that are present in the indoor and outdoor department, nutrition councils, and so forth. Suggestions for topics and methods of presentation are widely available learning/play environment or family child care home should be in line with the healthy and safe behaviors (7). Examples include, but are not limited to, routine pre- ventive care by health professionals; nutrition education and attitudes they wish to impart to the children. and physical activity to prevent obesity; crossing streets Facilities should use developmentally appropriate health safely; how to develop and use outdoor learning/play envi - and safety education materials in the children’s activities ronments; car seat safety; poison safety; latch key programs; and should also share these with the families whenever health risks from secondhand smoke (exhaled smoke from possible. smokers into the air), thirdhand smoke (residual smoke and All health and safety education activities should be geared chemicals on the smoker’s clothes and hair or on surfaces to the child’s developmental age and should take into where smoking occurs) (8,9), and secondhand emission account individual personalities and interests. from e-cigarettes (exhaled vapors into the air) (9); personal hygiene; and oral health; including limiting sweets; rinsing RATIONALE the mouth with water after sweets; and regular tooth brush - Modeling is an effective way of confirming that a behavior ing. It can be helpful to place visual cues in the indoor and is one to be imitated. Young children are particularly outdoor learning/play environments to serve as reminders dependent on adults for their nutritional needs in both (e.g., posters). “Risk Watch” is a prepared curriculum from - the home (1) and child care environment (2). Thus, model the National Fire Protection Association (NFPA) offering ing healthy and safe behaviors is an important way to comprehensive injury prevention strategies for children in demonstrate and reinforce healthy and safe behaviors of preschool through eighth grade (10). caregivers/teachers and children. Young children learn better through experiencing an activity and observing TYPE OF FACILITY behavior than through didactic training (3,4). Learning Center, Large Family Child Care Home and play have a reciprocal relationship; play experiences RELATED STANDARDS are closely related to learning (4). Caregivers/teachers Screen Time/Digital Media Use 2.2.0.3 impact the nutrition habits of the children under their 2 . 4 .1.1 Health and Safety Education Topics for Children care, not only by making choices regarding the types of - foods that are available but by influencing children’s atti 2 . 4 .1. 2 Staff Modeling of Healthy and Safe Behavior and tudes and beliefs about that food as well as social interac - Health and Safety Education Activities tions at mealtime. This provides a unique opportunity for 3.1. 3.1 Active Opportunities for Physical Activity programs to guide children’s choices by assigning parents/ Playing Outdoors 3.1.3.2 guardians and caregivers/teachers to the role of nutritional Caregivers’/Teachers’ Encouragement of Physical 3.1.3.4 gatekeepers for the young children in their care. Such Activity intervention is consistent with the U.S. Department of Situations that Require Hand Hygiene 3.2.2.1 Agriculture’s (USDA’s) and U.S. Department of Health and Human Services’ (DHHS’) 2015-2020 Dietary Guidelines Handwashing Procedure 3.2.2.2 for Americans, 8th Edition. The Dietary Guidelines focus 3. 4 .1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, on increased healthy eating and physical activity to reduce and Drugs the current rate of overweight or obesity in American 4 . 2 . 0.1 Written Nutrition Plan children (one in three in the nation) (5). Availability of Drinking Water 4.2.0.6 The effectiveness of health and safety education is enhanced General Plan for Feeding Infants 4 . 3.1.1 when shared between the caregiver/teacher and the parents/ 4.3.1.3 Preparing, Feeding, and Storing Human Milk guardians (6,7). Serving Size for Toddlers and Preschoolers 4.3.2.2 COMMENTS 4.3.3.1 Meal and Snack Patterns for School-Age Children Caregivers/teachers are important in the lives of the young 4.5.0.4 Socialization During Meals children in their care. They should be educated and sup- 4.5.0.7 Participation of Older Children and Staff in ported to be able to interact optimally with the children Mealtime Activities

115 88 Caring for Our Children: National Health and Safety Performance Standards 4.6.0.2 Nutritional Quality of Food Brought From Home References 1. Stein, M., K. Zuckert, S. Dixon. 2001. Sammy: Gender identity concerns in 4.7.0.1 Nutrition Learning Experiences for Children a six year old boy. Pediatrics 107:850-854. National Association for the Education of Young Children (NAEYC). 1997. 2. References Teaching young children to resist bias. Early Years are Learning Years Series. 1. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The role of Washington, DC: NAEYC. 16:169-86. Future Child parents in preventing childhood obesity. 3. Couchenour, D., K. Chrisman. 2002. Healthy sexuality development: A guide Ward, S., et al. 2015. Systematic review of the relationship between 2. for early childhood educators and families. Washington, DC: National childcare educators’ practices and preschoolers’ physical activity and Association for the Education of Young Children. Obesity Reviews 16: 1055-1070. eating behaviors. 4. Brill, S. A., R. Pepper. 2008. The transgender child: A handbook for families 3. Hemmeter, M. L., L. Fox, S. Jack, L. Broyles. 2007. A program-wide model and professionals. San Francisco: Cleis. of positive behavior support in early childhood settings. J Early 29:337-55. Intervention White. R.E. The power of play. A research summary on play and learning. 4. 2012. http://www.childrensmuseums.org/images/ MCMResearchSummary.pdf. 2.4.2 5. U.S. Department of Health and Human Services and U.S. Department of HEALTH EDUCATION FOR STAFF Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. http://health.gov/dietaryguidelines/2015/guidelines/. December 2015. 6. Centers for Disease Control and Prevention. Education and community 2.4.2.1 http://www.cdc.gov/healthliteracy/ support for health literacy. 2016. Health and Safety Education Topics for Staff education-support/index.html. 7. Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. Health and safety education for staff should include physical, 2005. Opportunities for health promotion education in child care. oral, mental, emotional, nutritional, physical activity, and Pediatrics 116: e499-505. http://pediatrics.aappublications.org/ social health of children. In addition to the health and safety content/116/4/e499. ht tp:// Dale, L. 2014. What is thirdhand smoke, and why is it a concern? 8. topics for children in Standard 2.4.1.1, health education topics www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/ for staff should include: third-hand-smoke/faq-20057791. ht tp:// 9. American Lung Association. E-cigarettes and Lung Health. 2016. Promoting healthy mind and brain development a. www.lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health. through child care; html?referrer=https://www.google.com/. Kendrick, D., L. Groom, J. Stewart, M. Watson, C. Mulvaney, R. 10. b. Healthy indoor and outdoor learning/play environments; Casterton. 2007. Risk Watch: Cluster randomized controlled trial Behavior/discipline; c. 13:93-99. Injury Prevention evaluating an injury prevention program. d. Managing emergency situations; NOTES Monitoring developmental abilities, including indicators e. Content in the STANDARD was modified on 1/10/2017. of potential delays; Nutrition (i.e., healthy eating to prevent obesity); f. g. Food safety; 2 . 4 .1. 3 h. Water safety; Gender and Body Awareness Safety/injury prevention; i. The facility should prepare caregivers/teachers to appro- Safe use, storage, and clean-up of chemicals; j. priately discuss with the children anatomical facts related Hearing, vision, and language problems; k. to gender identity and sex differences. When talking with l. Physical activity and outdoor play and learning; parents/guardians, caregivers/teachers should take a m. Immunizations; general approach, while respecting cultural differences, Gaining access to community resources; n. acknowledging that all children engage in fantasy play, Maternal or parental/guardian depression; o. dressing up and trying out different roles (1). Caregivers/ Exclusion policies; p. teachers should give children messages that contrast with Tobacco use/smoking and electronic cigarette q. stereotypes, such as men and women in non-traditional (e-cigarette) use/vaping; roles (2). Facilities should strive for developing common r. Marijuana use; language and understanding among all the partners. s. Safe sleep environments and SIDS prevention; RATIONALE t. Breastfeeding support; u. Environmental health and reducing exposures to Open discussions among adults concerning childhood sex- environmental toxins; uality increase their comfort with the subject. The adults’ v. Children with special needs; comfort may reduce children’s anxiety about sexuality (3,4). w. Shaken baby syndrome and abusive head trauma; COMMENTS Safe use, storage of firearms; x. Discussing sexuality and gender identity topics with young y. Safe medication administration and appropriate children is not always easy because the views of facility antibiotic use; administrators, caregivers/teachers, parents/guardians, and z. Safe storage of medications; community leaders on these topics may differ. aa. Safe storage of marijuana (in all forms, including oils, TYPE OF FACILITY liquids, and edible products); and ab. Safe storage of toxic substances. Center, Large Family Child Care Home

116 89 Chapter 2: Program Activities for Healthy Development Payment for Continuing Education RATIONALE 1.4.6. 2 When child care staff are knowledgeable in health and safety Child Care Health Consultants 1. 6 . 0.1 practices, programs are more likely to be healthy and safe (1). 2 .1.1. 2 Health, Nutrition, Physical Activity, and Safety Compliance with twenty hours per year of staff continuing Awareness education in the areas of health, safety, child development, 2 .1.1. 4 Monitoring Children’s Development/Obtaining and abuse identification was the most significant predictor Consent for Screening for compliance with state child care health and safety regu - Supervision Near Bodies of Water 2.2.0.4 lations (2). Child care staff often receive their health and 2.2.0.6 Discipline Measures safety education from a child care health consultant. Data - support the relationship between child care health consulta 2 . 4 .1.1 Health and Safety Education Topics for Children tion and the increased quality of the health of the children Use of Tobacco, Electronic Cigarettes, Alcohol, 3. 4 .1.1 and safety of the child care center environment (3,4). and Drugs COMMENTS Emergency Procedures 3.4.3.1 Community resources can provide written health- and safety- Preventing and Identifying Shaken Baby Syndrome/ 3.4.4.3 related materials. Examples of materials can be found here: Abusive Head Trauma https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health and 3. 6 .1.1 Inclusion/Exclusion/Dismissal of Children http://www.childhealthonline.org/. Consultation or training 3.6.3.1 Medication Administration can be sought from a child care health consultant (CCHC) 4 . 3.1.1 General Plan for Feeding Infants or certified health education specialist (CHES). Use and Storage of Toxic Substances 5. 2 . 9.1 Child care programs should consider offering “credit” Firearms 5.5.0.8 for health education classes or encourage staff members 7. 2 . 0 .1 Immunization Documentation to attend accredited education programs that can give education credits. 7.2.0.2 Unimmunized Children 7. 2 . 0 . 3 Immunization of Caregivers/Teachers The American Association for Health Education (AAHE) and the National Commission for Health Education Community Resource Information 9. 4 .1.19 Credentialing (NCHEC) provide information on certified 9.4.2.4 Contents of Child’s Primary Care Provider’s health education specialists. Assessment TYPE OF FACILITY References 1. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health Center, Large Family Child Care Home consultation improves health and safety policies and practices. Academic RELATED STANDARDS Pediatrics 9:366–70. http://www.academicpedsjnl.net/article/S1876- 2859(09)00123-5/abstract. 1.1.1.5 Ratios and Supervision for Swimming, Wading, and Crowley, A. A., M. S. Rosenthal. 2009. Ensuring the health and safety of 2. Water Play Connecticut’s early care and education programs. Farmington, CT: The Child Health and Development Institute of Connecticut. Additional Qualifications for Caregivers/Teachers 1. 3. 2.4 3. Alkon, A., et al. 2014. NAPSACC intervention in child care improves nutrition Serving Children Three to Thirty-Five Months and physical activity knowledge, policies, practices, and children’s BMI. BMC Pediatrics 14: 215. of Age 4. Alkon, A., et al. 2016. Integrated pest management intervention in child care 1. 4 . 2 .1 Initial Orientation of All Staff centers improves knowledge, pest control, and practices . Journal of Pediatric 30(6): e27-e41. Health Care Orientation for Care of Children with Special 1.4.2.2 Health Care Needs Additional References Rosenthal, M. S., A. A. Crowley, L. Curry. 2009. Promoting child development 1.4. 2. 3 Orientation Topics and behavioral health: Family child care providers’ perspectives. 1. 4 . 3.1 First Aid and CPR Training for Staff J Pediatric Health Care 23:289-97. Centers for Disease Control and Prevention. Get smart: Know when antibiotics Topics Covered in First Aid Training 1.4. 3. 2 work. http://www.cdc.gov/getsmart/. 1.4.3.3 CPR Training for Swimming and Water Play American Lung Association. E-cigarettes and Lung Health. 2016. http://www. 1.4.4.1 Continuing Education for Directors and Caregivers/ lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health. html?referrer=https://www.google.com/. Teachers in Centers and Large Family Child Care Homes National Institute on Drug Abuse. DrugFacts - Marijuana. 2016. https://www. drugabuse.gov/publications/drugfacts/marijuana. 1.4.4.2 Continuing Education for Small Family Child Care Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. Home Caregivers/Teachers Opportunities for health promotion education in child care. Pediatrics 116: Training of Staff Who Handle Food 1. 4 . 5.1 e499-e505. http://pediatrics.aappublications.org/content/116/4/e499. 1.4.5. 2 Child Abuse and Neglect Education Centers for Disease Control and Prevention. Education and community support for health literacy. 2016. http://www.cdc.gov/healthliteracy/education-support/ 1.4.5. 3 Training on Occupational Risk Related to Handling index.html. Body Fluids NOTES 1.4.5.4 Education of Center Staff Content in the STANDARD was modified on 1/10/2017. Training Time and Professional Development Leave 1. 4 . 6 .1

117 90 Caring for Our Children: National Health and Safety Performance Standards Importance of well-child care (such as immunizations, e. 2.4.3 hearing/vision screening, monitoring growth and development); HEALTH EDUCATION Child development and behavior including bonding f. FOR PARENTS/GUARDIANS and attachment; Domestic and relational violence; g. 2 . 4 . 3 .1 h. Conflict management and violence prevention; Opportunities for Communication and i. Oral health promotion and disease prevention; Modeling of Health and Safety Education Effective toothbrushing, handwashing, diapering, j. and sanitation; for Parents/Guardians k. Positive discipline, effective communication, and Parents/guardians should be given opportunities to observe behavior management; staff members modeling healthy and safe behavior and Handling emergencies/first aid; l. facilitating child development, both indoors and outdoors. Child advocacy skills; m. Parents/guardians should also have opportunities to ask Special health care needs; n. questions and to describe how effective the modeling has o. Information on how to access services such as the been. For parents/guardians who may not have the oppor - supplemental food and nutrition program (i.e., The tunity to visit their child or observe during the day, there Women, Infants and Children [WIC] Supplemental should be alternate forms of communication between the Food Program), Food Stamps (SNAP), food pantries, staff and the parents/guardians. This can be handouts, as well as access to medical/health care and services written journals that would go between facility and home, for developmental disabilities for children; newsletters, electronic communication, or events. p. Handling loss, deployment, and divorce; RATIONALE q. The importance of routines and traditions (including Modeling and communication about healthy and safe reading and early literacy) with a child. behaviors that promote positive development can be an Health and safety education for parents/guardians should effective educational tool (1,2). - utilize principles of adult learning to maximize the poten TYPE OF FACILITY tial for parents/guardians to learn about key concepts. Center, Large Family Child Care Home Facilities should utilize opportunities for learning, such as the case of an illness present in the facility, to inform References 1. Lehman, G. R., E. S. Geller. 1990. Participative education for children: An parents/guardians about illness and prevention strategies. effective approach to increase safety belt use. J Appl Behav Anal 23:219-25. The staff should introduce seasonal topics when they are 2. Lindsay, A. C., K. M. Sussner, J. Kim, S. Gortmaker. 2006. The role of parents in preventing childhood obesity. Future Child 16:169-86. relevant to the health and safety of parents/guardians and children. 2.4.3.2 RATIONALE Parent/Guardian Education Plan Adults learn best when they are motivated, comfortable, The content of a parent/guardian education plan should be and respected; when they can immediately apply what they individualized to meet each family’s needs and should be have learned; and when multiple learning strategies are sensitive to cultural values and beliefs. Written material, used. Individualized content and approaches are needed for at a minimum, should address the most important health successful intervention. Parent/guardian attitudes, beliefs, and safety issues for all age groups served, should be in fears, and educational and socioeconomic levels all should a language understood by families, and may include the be given consideration in planning and conducting parent/ topics listed in Standard 2.4.1.1, with special emphasis on guardian education (1,2). Parental/guardian behavior can the following: be modified by education. Parents/guardians should be involved closely with the facility and be actively involved Safety (such as home, community, playground, firearm, a. in planning parent/guardian education activities. If done age- and size-appropriate car seat use, safe medication well, adult learning activities can be effective for educating administration procedures, poison awareness, vehicular, parents/guardians. If not done well, there is a danger of or bicycle, and awareness of environmental toxins and demeaning parents/guardians and making them feel less, healthy choices to reduce exposure); rather than more, capable (1,2). Value of developing healthy and safe lifestyle choices b. early in life and parental/guardian health (such as exer - The concept of parent/guardian control and empowerment cise and routine physical activity, nutrition, weight con- is key to successful parent/guardian education in the child trol, breastfeeding, avoidance of substance abuse and care setting. Support and education for parents/guardians tobacco use, stress management, maternal depression, lead to better parenting skills and abilities. HIV/AIDS prevention); c. Importance of outdoor play and learning; d. Importance of role modeling;

118 91 Chapter 2: Program Activities for Healthy Development Knowing the family will help the staff such as the health References 1. National Association for the Education of Young Children. 2012. and safety advocate determine content of the parent/ Supporting cultural competence: Accreditation of programs for guardian education plan and method for delivery. Specific young children cross-cutting theme in program standards. attention should be paid to the parents’/guardians’ need for https://www.naeyc.org/academy/ files/academy/file/ TrendBriefsSupportingCulturalCompetence.pdf. support and consultation and help locating resources for Gupta, R. S., S. Shuman, E. M. Taveras, M. Kulldorff, J. A. Finkelstein. 2005. 2. their problems. If the facility suggests a referral or resource, 116: Opportunities for health promotion education in child care. Pediatrics this should be documented in the child’s record. Specifics of e499-e505. http://pediatrics.aappublications.org/content/116/4/e499. what the parent/guardian shared need not be recorded. Additional References Centers for Disease Control and Prevention. Education and community COMMENTS support for health literacy. 2016. http://www.cdc.gov/healthliteracy/ Community resources can provide written health- and education-support/index.html. safety-related materials. Centers for Disease Control and Prevention. Tips for parents – Ideas to help children maintain a healthy weight. 2016. http://www.cdc.gov/healthyweight/ TYPE OF FACILITY children/. Center, Large Family Child Care Home Office of Head Start. Head start cultural and linguistic responsiveness resource catalogue. Volume three : Cultural responsiveness (first edition). RELATED STANDARDS 2012. https://eclkc.ohs.acf.hhs.gov/hslc/tta-system/cultural-linguistic/ 1. 3. 2.7 Qualifications and Responsibilities for Health fcp/docs/resource-catalogue-cultural-linguistic-responsiveness.pdf. Advocates NOTES 1. 6 . 0.1 Child Care Health Consultants Content in the STANDARD was modified on 1/17/17. Helping Families Cope with Separation 2 .1.1. 5 2 . 3.1.1 Mutual Responsibility of Parents/Guardians and Staff 2 . 4 .1.1 Health and Safety Education Topics for Children 9. 4 .1.19 Community Resource Information

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122 95 Chapter 3: Health Promotion and Protection alternative means to accurately convey important infor- 3 .1 mation. Handwritten notes, electronic communications, HEALTH PROMOTION health checklists, and/or daily logs are examples of how parents/guardians and staff can exchange information IN CHILD CARE when face-to-face is not possible. 3 .1.1 TYPE OF FACILITY DAILY HEALTH CHECK Center, Large Family Child Care Home 3 .1.1.1 RELATED STANDARDS Conduct of Daily Health Check 1. 6 . 0.1 Child Care Health Consultants Every day, a trained staff member should conduct a health 3. 6 .1.1 Inclusion/Exclusion/Dismissal of Children check of each child. This health check should be conducted Appendix F: Enrollment/Attendance/Symptom Record as soon as possible after the child enters the child care facility and whenever a change in the child’s behavior or 3 .1.1. 2 appearance is noted while that child is in care. The health Documentation of the Daily Health Check check should address: The caregiver/teacher should conduct and document a daily a. Reported or observed illness or injury affecting the health check of each child upon arrival. The daily health child or family members since the last date of check documentation should be kept for one month. attendance; RATIONALE Reported or observed changes in behavior of the child b. (such as lethargy or irritability) or in the appearance The vast majority of infectious diseases of concern in child (e.g., sad) of the child from the previous day at home care have incubation periods of less than twenty-one days or the previous day’s attendance at child care; (1). This information may be helpful to public health Skin rashes, impetigo, itching or scratching of the skin, c. authorities investigating occasional outbreaks. itching or scratching of the scalp, or the presence of one COMMENTS or more live crawling lice; The documentation should note that the daily health check A temperature check if the child appears ill (a daily d. was done and any deviation from the usual status of the screening temperature check is not recommended); child and family. e. Other signs or symptoms of illness and injury (such as TYPE OF FACILITY drainage from eyes, vomiting, diarrhea, cuts/lacerations, pain, or feeling ill). Center, Large Family Child Care Home The caregiver/teacher should gain information necessary RELATED STANDARDS to complete the daily health check by direct observation of Records of Injury 9. 4 .1. 9 the child, by querying the parent/guardian, and, where Documentation of Parent/Guardian Notification of 9. 4 .1.10 applicable, by conversation with the child. Injury, Illness, or Death in Program RATIONALE Review and Accessibility of Injury and Illness 9. 4 .1.11 Daily health checks seek to identify potential concerns Reports about a child’s health including recent illness or injury in Contents of Child’s Records 9. 4 . 2 .1 the child and the family. Health checks may serve to reduce 9.4.2.2 Pre-Admission Enrollment Information for Each the transmission of infectious diseases in child care settings Child by identifying children who should be excluded, and enable 9.4.2.3 Contents of Admission Agreement Between Child the caregivers/teachers to plan for necessary care while the Care Program and Parent/Guardian child is in care at the facility. Contents of Child’s Primary Care Provider’s 9.4.2.4 COMMENTS Assessment The daily health check should be performed in a relaxed 9.4.2.5 Health History and comfortable manner that respects the family’s culture 9.4.2.6 Contents of Medication Record as well as the child’s body and feelings. The child care Contents of Facility Health Log for Each Child 9.4.2.7 health consultant should train the caregiver/teacher(s) in conducting a health check. The items in the standard can Release of Child’s Records 9.4.2.8 serve as a checklist to guide learning the procedure until it Reference becomes routine. 1. California Childcare Health Program. CCHP health and safety checklist. Rev. ed. http://www.ucsfchildcarehealth.org/html/pandr/formsmain. The obtaining of information from the parent/guardian htm#hscr/. should take place at the time of transfer of care from the parent/guardian to the staff of the child care facility. If this exchange of information happens outside the facility (e.g., when the child is put on a bus), the facility should use an

123 96 Caring for Our Children: National Health and Safety Performance Standards the general population. Their use by the primary care pro- 3 .1. 2 vider may facilitate early recognition of growth concerns, leading to further evaluation, diagnosis, and the develop - ROUTINE HEALTH SUPERVISION ment of a plan of care. Such a plan of care, if communicated 3 .1. 2 .1 to the caregiver/teacher, can direct the caregiver’s/teacher’s attention to disease, poor nutrition, or inadequate physical Routine Health Supervision and activity that requires modification of feeding or other health Growth Monitoring practices in the early care and education setting (2). The facility should require that each child has routine health supervision by the child’s primary care provider, COMMENTS according to the standards of the American Academy of Periodic and accurate height and weight measurements that Pediatrics (AAP) (3). For all children, health supervision are obtained, plotted, and interpreted by a person who is includes routine screening tests, immunizations, and competent in performing these tasks provide an important chronic or acute illness monitoring. For children younger indicator of health status. If such measurements are made than twenty-four months of age, health supervision includes in the early care and education facility, the data from the documentation and plotting of sex-specific charts on child measurements should be shared by the facility, subject to growth standards from the World Health Organization parental/guardian consent, with everyone involved in (WHO), available at http://www.who.int/childgrowth/ the child’s care, including parents/guardians, caregivers/ standards/en/, and assessing diet and activity. For children teachers, and the child’s primary care provider. The child twenty-four months of age and older, sex-specific height care health consultant can provide staff training on growth and weight graphs should be plotted by the primary care assessment. It is important to maintain strong linkage provider in addition to body mass index (BMI), according among the early care and education facility, school, parent/ to the Centers for Disease Control and Prevention (CDC). guardian, and the child’s primary care provider. Screening BMI is classified as underweight (BMI less than 5%), healthy results (physical and behavioral) and laboratory assess - weight (BMI 5%-84%), overweight (BMI 85%-94%), and ments are only useful if a plan for care can be developed to obese (BMI equal to or greater than 95%). Follow-up visits initiate and maintain lifestyle changes that incorporate the with the child’s primary care provider that include a full child’s activities during their time at the early care and assessment and laboratory evaluations should be scheduled education program. for children with weight for length greater than 95% and The Special Supplemental Nutrition Program for Women, BMI greater than 85% (5). Infants, and Children (WIC) can also be a source for the School health services can meet this standard for school- BMI data with parental/guardian consent, as WIC tracks age children in care if they meet the AAP’s standards for growth and development if the child is enrolled. school-age children and if the results of each child’s exam - For BMI charts by sex and age, see http://www.cdc.gov/ inations are shared with the caregiver/teacher as well as growthcharts/clinical_charts.htm. with the school health system. With parental/guardian TYPE OF FACILITY consent, pertinent health information should be exchanged among the child’s routine source of health care and all Center, Large Family Child Care Home participants in the child’s care, including any school RELATED STANDARD health program involved in the care of the child. 4.2.0.2 Assessment and Planning of Nutrition for RATIONALE Individual Children Provision of routine preventive health services for children References ensures healthy growth and development and helps detect 1. Paige, D. M. 1988. Clinical nutrition. 2nd ed. St. Louis: Mosby. Kleinman, R. E. 2009. Pediatric nutrition handbook. 6th ed. Elk Grove 2. disease when it is most treatable. Immunization prevents or Village, IL: American Academy of Pediatrics. reduces diseases for which effective vaccines are available. 3. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines When children are receiving care that involves the school for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics. health system, such care should be coordinated by the 4. Story, M., K. Holt, D. Sofka, eds. 2002. Bright futures in practice: Nutrition. exchange of information, with parental/guardian permis - 2nd ed. Arlington, VA: National Center for Education in Maternal and sion, among the school health system, the child’s medical Child Health. 5. Centers for Disease Control and Prevention. 2011. About BMI for home, and the caregiver/teacher. Such exchange will ensure children and teens. http://www.cdc.gov/healthyweight/assessing/bmi/ that all participants in the child’s care are aware of the childrens_bmi/about_childrens_bmi.html. 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

124 97 Chapter 3: Health Promotion and Protection b. Place toys in a circle around the infant. Reaching to 3 .1. 3 different points in the circle will allow him/her to develop the appropriate muscles to roll over, scoot PHYSICAL ACTIVITY AND on his/her belly, and crawl. LIMITING SCREEN TIME Lie on your back and place the infant on your chest. c. The infant will lift his/her head and use his/her arms 3 .1. 3 .1 to try to see your face (3,4). Active Opportunities for Physical Activity The facility should promote all children’s active play Structured activities have been shown to produce higher every day. Children should have ample opportunity to do levels of physical activity in young children, therefore it is moderate to vigorous activities, such as running, climbing, recommended that caregivers/teachers incorporate 2 or dancing, skipping, and jumping, to the extent of their more short, structured activities or games daily that abilities. promote physical activity (5). All children, birth to 6 years of age, should participate Opportunities to actively enjoy physical activity should be daily in: incorporated into part-time programs by prorating these Two to 3 occasions of active play outdoors, weather a. recommendations accordingly (eg, 20 minutes of outdoor permitting (see Standard 3.1.3.2: Playing Outdoors for play for every 3 hours in the facility). appropriate weather conditions) Active play should never be withheld from children who b. Two or more structured or caregiver/teacher/adult-led - misbehave (eg, child is kept indoors to help another care activities or games that promote movement over the giver/teacher while the rest of the children go outside) course of the day—indoor or outdoor (6). However, children with out-of-control behavior may c. Continuous opportunities to develop and practice need 5 minutes or fewer to calm themselves or settle down age-appropriate gross motor and movement skills before resuming cooperative play or activities. The total time allotted for outdoor play and moderate to Infants should not be seated for more than 15 minutes at vigorous indoor or outdoor physical activity can be a time, except during meals or naps (5). Infant equipment, adjusted for the age group and weather conditions. such as swings, stationary activity centers, infant seats Outdoor play (eg, bouncers), and molded seats, should only be used for Infants (birth–12 months of age) should be taken a. short periods, if used at all. A least-restrictive environment outside 2 to 3 times per day, as tolerated. There is no should be encouraged at all times (7). recommended duration of infants’ outdoor play. Children should have adequate space for indoor and b. Toddlers (12–35 months) and preschoolers (3–6 years) outdoor play. should be allowed 60 to 90 total minutes of outdoor RATIONALE pl ay (1). Time spent outdoors has been found to be a strong, consis - These outdoor times can be curtailed somewhat during tent predictor of children’s physical activity (8). Children adverse weather conditions in which children may still play can accumulate opportunities for activity over the course safely outdoors for shorter periods, but the time of indoor of several shorter segments of at least 10 minutes each (9). activity should increase so the total amount of exercise Free play, active play, and outdoor play are essential compo - remains the same. nents of young children’s development (10). Children learn Total time allotted for moderate to vigorous activities: through play, developing gross motor, socioemotional, and a. Toddlers should be allowed 60 to 90 minutes per 8-hour cognitive skills. During outdoor play, children learn about day for moderate to vigorous physical activity, including their environment, science, and nature (10). running. Infants’ and young children’s participation in physical Preschoolers should be allowed 90 to 120 minutes per b. activity is critical to their overall health, development of 8-hour day for moderate to vigorous physical activity, motor skills, social skills, and maintenance of healthy including running (1,2). weight (11). Daily physical activity promotes young chil - Infants should have supervised tummy time every day dren’s gross motor development and provides numerous when they are awake. Beginning on the first day at the early health benefits, including improved fitness and cardiovas - care and education program, caregivers/teachers should cular health, healthy bone development, improved sleep, interact with an awake infant on his/her tummy for short and improved mood and sense of well-being (12). periods (3–5 minutes), increasing the amount of time as Toddlers and preschoolers generally accumulate moderate the infant shows he/she enjoys the activity (3). to vigorous physical activity over the course of the day in There are many ways to promote tummy time with infants: very short bursts (15–30 seconds) (5). Children may be able Place yourself or a toy just out of the infant’s reach a. to learn better during or immediately after these types of during playtime to get him/her to reach for you or short bursts of physical activity, due to improved attention t he toy. and focus (13).

125 98 Caring for Our Children: National Health and Safety Performance Standards Tummy time prepares infants to be able to slide on their References 1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental bellies and crawl. As infants grow older and stronger they factors associated with physical activity in childcare centers. Int J Behav will need more time on their tummies to build their own Nutr Phys Act. 2015;12:43 strength (3). 2. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity levels among preschoolers in home-based childcare: a systematic review. Childhood obesity prevalence, for children 2 to 5 years old, J Phys Act Health. 2015;12(6):879–889 3. American Academy of Pediatrics. Back to sleep, tummy to play. has steadily decreased from 13.9% in 2004 to 9.4% in 2014 HealthyChildren.org Web site. https://www.healthychildren.org/English/ (14). Incorporating government food programs, physical ages-stages/baby/sleep/Pages/Back-to-Sleep-Tummy-to-Play.aspx. activities, and wellness education into child care centers Updated January 20, 2017. Accessed January 11, 2018 4. Zachry AH. Tummy time activities. American Academy of Pediatrics has been associated with these decreases (15). HealthyChildren.org Web site. https://www.healthychildren.org/English/ Establishing communication between caregivers/teachers ages-stages/baby/sleep/Pages/The-Importance-of-Tummy-Time.aspx. Updated November 21, 2015. Accessed January 11, 2018 - and parents/guardians helps facilitate integration of class 5. US Department of Agriculture, US Department of Health and Human room physical activities into the home, making it more Services. Provide opportunities for active play every day. Nutrition and likely that children will stay active outside of child care wellness tips for young children: provider handbook for the Child and Adult Care Food Program. https://fns-prod.azureedge.net/sites/default/ hours (16). Very young children and those not yet able to files/opportunities_play.pdf. Published June 2013. Accessed January 11, walk, are entirely dependent on their caregivers/teachers 2018 for opportunities to be active (17). 6. Centers for Disease Control and Prevention and SHAPE America-Society of Health and Physical Educators. Physical activity during school: Especially for children in full-time care and for children Providing recess to all students. 2017. https://www.cdc.gov/ healthyschools/physicalactivity/pdf/Recess_All_Students.pdf. Accessed who don’t have access to safe playgrounds, the early care January 11, 2018 and education facility may provide the child’s only daily 7. Moir C, Meredith-Jones K, Taylor BJ, et al. Early intervention to opportunity for active play. Physical activity habits learned encourage physical activity in infants and toddlers: a randomized controlled trial. Med Sci Sports Exerc. 2016;48(12):2446–2453 early in life may track into adolescence and adulthood, 8. Vanderloo LM, Martyniuk OJ, Tucker P. Physical and sedentary activity supporting the importance for children to learn lifelong levels among preschoolers in home-based childcare: a systematic review. J healthy physical activity habits while in the early care Phys Act Health. 2015;12(6):879–889 9. Hnatiuk JA, Salmon J, Hinkley T, Okely AD, Trost S. A review of and education program (18). preschool children’s physical activity and sedentary time using objective measures. Am J Prev Med. 2014;47(4):487–497 Additional Resources 10. Bento G, Dias G. The importance of outdoor play for young children’s Choosy Kids (https://choosykids.com) healthy development. Porto Biomed J. 2017;2(5):157–160 EatPlayGrow Early Childhood Health Curriculum, Children’s Museum of 11. Jayasuriya A, Williams M, Edwards T, Tandon P. Parents’ perceptions of Manhattan (w w w.eatplaygrow.org) preschool activities: exploring outdoor play. Early Educ Dev. 2016;27(7):1004–1017 Head Start Early Childhood Learning & Knowledge Center, US Department of 12. Timmons BW, Leblanc AG, Carson V, et al. Systematic review of physical Health and Human Services, Administration for Children & Families (https:// activity and health in the early years (aged 0-4 years). Appl Physiol Nutr eclkc.ohs.acf.hhs.gov/physical-health/article/little-voices-healthy-choices) Metab. 2012;37(4):773–792 Healthy Kids, Healthy Future; The Nemours Foundation (https:// Donnelly JE, Hillman CH, Castelli D, et al. Physical activity, fitness, 13. healthykidshealthyfuture.org) cognitive function, and academic achievement in children: a systematic review. Med Sci Sports Exerc. 2016;48(6):1197–1222 Nutrition and Physical Activity Self-Assessment for Child Care, Center for Centers for Disease Control and Prevention. Overweight & obesity. 14. Health Promotion and Disease Prevention, University of North Carolina Childhood obesity facts. Prevalence of childhood obesity in the United (http://healthyapple.arewehealthy.com/documents/ States, 2011-2014. https://www.cdc.gov/obesity/data/childhood.html. PhysicalActivityStaff Handouts_NAPSACC.pdf ) Updated April 10, 2017. Accessed January 11, 2018 Online Physical Education Network (http://openphysed.org) 15. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through Spark (www.sparkpe.org) 2013-2014. JAMA. 2016;315(21):2292–2299 16. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the TYPE OF FACILITY cumulative effect of TV viewing at home and in preschool on children’s Center, Large Family Child Care Home, Small Family activity patterns and weight status. Pediatr Exerc Sci. 2013;25(2):262–272 17. Society of Health and Physical Educators. Active Start: A Statement of Child Care Home Physical Activity Guidelines for Children From Birth to Age 5. 2nd ed. RELATED STANDARDS Reston, VA: SHAPE America; 2009. https://www.shapeamerica.org/ standards/guidelines/activestart.aspx. Accessed January 11, 2018 2 .1.1. 2 Health, Nutrition, Physical Activity, and 18. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult 18. Safety Awareness obesity from childhood obesity: a systematic review and meta–analysis. Obes Rev. 2016;17(2)95 –107 Playing Outdoors 3.1.3.2 NOTES 3.1.3.4 Caregivers’/Teachers’ Encouragement of Content in the STANDARD was modified on 05/29/2018. Physical Activity 5. 3.1.10 Restrictive Infant Equipment Requirements 9. 2 . 3.1 Policies and Practices that Promote Physical Activity Appendix S: Physical Activity: How Much Is Needed?

126 99 Chapter 3: Health Promotion and Protection Infants should be offered opportunities for gross motor 3.1.3.2 play outdoors. Playing Outdoors RATIONALE Children should play outdoors when the conditions do not pose any concerns health and safety such as a significant Outdoor play is not only an opportunity for learning in a risk of frostbite or heat-related illness. Caregivers/teachers different environment; it also provides many health bene - must protect children from harm caused by adverse weather, fits. Outdoor play allows for physical activity that supports ensuring that children wear appropriate clothing and/or maintenance of a healthy weight (3) and better nighttime appropriate shelter is provided for the weather conditions. sleep (4). Short exposure of the skin to sunlight promotes Weather that poses a significant health risk includes wind the production of vitamin D that growing children require. chill factor below -15°F (-26°C) and heat index at or above Open spaces in outdoor areas, even those located on 90°F (32°C), as identified by the National Weather Service screened rooftops in urban play spaces, encourage children (NWS) (1). Child Care Center Directors as well as caregivers/ to develop gross motor skills and fine motor play in ways teachers directors should monitor weather-related conditions that are difficult to duplicate indoors. Nevertheless, some through several media outlets, including local e-mail and weather conditions make outdoor play hazardous. text messaging weather alerts. Children need protection from adverse weather and its Caregivers/teachers should also monitor the air quality for effects. Heat-induced illness and cold injury are prevent - safety. Please reference Standard 3.1.3.3 for more able. Weather alert services are beneficial to child care information. centers because they send out weather warnings, watches, Sunny weather and hurricane information. Alerts are sent to subscribers in Children should be protected from the sun between the a. the warned areas via text messages and e-mail. It is best hours of 10:00 am and 4:00 pm. Protective measures practice to use these services but do not rely solely on this include using shade; sun-protective clothing such as hats system. Weather radio or local news affiliates should also be and sunglasses; and sunscreen with UV-B and UV-A ray monitored for weather warnings and advisories. Heat and sun protection factor 15 or higher. Parental/guardian humidity can pose a significant risk of heat-related illnesses, permission is required for the use of sunscreen. as defined by the NWS (5). Children have a greater surface area to body mass ratio than adults. Therefore, children do Wa r m weat her not adapt to extremes of temperature as effectively as adults a. Children should have access to clean, sanitary water when exposed to a high climatic heat stress or to cold. at all times, including prolonged periods of physical Children produce more metabolic heat per mass unit than activity, and be encouraged to drink water during adults when walking or running. They also have a lower periods of prolonged physical activity (2). sweating capacity and cannot dissipate body heat by evapo - Caregivers/teachers should encourage parents/guardians b. ration as effectively (6). to have children dress in clothing that is light-colored, - lightweight, and limited to one layer of absorbent mate Wind chill conditions can pose a risk of frostbite. Frostbite rial that will maximize the evaporation of sweat. is an injury to the body caused by freezing body tissue. The c. On hot days, infants receiving human milk in a bottle most susceptible parts of the body are the extremities such can be given additional human milk in a bottle but as fingers, toes, earlobes, and the tip of the nose. Symptoms should not be given water, especially in the first 6 months include a loss of feeling in the extremity and a white or pale of life. Infants receiving formula and water can be given appearance. Medical attention is needed immediately for additional formula in a bottle. frostbite. The affected area should be slowly rewarmed by immersing frozen areas in warm water (around 104°F Cold weather [40°C]) or applying warm compresses for 30 minutes. If a. Children should wear layers of loose-fitting, lightweight warm water is not available, wrap gently in warm blankets clothing. Outer garments, such as coats, should be tightly (7). Hypothermia is a medical emergency that occurs when woven and be at least water repellent when rain or snow the body loses heat faster than it can produce heat, causing is present. a dangerously low body temperature. An infant with hypo - b. Children should wear a hat, coat, and gloves/mittens thermia may have bright red, cold skin and very low energy. kept snug at the wrist. There should be no hood and A child’s symptoms may include shivering, clumsiness, neck strings.. - slurred speech, stumbling, confusion, poor decision-mak Caregivers/teachers should check children’s extremities c. - ing, drowsiness or low energy, apathy, weak pulse, or shal for normal color and warmth at least every 15 minutes. low breathing (7,8). Call 911 or your local emergency Caregivers/teachers should be aware of environmental number if a child has these symptoms. Both hypothermia hazards such as unsafe drinking water, loud noises, and lead and frostbite can be prevented by properly dressing a child. in soil when selecting an area to play outdoors. Children Dressing in several layers will trap air between layers and should be observed closely when playing in dirt/soil so that provide better insulation than a single thick layer of no soil is ingested. Play areas should be fully enclosed and clothing. away from heavy traffic areas. In addition, outdoor play for infants may include riding in a carriage or stroller.

127 100 Caring for Our Children: National Health and Safety Performance Standards American Academy of Pediatrics. Children & disasters. Extreme 6. Generally, infectious disease organisms are less concen - temperatures: heat and cold. https://www.aap.org/en-us/advocacy-and- trated in outdoor air than indoor air. The thought is often policy/aap-health-initiatives/Children-and-Disasters/Pages/Extreme- expressed that children are more likely to become sick if Temperatures-Heat-and-Cold.aspx. Accessed January 11, 2018 7. American Academy of Pediatrics. Winter safety tips from the American exposed to cold air; however, upper respiratory infections Academy of Pediatrics. https://www.aap.org/en-us/about-the-aap/ and flu are caused by viruses, and not exposure to cold air. aap-press-room/news-features-and-safety-tips/Pages/AAP-Winter-Safety- These viruses spread easily during the winter when children Tips.aspx. Published January 2018. Accessed January 11, 2018 8. American Academy of Pediatrics. Extreme temperature exposure. are kept indoors in close proximity. The best protection HealthyChildren.org Web site. https://www.healthychildren.org/English/ against the spread of illness is regular and proper hand health-issues/injuries-emergencies/Pages/Extreme-Temperature-Exposure. hygiene for children and caregivers/teachers, as well as aspx. Updated November 21, 2015. Accessed January 11, 2018 proper sanitation procedures during mealtimes and NOTES when there is any contact with bodily fluids. Content in the STANDARD was modified on 8/8/2013 and Additional Resources 05/29/2018. 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 3.1.3.3 are comfortable for outdoor play (www.nws.noaa.gov/om/heat/index.shtml). Protection from Air Pollution While Children The National Oceanic and Atmospheric Administration (NOAA) Weather Are Outside Radio All Hazards (NWR) broadcasts continuous weather information 24 hours a day, 7 days a week, directly from the nearest NWR office. As an Supervising adults should check the air quality index (AQI) all-hazards radio network, it is a single source for comprehensive weather each day and use the information to determine whether it is and emergency information. In conjunction with federal, state, and local emergency managers and other public officials, NWR also broadcasts warn- safe for children to play outdoors. ing and post-event information for all types of hazards, including natural RATIONALE (eg, earthquakes, avalanches), environmental (eg, chemical releases, oil spills), and public safety (eg, AMBER alerts, 911 telephone outages). A special radio Children need protection from air pollution. Air pollution receiver or scanner capable of picking up the signal is required to receive can contribute to acute asthma attacks in sensitive children NWR. Such radios/receivers can usually be found in most electronic store chains across the country; you can also purchase NOAA weather radios and, over multiple years of exposure, can contribute to online at www.noaaweatherradios.com. permanent decreased lung size and function (1,2). To access the latest local weather information and warnings, visit the COMMENTS NWS at www.weather.gov; for local air quality conditions, visit https://www.airnow.gov. The federal Clean Air Act requires that the Environmental Protection Agency (EPA) establish ambient air quality TYPE OF FACILITY health standards. Most local health departments monitor Center, Large Family Child Care Home weather and air quality in their jurisdiction and make RELATED STANDARDS appropriate announcements. AQI is usually reported Active Opportunities for Physical Activity 3.1. 3.1 with local weather reports on media outlets or individuals can sign up for email or text message alerts at http://www. 3.1.3.3 Protection from Air Pollution While Children enviroflash.info. Are Outside 3.1.3.4 Caregivers’/Teachers’ Encouragement of The AQI (available at http://www.airnow.gov) is a cumula - Physical Activity tive indicator of potential health hazards associated with local or regional air pollution. The AQI is divided into six Sun Safety Including Sunscreen 3. 4 . 5.1 categories; each category corresponds to a different level of Inclusion in All Activities 8 . 2 . 0.1 health concern. The six levels of health concern and what Appendix S: Physical Activity: How Much Is Needed? they mean are: References - “Good” AQI is 0 - 50. Air quality is considered satisfac a. 1. National Weather Service, National Oceanic and Atmospheric tory, and air pollution poses little or no risk. Administration. Wind chill safety. https://www.weather.gov/bou/windchill. b. “Moderate” AQI is 51 - 100. Air quality is acceptable, Accessed January 11, 2018 2. Centers for Disease Control and Prevention. Increasing Access to Drinking however, for some pollutants there may be a moderate Water and Other Healthier Beverages in Early Care and Education Settings. health concern for a very small number of people. For Atlanta, GA: US Department of Health and Human Services; 2014. https:// example, people who are unusually sensitive to ozone www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit- final-508reduced.pdf. Accessed January 11, 2018 may experience respiratory symptoms. 3. Cleland V, Crawford D, Baur LA, Hume C, Timperio A, Salmon J. A “Unhealthy for Sensitive Groups” AQI is 101 - 150. c. prospective examination of children’s time spent outdoors, objectively Although general public is not likely to be affected at measured physical activity and overweight. Int J Obes (Lond). 20 08;32(11):1685 –1693 this AQI range, people with heart and lung disease, 4. Söderström M, Boldemann C, Sahlin U, Mårtensson F, Raustorp A, older adults, and children are at a greater risk from Blennow M. The quality of the outdoor environment influences children’s exposure to ozone and the presence of particles in health—a cross-sectional study of preschoolers. Acta Paediatr. 2013;102(1):83–91 the air. 5. KidsHealth from Nemours. Heat illness. http://kidshealth.org/en/parents/ heat.html. Reviewed February 2014. Accessed January 11, 2018

128 101 Chapter 3: Health Promotion and Protection “Unhealthy” AQI is 151 - 200. Everyone may begin to d. R ATI O NALE experience some adverse health effects, and members Children learn from the adult modeling of healthy and of the sensitive groups may experience more safe behavior. Caregivers/teachers may not be comfort- serious effects. able promoting active play, perhaps due to inhibitions e. “Very Unhealthy” AQI is 201 - 300. This would trigger a about their own physical activity skills or lack of training. health alert signifying that everyone may experience Caregivers/teachers may also assume their sole role on the more serious health effects. playground is to supervise and keep children safe, rather “Hazardous” AQI greater than 300. This would trigger a f. than to promote physical activity. Continuing education health warning of emergency conditions. The entire activities are useful in disseminating knowledge about population is more likely to be affected. effective games to promote physical activity in early care and education while keeping children safe (4). TYPE OF FACILITY Center, Large Family Child Care Home Children exposed to less screen time/digital media in early care and education settings engage in more moderate-to- RELATED STANDARDS vigorous physical activity compared with children who are 3.1.3.2 Playing Outdoors exposed to more screen time (5). This gives caregivers/ 5. 2 .1.1 Ensuring Access to Fresh Air Indoors teachers the opportunity to model the limitation of screen time/digital media use and to educate parents/guardians References 1. Gehring, U., Gruzieva, O., Agius, R., Beelen, R., Custovic, A., Cyrys, J.,Von about alternative activities that families can do with their Berg. (2013). Air pollution exposure and lung function in children: The children (2). ESCAPE project. Environmental Health Perspectives: EHP. 121(11-12), 1357-1364. ADDITIONAL RESOURCE 2. Lerodiakonou, D. (2016). Ambient air pollution, lung function, and airway American Academy of Pediatrics Council on responsiveness in asthmatic children. The Journal of Allergy and Clinical Immunology. 137(2), 390. Communications and Media. Media and young minds. Ped iat rics. 2016;138(5):e20162591 NOTES Content in the STANDARD was modified on 8/25/2016. TYPE OF FACILITY Center, Large Family Child Care Home, Small Family Child Care Home 3.1.3.4 Caregivers’/Teachers’ Encouragement RELATED STANDARDS of Physical Activity 2.2.0.3 Screen Time/Digital Media Use Caregivers/teachers should promote children’s active play Active Opportunities for Physical Activity 3.1. 3.1 and participate in children’s active games at times when 3.1.3.2 Playing Outdoors they can safely do so. Caregivers/teachers should 9. 2 . 3.1 Policies and Practices that Promote Physical Lead structured activities to promote children’s a. Activity activities 2 or more times per day. Wear clothing and footwear that permits easy and b. Appendix S: Physical Activity: How Much Is Needed? safe movement (1). References Provide prompts for children to be active (2,3). c. 1. Henderson KE, Grode GM, O’Connell ML, Schwartz MB. Environmental (eg, “Good throw!”). factors associated with physical activity in childcare centers. Int J Behav Nutr Phys Act. 2015;12:43 Encourage children’s physical activities that are d. 2. Tandon PS, Saelens BE, Copeland KA. A comparison of parent and appropriate and safe in the setting (eg, do not prohibit childcare provider’s attitudes and perceptions about preschoolers’ physical running on the playground when it is safe to run). activity and outdoor time. Child Care Health Dev. 2017;43(5):679–686 3. Tandon PS, Walters KM, Igoe BM, Payne EC, Johnson DB. Physical activity e. Have orientation and annual training opportunities to practices, policies and environments in Washington state child care learn about age-appropriate gross motor activities and settings: results of a statewide survey. Matern Child Health J. games that promote children’s physical activity (2,4). 2017;21(3):571–582 Copeland KA, Khoury JC, Kalkwarf HJ. Child care center characteristics 4. f. Not sit during active play. associated with preschoolers’ physical activity. Am J Prev Limit screen time and other digital media as outlined g. Med. 2016;50(4):470–479 in Standard 2.2.0.3. 5. Taverno Ross S, Dowda M, Saunders R, Pate R. Double dose: the cumulative effect of TV viewing at home and in preschool on children’s activity patterns Caregivers/teachers should consider incorporating struc - and weight status. Pediatr Exerc Sci. 2013;25(2):262–272 - tured activities into the curriculum indoors or after chil NOTES dren have been on the playground for 10 to 15 Content in the STANDARD was modified on 05/29/2018. minutes. Caregivers/teachers should communicate with parents/guards about their use of screen time/digital media in the home.

129 102 Caring for Our Children: National Health and Safety Performance Standards If an infant falls asleep in any place that is not a safe sleep e. 3 .1. 4 environment, staff should immediately move the infant and place them in the supine position in their crib; SAFE SLEEP Only one infant should be placed in each crib (stackable f. 3 .1. 4 .1 cribs are not recommended); Soft or loose bedding should be kept away from sleeping g. Safe Sleep Practices and Sudden Unexpected infants and out of safe sleep environments. These include, Infant Death (SUID)/SIDS Risk Reduction but are not limited to: bumper pads, pillows, quilts, - Safe sleep practices help reduce the risk of sudden unex comforters, sleep positioning devices, sheepskins, blan - pected infant deaths (SUIDs). Facilities should develop a kets, flat sheets, cloth diapers, bibs, etc. Also, blankets/ written policy describing the practices to be used to pro- items should not be hung on the sides of cribs. Loose or mote safe sleep for infants. The policy should explain that ill-fitting sheets have caused infants to be strangled or these practices aim to reduce the risk of SUIDs, including suffocated (2). sudden infant death syndrome (SIDS), suffocation and h. Swaddling infants when they are in a crib is not neces - other deaths that may occur when an infant is in a crib or sary or recommended, but rather one-piece sleepers asleep. About 3,500 SUIDs occurred in the U.S. in 2014 (1). should be used (see Standard 3.1.4.2 for more detailed All staff, parents/guardians, volunteers and others approved information on swaddling) (2); to enter rooms where infants are cared for should receive a - i. Toys, including mobiles and other types of play equip copy of the Safe Sleep Policy and additional educational ment that are designed to be attached to any part of the information and training on the importance of consistent crib should be kept away from sleeping infants and out use of safe sleep policies and practices before they are of safe sleep environments; allowed to care for infants (i.e., first day as an employee/ When caregivers/teachers place infants in their crib for j. volunteer/subsitute). Documentation that training has sleep, they should check to ensure that the temperature in occurred and that these individuals have received and the room is comfortable for a lightly clothed adult, check reviewed the written policy before they care for children the infants to ensure that they are comfortably clothed should be kept on file. Additional educational materials can (not overheated or sweaty), and that bibs, necklaces, and be found at https://www.nichd.nih.gov/sts/materials/Pages/ garments with ties or hoods are removed. (Safe clothing default.aspx. sacks or other clothing designed for safe sleep can be used in lieu of blankets.); All staff, parents/guardians, volunteers and others who care Infants should be directly observed by sight and sound at k. for infants in the child care setting should follow these all times, including when they are going to sleep, are required safe sleep practices as recommended by the sleeping, or are in the process of waking up; American Academy of Pediatrics (AAP) (2): l. Bedding should be changed between children, and if a. Infants up to twelve months of age should be placed for mats are used, they should be cleaned between uses. sleep in a supine position (wholly on their back) for The lighting in the room must allow the caregiver/teacher to every nap or sleep time unless an infant’s primary see each infant’s face, to view the color of the infant’s skin, health care provider has completed a signed waiver indi - and to check on the infant’s breathing and placement of the cating that the child requires an alternate sleep position; pacifier (if used). b. Infants should be placed for sleep in safe sleep environ - ments; which include a firm crib mattress covered by a A caregiver/teacher trained in safe sleep practices and tight-fitting sheet in a safety-approved crib (the crib approved to care for infants should be present in each room should meet the standards and guidelines reviewed/ at all times where there is an infant. This caregiver/teacher approved by the U.S. Consumer Product Safety should remain alert and should actively supervise sleeping Commission [CPSC] (3) and ASTM International infants in an ongoing manner. Also, the caregiver/teacher [ASTM]). No monitors or positioning devices should be should check to ensure that the infant’s head remains uncov - used unless required by the child’s primary health care ered and re-adjust clothing as needed. provider, and no other items should be in a crib occu - The construction and use of sleeping rooms for infants sepa - pied by an infant except for a pacifier; rate from the infant group room is not recommended due to Infants should not nap or sleep in a car safety seat, bean c. the need for direct supervision. In situations where there are bag chair, bouncy seat, infant seat, swing, jumping chair, existing facilities with separate sleeping rooms, facilities play pen or play yard, highchair, chair, futon, sofa/ have a plan to modify room assignments and/or practices to couch, or any other type of furniture/equipment that is eliminate placing infants to sleep in separate rooms. not a safety-approved crib (that is in compliance with the CPSC and ASTM safety standards) (3); Facilities should follow the current recommendation of the If an infant arrives at the facility asleep in a car safety d. AAP about pacifier use (2). If pacifiers are allowed, facilities seat, the parent/guardian or caregiver/teacher should - should have a written policy that describes relevant proce immediately remove the sleeping infant from this seat dures and guidelines. Pacifier use outside of a crib in rooms and place them in the supine position in a safe sleep and programs where there are mobile infants or toddlers is environment (i.e., the infant’s assigned crib); not recommended.

130 103 Chapter 3: Health Promotion and Protection The facilty should encourage, provide arrangements for, and COMMENTS support breastfeeding. Breastfeeing or feeding an infant Background: Deaths of infants who are asleep in child care with their mother’s expressed breast milk is also associated may be under-reported because of the lack of consistency in with a reduced risk of sleep-related infant deaths (2). training and regulating death scene investigations and determining and reporting cause of death. Not all states RATIONALE require documentation that clarifies that an infant died - Despite the decrease in deaths attributed to sleeping prac while being cared for by someone other than their parents/ tices and the decreased frequency of prone (tummy) infant guardians. sleep positioning over the past two decades, some caregiv - ers/teachers continue to place infants to sleep in positions Although the cause of many sudden infant deaths may not or environments that are not safe. Most sleep-related deaths be known, researchers believe that some infants develop in in child care facilities occur in the first day or first week a manner that makes it challenging for them to be aroused that an infant starts attending a child care program (4). or to breathe when they experience a life-threatening chal - Many of these deaths appear to be associated with prone lenge during sleep. Although some state regulations require positioning, especially when the infant is unaccustomed to that caregivers/teachers “check on” sleeping infants every being placed in that position (2). Training that includes ten, fifteen, or thirty minutes, an infant can suffocate or die observations and addresses barriers to changing caregiver/ in only a few minutes. It is for this reason that the standards teacher practices would be most effective. Use of safe sleep above discourage toys or mobiles in cribs and recommend policies, continued education of parents/guardians, direct, active, and ongoing supervision when infants are expanded training efforts for child care professionals, state - falling to sleep, are sleeping, or are becoming awake. This is wide regulations and mandates, and increased monitoring describes a safe sleep also why Caring for Our Children - and observation of intants while they are sleeping are criti environment as one that includes a safety-approved crib, cal to reduce the risk of SUIDs in child care (2). firm mattress, firmly fitted sheet, and the infant placed on their back at all times, in comfortable, safe garments, but Infants who are cared for by adults other than their parent/ nothing else – not even a blanket. guardian or primary caregiver/teacher are at increased risk of SUID (4,5). Recent research and demonstration projects When infants are being dropped off, staff may be busy. (6,7) have revealed that: Requiring parents/guardians to remove the infant from the car seat and reposition them in the supine position in their Caregivers/teachers are unaware of the dangers or risks a. crib (if they are sleeping), will reinforce safe sleep practices associated with prone or side infant sleep positioning, and reassure parents/guardians that their child is in a safe and many believe that they are using the safest practices position before they leave the facility. possible, even when they are not; b. Although training programs are effective in improving Challenges: National recommendations for reducing the the knowledge of caregivers/teachers, these programs risk of SUIDs are provided for use in the general popula - alone do not always lead to changes in caregiver/teacher tion. Most research reviewed to guide the development of practices, beliefs, or attitudes; and these recommendations was not conducted in child care Caregivers/teachers report the following major barriers c. settings. Because infants are at increased risk for dying to implementing safe sleep practices: from sleep-related causes in child care (4,5), caregivers/ teachers must provide the safest sleep environment for the 1. They have been misinformed about methods shown to infants in their care. reduce the risk of SUID; When hospital staff or parents/guardians of infants who 2. Facilities do not have or use written “safe sleep” policies may attend child care place the infant in a position other or guidelines; than supine for sleep, the infant becomes accustomed to 3. State child care regulations do not mandate the use of this and can have a more difficult time adjusting to child supine (wholly on their back) sleep position for infants in care, especially when they are placed for sleep in a new child care and/or training for infant caregivers/teachers; unfamiliar position. 4. Other caregivers/teachers or parents/guardians have Parents/guardians and caregivers/teachers want infants to objections to use of safe sleep practices, either because of transition to child care facilities in a comfortable and easy their concern for choking or aspiration, and/or their manner. It can be challenging for infants to fall asleep in a concern that some infants do not sleep well in the - new environment because there are different people, equip supine position; and ment, lighting, noises, etc. When infants sleep well in child 5. care, adults feel better. Placing personal items in cribs with Parents/guardians model their practices after what infants and covering or wrapping infants with blankets happens in the hospital or what others recommend. may help the adults to believe that the child is more Infants who were placed to sleep in other positions in comfortable or feels comforted. However, this may or may the hospital or home environments may have difficulty not be true. These practices are not the safest practices for transitioning to supine positioning at home and later infants in child care, and they should not be allowed. in child care. Efforts to educate the public about the risk of sleep-related

131 104 Caring for Our Children: National Health and Safety Performance Standards deaths promoting the use of consistent safe sleep practices Concern about Plagiocephaly: If parents/guardians or care - - need to continue. givers/teachers are concerned about positional plagioceph aly (flat head or flat spot on head), they can continue to use Special Care Plans: Some facilities require staff to place safe sleep practices but also do the following: - infants in a supine position for sleep unless there is docu a. Offer infants opportunities to be held upright and par- mentation in a child’s special care plan indicating a medical ticipate in supervised “tummy time” when they are need for a different position. This can provide the caregiver/ awake; teacher with more confidence in implementing the safe Alter the position of the infant, and thereby alter the sleep policy and refusing parental demands that are not b. consistent with safe sleep practices. It is likely that an supine position of the infant’s head and face. This can easily be accomplished by alternating the placement of infant will be unaccustomed to sleeping supine if his or her parents/guardians object to the supine position (and the infant in the crib – place the infant to sleep with their head facing to one side for a week and then turning are therefore placing the infant prone to sleep at home). By the infant so that their head and face are placed the providing educational information on the importance of consistent use of safe sleep policies and practices to expect other way. Infants typically turn their head to one side - ant parents, facilities will help raise awareness of these toward the room or door, so if they are placed with their head toward one side of the bed for one sleep time and issues, promote infant safety, and increase support for proper implementation of safe sleep policies and then placed with their head toward the other side of the practices in the future. bed the next time, this changes the area of the head that is in contact with the mattress. Use of Pacifiers: Caregivers/teachers should be aware of the A common question among caregivers/teachers and current recommendation of the AAP about pacifier use to parents/guardians is whether they should return the infant reduce the risk of SUIDs (2). While using pacifiers to reduce the risk of SIDS seems prudent (especially if the infant is to the supine position if they roll onto their side or their already sleeping with a pacifier at home), pacifier use has tummies. Infants up to twelve months of age should be - also been shown to be associated with an increased risk of placed wholly supine for sleep every time. In fact, all chil dren should be placed (or encouraged to lie down) on their ear infections. Keeping pacifiers clean and limiting their use backs to sleep. When infants are developmentally capable of to sleep time is best. Using pacifiers in a sanitary and safe rolling comfortably from their backs to their fronts and fashion in group care settings requires special diligence. back again, there is no evidence to suggest that they should Pacifiers should be inspected for tears before use. Pacifiers be re-positioned into the supine position. should not be clipped to an infant’s clothing or tied around The California Childcare Health Program has available a an infant’s neck. Safe Sleep Policy for Infants in Child Care Programs. AAP For children in the general population, the AAP recom - provides a free online course on safe sleep practices. mends the following: TYPE OF FACILITY Child care faciltites require written permission from the a. Center, Large Family Child Care Home child’s parent/guardian for pacifier use; Consider offering a pacifier when placing the infant b. RELATED STANDARDS down for nap and sleep time; Methods of Supervision of Children 2.2.0.1 If the infant refuses the pacifier, s/he should not be c. Swaddling 3.1. 4 . 2 forced to take it; Pacifier Use 3.1. 4 . 3 d. If the infant falls asleep and the pacifier falls out of the 3.1.4.4 Scheduled Rest Periods and Sleep Arrangements infant’s mouth, it should be removed from the crib and does not need to be reinserted. A pacifier has been Use of Tobacco, Electronic Cigarettes, Alcohol, 3. 4 .1.1 shown to reduce the risk of SIDS, even if the pacifier and Drugs falls out during sleep (2); 3. 4 . 6 .1 Strangulation Hazards Pacifiers should not be coated in any sweet solution, and e. 3.6.4.5 Death they should be cleaned and replaced regularly; and General Plan for Feeding Infants 4 . 3.1.1 For breastfed infants, delay pacifier introduction until f. 4.5.0.3 Activities that Are Incompatible with Eating fifteen days of age to ensure that breastfeeding is well-established (2). Sleeping Equipment and Supplies 5.4.5.1 5.4.5.2 Cribs Swaddling: Hospital personnel or physicians, particularly those who work in neonatal intensive care units or infant 6 . 4 .1. 3 Crib Toys nurseries in hospitals may recommend that newborns be 9. 2 . 3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, - swaddled in the hospital setting. Although parents/guard Illegal Drugs, and Toxic Substances - ians may choose to continue this practice at home, swad dling infants when they are being placed to sleep or are - sleeping in a child care facility is not necessary or recom mended. See Standard 3.1.4.2 for more detailed information.

132 105 Chapter 3: Health Promotion and Protection data about whether swaddling should or should not be References 1. U.S. Centers for Disease Control and Prevention. 2016. About SUID and used. Benefits of swaddling may include decreased crying, SIDS. http://www.cdc.gov/sids/aboutsuidandsids.htm. increased sleep periods, and improved temperature control. 2. American Academy of Pediatrics Task Force on Sudden Infant Death However, temperature can be maintained with appropriate Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 recommendations for a safe infant sleeping environment. infant clothing and/or an infant sleeping bag. Although Pediatrics.2016;138(6):e20162938. https://pediatrics.aappublications.org/ - swaddling may decrease crying, there are other, more seri content/138/5/e20162938. ous health concerns to consider, including SIDS and hip 3. U.S. Consumer Product Safety Commission (CPSC). 2012. Cribs. https:// www.cpsc.gov/safety-education/safety-guides/kids-and-babies/cribs. disease. If swaddling is used, it should be used less and less 4. First Candle. 2016. SIDS and daycare: A fatal combination. http://www. over the course of the first few weeks and months of an firstcandle.org/sids-and-daycare-a-fatal-combination/. infant’s life. 5. Healthy Child Care America. 2012. A child care provider’s guide to safe sleep. Helping you to reduce the risk of SIDS. http://www. TYPE OF FACILITY healthychildcare.org/PDF/SIDSchildcaresafesleep.pdf. 6. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of Center, Large Family Child Care Home sudden infant death syndrome: A Metaanalysis. Pediatrics;137(6):e20153275. RELATED STANDARD 7. Moon R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden Safe Sleep Practices and Sudden Unexpected Infant 3.1. 4 .1 infant death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-79. Death (SUID)/SIDS Risk Reduction Jenik, A. G., N. E. Vain, A. N. Gorestein, N. E. Jacobi, Pacifier and 8. References Breastfeeding Trial Group. 2009. Does the recommendation to use a 1. Pease AS, Fleming PJ, Hauck FR, et al. 2016. Swaddling and the risk of pacifier influence the prevalence of breastfeeding? Pediatrics 155:350-54. sudden infant death syndrome: A Meta-analysis. 9. UCSF California Childcare Health Program (CCHP). 2016. Safe sleep Pediatrics;137(6):e20153275. policy for infants in child care programs. UCSF School of Nursing 2. Richardson, H. L., A. M. Walker, R. S. Horne. 2010. Influence of swaddling California Childcare Health Program, San Francisco, CA: CCHP. http:// experience on spontaneous arousal patterns and autonomic control in cchp.ucsf.edu/Safe-Sleep-Policy. sleeping infants. J Pediatrics 157:85-91. 10. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep for 3. Contemporary Pediatrics. 2004. Guide for parents: Swaddling 101. http:// Infants in Child Care Programs: Reducing the Risk of SIDS and SUID. www.aap.org/sections/scan/practicingsafety/Toolkit_Resources/Module1/ UCSF School of Nursing California Childcare Health Program, San swadling.pdf. Francisco, CA: CCHP. http://cchp.ucsf.edu/SIDS-Note. 4. Van Sleuwen, B. E., A. C. Engelberts, M. M. Boere-Boonekamp, W. Kuis, 11. UCSF California Childcare Health Program (CCHP). 2016. Safe Sleep: T. W. J. Schulpen, M. P. L’Hoir. 2007. Swaddling: A systematic review. Reducing the Risk of Sudden Infant Death Syndrome (SIDS). UCSF Pediatrics 120:e1097-e1106. School of Nursing California Childcare Health Program, San Francisco, 5. Mahan, S. T., Kasser J. R. 2008. Does swaddling influence developmental CA: CCHP. http://cchp.ucsf.edu/Safe-Sleep-FAM. dysplasia of the Hip? Pediatrics 121:177-78. 12. Centers for Disease Control and Prevention. 2013. Sudden infant death Franco, P., N. Seret, J. N. Van Hees, S. Scaillet, J. Groswasser, A. Kahn. 6. syndrome (SIDS). http://www.cdc.gov/features/sidsawarenessmonth/. 2005. Influence of swaddling on sleep and arousal characteristics of Eunice Kennedy Shriver National Institute of Child Health and Human 13. healthy infants. Pediatrics 115:1307-11. Development. Safe sleep ® campaign materials. 2014. https://www.nichd. nih.gov/sts/materials/Pages/default.aspx. NOTES 3 .1. 4 . 3 Content in the STANDARD was modified on 12/05/2011 Pacifier Use and on 12/1/2016. Facilities should be informed and follow current recom - mendations of the American Academy of Pediatrics (AAP) about pacifier use (1-3). 3 .1. 4 . 2 Swaddling If pacifiers are allowed, facilities should have a written policy that indicates: In child care settings, swaddling is not necessary or recommended. a. Rationale and protocols for use of pacifiers; b. Written permission and any instructions or preferences RATIONALE from the child’s parent/guardian; There is evidence that swaddling can increase the risk of c. If desired, parent/guardian should provide at least two serious health outcomes, especially in certain situations. new pacifiers (labeled with their child’s name using a The risk of sudden infant death is increased if an infant is waterproof label or non-toxic permanent marker) on a swaddled and placed on his/her stomach to sleep (1,2) or regular basis for their child to use. The extra pacifier if the infant can roll over from back to stomach. Loose should be available in case a replacement is needed; blankets around the head can be a risk factor for sudden Staff should inspect each pacifier for tears or cracks (and d. infant death syndrome (SIDS) (3). With swaddling, there to see if there is unknown fluid in the nipple) before is an increased risk of developmental dysplasia of the each use; hip, a hip condition that can result in long-term disability e. Staff should clean each pacifier with soap and water - (4,5). Hip dysplasia is felt to be more common with swad before each use; dling because infants’ legs can be forcibly extended. With Pacifiers with attachments should not be allowed; pacifi f. - - excessive swaddling, infants may overheat (i.e., hyperther ers should not be clipped, pinned, or tied to an infant’s mia) (6). clothing, and they should not be tied around an infant’s COMMENTS neck, wrist, or other body part; Most infants in child care centers are at least six-weeks-old. g. If an infant refuses the pacifier, s/he should not be Even with newborns, research does not provide conclusive forced to take it;

133 106 Caring for Our Children: National Health and Safety Performance Standards If the pacifier falls out of the infant’s mouth, it does not h. RELATED STANDARDS need to be reinserted; Safe Sleep Practices and Sudden Unexpected 3.1. 4 .1 Pacifiers should not be coated in any sweet solution; i. Infant Death (SUID)/SIDS Risk Reduction j. - Pacifiers should be cleaned and stored open to air; sepa Oral Health Education 3.1. 5. 3 rate from the diapering area, diapering items, or other 3.3.0.3 Cleaning and Sanitizing Objects Intended for children’s personal items. the Mouth Infants should be directly observed by sight and sound at Strangulation Hazards 3. 4 . 6 .1 - all times, including when they are going to sleep, are sleep ing, or are in the process of waking up. The lighting in the References 1. American Academy of Pediatrics Task Force on Sudden Infant Death room must allow the caregiver/teacher to see each infant’s Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 face, to view the color of the infant’s skin, and to check on recommendations for a safe infant sleeping environment. the infant’s breathing and placement of the pacifier. Pediatrics.2016;138(6):e20162938. https://pediatrics.aappublications.org/ content/138/5/e20162938. Pacifier use outside of a crib in rooms and programs where Hauck, F. R. 2006. Pacifiers and sudden infant death syndrome: What 2. should we recommend? Pediatrics117:1811-12. there are mobile infants or toddlers is not recommended. 3. Mitchell, E. A., P. S. Blair, M. P. L’Hoir. 2006. Should pacifiers be Caregivers/teachers should work with parents/guardians to recommended to prevent sudden infant death syndrome? Pediatrics 117:1755-58. wean infants from pacifiers as the suck reflex diminishes 4. Reeves, D. L. 2006. Pacifier use in childcare settings. Healthy Child Care between three and twelve months of age. Objects which 9:12-13. provide comfort should be substituted for pacifiers (6). 5. Cornelius, A. N., J. P. D’Auria, L. M. Wise. 2008. Pacifier use: A systematic review of selected parenting web sites. J Pediatric Health Care 22:159-65. RATIONALE American Academy of Pediatrics, Back to Sleep, Healthy Child Care 6. America, First Candle. 2008. Reducing the risk of SIDS in child care. http:// Mobile infants or toddlers may try to remove a pacifier www.healthychildcare.org/pdf/SIDSfinal.pdf. from an infant’s mouth, put it in their own mouth, or try to 7. Mayo Clinic. 2009. Infant and toddler health. Pacifiers: Are they good for reinsert it in another child’s mouth. These behaviors can your baby? http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler- health/in-depth/pacifiers/art-20048140. increase risks for choking and/or transmission of infectious diseases. 3.1.4.4 Cleaning pacifiers before and after each use is recom - Scheduled Rest Periods and mended to ensure that each pacifier is clean before it is inserted into an infant’s mouth (5). This protects against Sleep Arrangements unknown contamination or sharing. Cleaning a pacifier The facility should provide an opportunity for, but should before each use allows the caregiver/teacher to worry less - not require, sleep and rest. The facility should make avail about whether the pacifier was cleaned by another adult able a regular rest period for all children and age appro- who may have cared for the infant before they did. This priate sleep/nap environment (See Standard 5.4.5.1). For may be of concern when there are staffing changes or children who are unable to sleep, the facility should pro- when parents/guardians take the pacifiers home with vide time and space for quiet play. A facility that includes them and bring them back to the facility. preschool-aged and school-aged children should make books, board games, and other forms of quiet play If a caregiver/teacher observes or suspects that a pacifier has available. been shared, the pacifier should be cleaned and sanitized. Caregivers/teachers should make sure the nipple is free of Facilities that offer infant care should provide a safe sleep fluid after cleaning to ensure the infant does not ingest it. environment and use a written safe sleep policy that For this reason, submerging a pacifier is not recommended. describes the practices they follow to reduce the risk of If the pacifier nipple contains any unknown fluid, or if a sudden infant death syndrome and other infant deaths. caregiver/teacher questions the safety or ownership, the For example, when infants fall asleep, they must be put pacifier should be discarded (4). down to sleep on their back in a crib with a firm mattress and no blankets or soft objects. While using pacifiers to reduce the risk of sudden infant death syndrome (SIDS) seems prudent (especially if the RATIONALE infant is already sleeping with a pacifier at home), pacifier Conditions conducive to sleep and rest for younger children - use has been associated with an increased risk of ear infec include a consistent caregiver, a routine quiet place, regular tions and oral health issues (7). times for rest, and use of routines and safe practices. Most preschool-aged children in all-day care benefit from sched - COMMENTS uled periods of rest. This rest may take the form of actual To keep current with the AAP’s recommendations on the napping, a quiet time, or a change of pace between activi - use of pacifiers, go to http://www.aap.org. ties. The times and duration of naps will affect behavior at TYPE OF FACILITY home (1). Center, Large Family Child Care Home Young children need to develop healthy sleep habits for optimal development. Yet, sleep problems, i.e. short sleep duration, behavioral sleep problems, and sleep-disordered

134 107 Chapter 3: Health Promotion and Protection Sivertsen B, Harvey AG, Reichborn-Kjennerud T, Torgersen L, Ystrom E, 6. breathing all peak during the preschool years. In 2016, the Hysing M. Later emotional and behavioral problems associated with sleep National Sleep Foundation issued recommended sleep problems in toddlers: a longitudinal study. JAMA Pediatr. durations for newborns (14–17 hours), infants (12–15 hours), 2015;169(6):575–582 7. Kelly, Y; Kelly, J; Sacker, A; (2013) Time for bed: associations with cognitive toddlers (11–14 hours), and preschoolers (10–13 hours), performance in 7-year-old children: a longitudinal population-based which include both daytime and nighttime sleep (2,3). study. Journal of Epidemiology and Community Health , 67 (11) pp. 926-931. Getting sufficient sleep helps prevent pediatric obesity. In 8. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. meta-analyses, short sleep duration before 5 years of age is 2012;129(4):e857–e865 associated with 30% to 90% increased odds of overweight/ NOTES obesity at later ages (4,5). To prevent early childhood obesity, the Institute of Medicine recommends that child Content in the STANDARD was modified on 05/30/2018. care providers be required to adopt practices that promote age-appropriate sleep duration and that staff be trained to 3 .1. 4 . 5 counsel parents about recommended sleep durations (6). Unscheduled Access to Rest Areas Behavioral sleep problems (i.e., difficulty getting to/falling All children should have access to rest or nap areas whenever asleep) at 18 months of age are associated with a 60% to the child desires to rest. These rest or nap areas should be set 80% increased risk of emotional and behavioral problems up to reduce distraction or disturbance from other activities. at 5 years of age (7). Irregular bedtimes throughout early All facilities should provide rest areas for children, including childhood are associated with reduced reading, math, and children who become ill (1,2), at least until the child leaves spatial ability scores (8). Sleep-disordered breathing (e.g., the facility for care elsewhere. Children need to be within snoring, apnea) in early childhood is associated with a sight and hearing of caregivers/teachers when resting. 60% to 80% increase in social and emotional difficulties at 7 years of age (9). RATIONALE Any child, especially children who are ill (1,2), may need COMMENTS more opportunity for rest or quiet activities. In the young infant, favorable conditions for sleep and rest include being dry, well fed, and comfortable. Infants may TYPE OF FACILITY need 1 or 2 (or sometimes more) naps during the time they Center, Large Family Child Care Home are in child care. As infants age, they typically transition to RELATED STANDARDS 1 nap per day, and having 1 nap per day is consistent with Safe Sleep Practices and Sudden Unexpected 3.1. 4 .1 the schedule that most facilities follow. Different practices, Infant Death (SUID)/SIDS Risk Reduction such as rocking, holding a child while swaying, singing, Scheduled Rest Periods and Sleep Arrangements 3.1.4.4 reading, or patting an arm or back, could be used to calm the child. Lighting does not need to be turned off during Inclusion/Exclusion/Dismissal of Children 3. 6 .1.1 nap time. 3.6.2.2 Space Requirements for Care of Children Who Are Ill TYPE OF FACILITY 3.6.2.3 Qualifications of Directors of Facilities That Center, Large Family Child Care Home, Small Family Care for Children Who Are Ill Child Care Home Program Requirements for Facilities That Care 3.6.2.4 RELATED STANDARDS for Children Who Are Ill Safe Sleep Practices and Sudden Unexpected Infant 3.1. 4 .1 3.6.2.5 Caregiver/Teacher Qualifications for Facilities Death (SUID)/SIDS Risk Reduction That Care for Children Who Are Ill Levels of Illumination 5.2.2.1 5.4.5.1 Sleeping Equipment and Supplies Child-Staff Ratios for Facilities That Care for 3.6.2.6 5.4.5.2 Cribs Children Who Are Ill Child Care Health Consultants for Facilities 3.6.2.7 References 1. National Sleep Foundation. How much sleep do we really need? https:// That Care for Children Who Are Ill sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need. 3.6.2.8 Licensing of Facilities That Care for Children Accessed November 14, 2017 2. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Consensus statement of the Who Are Ill American Academy of Sleep Medicine on the recommended amount of 3.6.2.9 Information Required for Children Who sleep for healthy children: methodology and discussion. J Clin Sleep Med. Are Ill 2016;12(11):1549–1561 3. Fatima Y, Doi SA, Mamun AA. Longitudinal impact of sleep on overweight Inclusion and Exclusion of Children from 3. 6 . 2 .10 and obesity in children and adolescents: a systematic review and bias- Facilities That Serve Children Who Are Ill adjusted meta-analysis. Obes Rev. 2015;16(2):137–149 Li L, Zhang S, Huang Y, Chen K. Sleep duration and obesity in children: a 4. 5.4.5.1 Sleeping Equipment and Supplies systematic review and meta-analysis of prospective cohort studies. J Paediatr Child Health. 2017;53(4):378–385 5. 4 . 6 .1 Space for Children Who Are Ill 5. Institute of Medicine. Early Childhood Obesity Prevention Policies: Goals, Appendix A: Signs and Symptoms Chart Recommendations, and Potential Actions. Washington, DC: Institute of Medicine; 2011. http://www.nationalacademies.org/hmd/~/media/Files/ Report%20Files/2011/Early-Childhood-Obesity-Prevention-Policies/ Young%20Child%20Obesity%202011%20Recommendations.pdf. Published June 2011. Accessed November 14, 2017

135 108 Caring for Our Children: National Health and Safety Performance Standards toothpaste at least once a day reduces build-up of decay- References 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in - causing plaque (2,3). The development of tooth decay-pro child care and schools: A quick reference guide, pp. 43-48. 4th Edition. ducing plaque begins when an infant’s first tooth appears Elk Grove Village, IL: American Academy of Pediatrics. in his/her mouth (4). Tooth decay cannot develop without 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Book: 2015 Report of the Committee on Infectious Diseases. this plaque which contains the acid-producing bacteria in 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. 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 3 .1. 5 hand eye coordination for independent brushing until - around age seven or eight so either caregiver/teacher brush ORAL HEALTH ing or close supervision is necessary in the preschool child. Tooth brushing and activities at home may not suffice to 3 .1. 5 .1 develop this skill or accomplish the necessary plaque Routine Oral Hygiene Activities removal, especially when children eat most of their meals Caregivers/teachers should promote the habit of regular and snacks during a full day in child care. tooth brushing. All children with teeth should brush or - have their teeth brushed with a soft toothbrush of age-ap COMMENTS propriate size at least once during the hours the child is in The caregiver/teacher should use a small smear (grain of child care. Children under three years of age should have rice) of fluoride toothpaste spread across the width of the only a small smear (grain of rice) of fluoride toothpaste on toothbrush for children under three years of age and a the brush when brushing. Those children ages three and pea-sized amount for children ages three years of age and older should use a pea-sized amount of fluoride toothpaste older (1). Children should attempt to spit out excess tooth - (1). An ideal time to brush is after eating. The caregiver/ paste after brushing. Fluoride is the single most effective teacher should either brush the child’s teeth or supervise way to prevent tooth decay. Brushing teeth with fluoride as the child brushes his/her own teeth. Disposable gloves toothpaste is the most efficient way to apply fluoride to the should be worn by the caregiver/teacher if contact with a teeth. Young children may occasionally swallow a small child’s oral fluids is anticipated. The younger the child, the amount of toothpaste and this is not a health risk. However, more the caregiver/teacher needs to be involved. The care - if children swallow more than recommended amounts of giver/teacher should teach the child the correct method of fluoride toothpaste on a consistent basis, they are at risk for tooth brushing. Young children want to brush their own fluorosis, a cosmetic condition (discoloration of the teeth) teeth, but they need help until about age 7 or 8. The care - caused by over exposure to fluoride during the first eight giver/teacher should monitor the tooth brushing activity years of life (5). Other products such as fluoride rinses can and thoroughly brush the child’s teeth after the child has pose a poisoning hazard if ingested (6). finished brushing, preferably for a total of two minutes. The children can rinse with water after a snack or a meal if Children whose teeth are properly brushed with fluoride their teeth have been brushed with fluoride toothpaste toothpaste at home twice a day and are at low risk for earlier. Rinsing with water helps to remove food particles dental caries may be exempt since additional brushing from teeth and may help prevent tooth decay. with fluoride toothpaste may expose a child to excess A sink is not necessary to accomplish tooth brushing in fluoride toothpaste. child care. Each child can use a cup of water for tooth The cavity-causing effect of exposure to foods or drinks brushing. The child should wet the brush in the cup, brush - containing sugar (like juice) may be reduced by having chil and then spit excess toothpaste into the cup. dren rinse with water after snacks and meals when tooth Caregivers/teachers should encourage replacement of brushing is not possible. Local dental health professionals toothbrushes when the bristles become worn or frayed or can facilitate compliance with these activities by offering approximately every three to four months (7,8). - education and training for the child care staff and provid ing oral health presentations for the children and parents/ Caregivers/teachers should encourage parents/guardians to guardians. establish a dental home for their child within six months after the first tooth erupts or by one year of age, whichever RATIONALE is earlier (4). The dental home is the ongoing relationship - Regular tooth brushing with fluoride toothpaste is encour between the dentist and the patient, inclusive of all aspects aged to reinforce oral health habits and prevent gingivitis of oral health care delivered in a comprehensive, continu - and tooth decay. There is currently no (strong) evidence ously accessible, coordinated and family-centered way. that shows any benefit to wiping the gums of a baby who Currently there are insufficient numbers of dentists who has no teeth. However, before the first tooth erupts, wiping incorporate infants and toddlers into their practices so a baby’s gums with clean gauze or a soft wet washcloth as primary care providers may provide oral health screening part of a daily routine may make the transition to tooth during well child care in this population while promoting brushing easier. Good oral hygiene is as important for a the establishment of a dental home (2). six-month-old child with one tooth as it is for a six-year-old with many teeth (2). Tooth brushing with fluoride

136 109 Chapter 3: Health Promotion and Protection Fluoride varnish applied to all children every 3-6 months at 3.1.5.2 primary care visits or at their dental home reduces tooth Toothbrushes and Toothpaste decay rates, and can lead to significant cost savings in res- In facilities where tooth brushing is an activity, each child torative dental care and associated hospital costs. Coupled - should have a personally labeled, soft toothbrush of age-ap with parent/guardian and caregiver/teacher education, propriate size. No sharing or borrowing of toothbrushes fluoride varnish is an important tool to improve children’s should be allowed. After use, toothbrushes should be stored he a lt h (9 -11). on a clean surface with the bristle end of the toothbrush up TYPE OF FACILITY to air dry in such a way that the toothbrushes cannot contact or drip on each other and the bristles are not in contact with Center, Large Family Child Care Home any surface (1). Racks and devices used to hold toothbrushes RELATED STANDARDS for storage should be labeled and disinfected as needed. The 3.1. 5. 2 Toothbrushes and Toothpaste toothbrushes should be replaced at least every three to four 3.1. 5. 3 Oral Health Education months, or sooner if the bristles become frayed (2-5). When 9. 4 . 2 .1 Contents of Child’s Records a toothbrush becomes contaminated through contact with another brush or use by more than one child, it should be Pre-Admission Enrollment Information for 9.4.2.2 discarded and replaced with a new one. Each Child Each child should have his/her own labeled toothpaste tube. Contents of Admission Agreement Between Child 9.4.2.3 Or if toothpaste from a single tube is shared among the chil - Care Program and Parent/Guardian dren, it should be dispensed onto a clean piece of paper or Contents of Child’s Primary Care Provider’s 9.4.2.4 - paper cup for each child rather than directly on the tooth Assessment brush (1,6). Children under three years of age should have Health History 9.4.2.5 only a small smear of fluoride toothpaste (grain of rice) on 9.4.2.6 Contents of Medication Record the brush when brushing. Those three years of age and older Contents of Facility Health Log for Each Child 9.4.2.7 should use a pea-sized amount of fluoride toothpaste (7). Release of Child’s Records 9.4.2.8 Toothpaste should be stored out of children’s reach. References A B 1. American Academy of Pediatrics, Section on Oral Health. 2014. Maintaining and improving the oral health of young children. http:// pediatrics.aappublications.org/content/134/6/1224 2. American Academy of Pediatrics, Section on Pediatric Dentistry. 2008. Preventive oral health intervention for pediatricians. Pediatrics 122:1387-94. 3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Small smear of fluoride toothpaste. Pea-sized amount of fluoride toothpaste. B. A. Photo Credit: National Center on Early Childhood Health and Wellness 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. When children require assistance with brushing, caregivers/ Pediatric Dentistry 30:112-18. teachers should wash their hands thoroughly between 4. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. brushings for each child. Caregivers/teachers should wear Policy statement: Oral health risk assessment timing and establishment of the dental home. Pediatrics 124:845. gloves when assisting such children with brushing their 5. Centers for Disease Control and Prevention, Fluoride Recommendations teeth. Work Group. 2001. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 50(RR14): 1-42. RATIONALE Centers for Disease Control and Prevention. 2013. Community water 6. Toothbrushes and oral fluids that collect in the mouth fluoridation. http://www.cdc.gov/fluoridation/faqs/ 7. American Academy of Pediatric Dentistry. Early childhood caries. during tooth brushing are contaminated with infectious Chicago: AAPD. http://www.aapd.org/assets/2/7/ECCstats.pdf. - agents and must not be allowed to serve as a conduit of infec 8. American Dental Association. ADA positions and statements. ADA tion from one individual to another (1). Individually labeling statement on toothbrush care: Cleaning, storage, and replacement. Chicago: ADA. http://www.ada.org/1887.aspx. - the toothbrushes will prevent different children from shar 9. Marinho, V.C., et al. 2002. Fluoride varnishes for preventing dental caries ing the same toothbrush. As an alternative to racks, children in children and adolescents. Cochrane Database System Rev 3, no. can have individualized, labeled cups and their brush can be CD002279. http://www.ncbi.nlm.nih.gov/pubmed/12137653 American Academy of Pediatric Dentistry. 2006. Talking points: AAPD 10. stored bristle-up in their cup. Some bleeding may occur perspective on physicians or other non-dental providers applying fluoride during tooth brushing in children who have inflammation varnish. Dental Home Resource Center.http://www.aapd.org/ of the gums. The Occupational Safety and Health Adminis- dentalhome/1225.pdf. American Academy of Pediatrics, Committee on Practice and 11. tration (OSHA) regulations apply where there is potential Ambulatory Medicine.2016. Policy statement: 2016 Recommendations for exposure to blood. Saliva is considered an infectious vehicle preventive pediatric health care. http://pediatrics.aappublications.org/ whether or not it contains blood, so caregivers/teachers content/early/2015/12/07/peds.2015-3908 should protect themselves from saliva by implementing NOTES standard precautions. Content in the STANDARD was modified on 3/10/2016.

137 110 Caring for Our Children: National Health and Safety Performance Standards School-age children should receive additional information COMMENTS including: Children can use an individually labeled or disposable cup of water to brush their teeth (1). The preventive use of fluoride; a. Dental sealants; b. Toothpaste is not necessary if removal of food and plaque Mouth guards for protection when playing sports; c. is the primary objective of tooth brushing. However, no d. The importance of healthy eating behaviors; and anti-caries benefit is achieved from brushing without e. Regularly scheduled dental visits. fluoride toothpaste. Adolescent children should be informed about the effect Some risk of infection can occur when numerous children of tobacco products on their oral health and additional brush their teeth and spit into the sink that is not sanitized reasons to avoid tobacco. between uses. Caregivers/teachers and parents/guardians should be taught Tooth brushing ability varies by age. Young children want to not place a child’s pacifier in the adult’s mouth to clean to brush their own teeth, but they need help until about age or moisten it or share a toothbrush with a child due to the seven or eight. Adults helping children brush their teeth not risk of promoting early colonization of the infant oral only help them learn how to brush, but also improve the (1). Streptococcus mutans cavity with removal of plaque and food debris from all teeth (5). Caregivers/teachers should limit juice consumption to no TYPE OF FACILITY more than four to six ounces per day for children one Center, Large Family Child Care Home through six years of age. RELATED STANDARDS RATIONALE Routine Oral Hygiene Activities 3.1. 5.1 Studies have reported that the oral health of participants Oral Health Education 3.1. 5. 3 improved as a result of educational programs (2). Sharing of Personal Articles Prohibited 3. 6 .1. 5 COMMENTS 5.5.0.1 Storage and Labeling of Personal Articles Caregivers/teachers are encouraged to advise parents/ References - guardians on the following recommendations for preven 1. Centers for Disease Control and Prevention. 2005. Infection control in tive and early intervention dental services and education: dental settings: The use and handling of toothbrushes. http://www.cdc.gov/ OralHealth/InfectionControl/factsheets/toothbrushes.htm Dental or primary care provider visits to evaluate the a. 2. American Dental Association, Council on Scientific Affairs. 2005. ADA need for supplemental fluoride therapy (prescription statement on toothbrush care: Cleaning, storage, and replacement. http:// www.ada.org/1887.aspx. pills or drops if tap water does not contain fluoride) 3. American Academy of Pediatric Dentistry. 2004. Early childhood caries starting at six months of age, and professionally applied (ECC).http://www.aapd.org/assets/2/7/ECCstats.pdf. topical fluoride treatments for all children every 3-6 4. American Dental Hygienists’ Association. Proper brushing. http://www. adha.org/oralhealth/brushing.htm. months starting when teeth are present (3,4); 5. 12345 First Smiles. 2006. Oral health considerations for children with b. First dental visit within six months after the first tooth special health care needs (CSHCN). http://www.first5oralhealth.org/page. erupts or by one year of age, whichever is earlier and asp?page_id=432. Davies, R. M., G. M. Davies, R. P. Ellwood, E. J. Kay. 2003. Prevention. Part 6. whenever there is a question of an oral health problem; 4: Toothbrushing: What advice should be given to patients? Brit Dent Jour Dental sealants generally at six or seven years of age for c. 195:135-41. first permanent molars and for primary molars if deep 7. American Academy of Pediatrics, Section on Oral Health. 2014 Maintaining and improving the oral health of young children. http://pediatrics. pits and grooves or other high risk factors are present aappublications.org/content/134/6/1224. (4 , 6). NOTES Caregivers/teachers should provide education for parents/ Content in the STANDARD was modified on 2/6/2013, guardians on good oral hygiene practices and avoidance of 04/22/2013, and 3/10/2016. behaviors that increase the risk of early childhood caries, such as inappropriate use of a bottle, frequent consumption of carbohydrate-rich foods, and sweetened beverages such 3.1.5.3 as juices with added sweeteners, soda, sports drinks, fruit Oral Health Education nectars, and flavored teas. All children with teeth should have oral hygiene education as a part of their daily activity. For more resources on oral health education, see: Children three years of age and older should have develop - Parent’s Checklist for Good Dental Health Practices in mentally appropriate oral health education that includes: Child Care, a parent handout in English and Spanish, developed by the National Resource Center for Health and Information on what plaque is; a. Safety in Child Care and Early Education at http://nrckids. The process of dental decay; b. org/dentalchecklist.pdf; Diet influences on teeth, including the contribution of c. - sugar-sweetened beverages and foods to cavity develop Bright Futures for Oral Health at http://brightfutures.aap. ment; and org/practice_guides_and_other_resources.html; The importance of good oral hygiene behaviors. d.

138 111 Chapter 3: Health Promotion and Protection California Childcare Health Program Health and Safety in time (1). Whichever diapering system is used in the facility, the Child Care Setting: Promoting Children’s Oral Health clothes should be worn over diapers while the child is in A Curriculum for Health Professionals and Child Care the facility. Providers (in English and Spanish) at http://cchp.ucsf.edu/ No rinsing or dumping of the contents of cloth diapers and its 12345 first smiles program at http://first5oralhealth. should be performed at the child care facility. Soiled cloth org; and National Training Institute for Child Care Health diapers should be stored in a labeled container with a Consultant’s Healthy Smiles Through Child Care Health tight-fitting lid provided by an accredited commercial Consultation course at http://nti.unc.edu/healthy_smiles/. diaper service, or in a sealed plastic bag for removal from the facility by an individual child’s family, stored in a loca TYPE OF FACILITY - tion inaccessible to children, and given directly to the Center parent/guardian daily upon discharge of the child. Children RELATED STANDARDS of all ages who are incontinent of urine or stool should wear Pacifier Use 3.1. 4 . 3 a barrier method, such as a disposable diaper or a cloth Routine Oral Hygiene Activities 3.1. 5.1 diaper that is completely covered with an outer waterproof layer and a waist closure. 3.1. 5. 2 Toothbrushes and Toothpaste 100% Fruit Juice 4.2.0.7 While single unit reusable diaper systems, with an inner cloth lining attached to an outer waterproof covering, and Oral Health Policy 9. 2 . 3.14 reusable cloth diapers, worn with a front closure waterproof References cover, meet the physical criteria of this standard (if used as 1. American Academy of Pediatrics, Oral Health Initiative. Protecting All Children’s Teeth (PACT): A pediatric oral health training program. Factors described), they have not been evaluated for their ability to in Development: Bacteria. http://www2.aap.org/oralhealth/pact/ reduce fecal contamination, or for their association with Dye, B. A., J. D. Shenkin, C. L. Ogden, T. A. Marshould, S. M. Levy, M. J. 2. diaper dermatitis (rash). Moreover, it has not been demon - Kanellis. 2004. The relationship between healthful eating practices and dental caries in children aged 2-5 years in the United States. J Am Dent strated that the waterproof covering materials remain Assoc 135:55-66. waterproof with repeated cleaning and disinfecting. 3. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Therefore, single-use disposable diapers should be Council on Clinical Affairs. 2008-2009. Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, encouraged for use in child care facilities. and oral treatment for infants, children, and adolescents. Pediatric RATIONALE Dentistry 30:112-18. American Academy of Pediatrics, Committee on Practice and Ambulatory 4. Procedures that reduce fecal contamination help control Medicine.2016. Policy statement: 2016 Recommendations for preventive the spread of disease. Fecal contamination has been associ - pediatric health care. http://pediatrics.aappublications.org/content/ early/2015/12/07/peds.2015-3908 ated with increased diarrheal rates in child care facilities 5. American Academy of Pediatrics, Section on Pediatric Dentistry. 2009. (1). Gastrointestinal tract disease, or diarrhea (caused by Policy statement: Oral health risk assessment timing and establishment of bacteria, viruses, and parasites) and hepatitis A virus the dental home. Pediatrics 124:845. American Academy of Pediatrics, Section on Pediatric Dentistry.2008. 6. infection are spread from infected persons through fecal 122:1387-94. Pediatrics Preventive oral health intervention for pediatricians. contamination of hands and objects. Protective procedures includes minimal handling of soiled diapers and clothing, thorough hand hygiene, and containment of fecal matter. 3.2 Fecal contamination in child care settings may be reduced HYGIENE when single-use, disposable diapers are used compared to cloth diapers worn with pull-on waterproof pants (3). When 3 . 2 .1 clothes are worn over either disposable or cloth diapers DIAPERING AND CHANGING with pull-on waterproof pants, there is a reduction in SOILED CLOTHING contamination of the environment (1, 3). DIAPER RASH 3 . 2 .1.1 Diaper dermatitis (rash) occurs frequently in diapered chil - Type of Diapers Worn dren. Diapering practices that reduce the frequency and Facilities should adhere to the procedures outlined in severity of diaper dermatitis will require less application of 3.2.1.2: Handling Cloth Diapers and 3.2.1.4: Diaper skin creams and ointments, thereby decreasing the likeli - Changing Procedure to prevent and control infections hood for fecal contamination of caregivers/teachers’ hands. caused by fecal contact: Most common diaper dermatitis is caused by prolonged Diapers worn by children should be able to contain urine contact of the skin with urine, feces, or both (1). The action and stool and minimize exposure to human waste in the of fecal digestive enzymes on urinary urea and the resulting child care setting. Children should use disposable diapers production of ammonia make the diapered area more alka - with absorbent material (e.g., polymers) or cloth diapers. line, which has been shown to damage skin (1). Damaged Cloth diapers should have an absorbent inner layer that is skin is more susceptible to other biological, chemical, and completely covered with an outer waterproof layer that has physical insults that can cause or aggravate diaper dermati - a waist closure (i.e., not pull-on waterproof pants). The cloth tis (1). Frequency and severity of diaper dermatitis are lower diaper and waterproof later should be changed at the same

139 112 Caring for Our Children: National Health and Safety Performance Standards when diapers are changed more often, regardless of the diaper There is no reason to use the toilet for stool if disposable used (1). The use of disposable diapers with absorbent material diapers are being used. Commercial diaper laundries use a has been associated with less frequent and less severe diaper procedure that separates solid components from the diapers dermatitis in some children than with the use of cloth diapers and does not require prior dumping of feces into the toilet. and pull-on pants made of a waterproof material (2, 3). TYPE OF FACILITY COMMENTS Center, Large Family Child Care Home Reusable cloth diapers worn either without a covering or RELATED STANDARDS with pull-on waterproof pants do not meet the physical Type of Diapers Worn 3. 2 .1.1 requirements of the standard. Procedure for Changing Children’s Soiled 3. 2 .1. 5 TYPE OF FACILITY Underwear/Pull-Ups and Clothing Center, Large Family Child Care Home Reference 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child RELATED STANDARDS care and schools: A quick reference guide, 4th Edition. Elk Grove Village, 3.2.1.2 Handling Cloth Diapers IL: American Academy of Pediatrics. 3. 2 .1. 4 Diaper Changing Procedure Procedure for Changing Children’s Soiled 3. 2 .1. 5 3 . 2 .1. 3 Underwear/Pull-Ups and Clothing Checking for the Need to Change Diapers Situations that Require Hand Hygiene 3.2.2.1 Diapers should be checked for wetness and feces at least Handwashing Procedure 3.2.2.2 hourly, visually inspected at least every two hours, and whenever the child indicates discomfort or exhibits behav - Assisting Children with Hand Hygiene 3.2.2.3 ior that suggests a soiled or wet diaper. Diapers should be Training and Monitoring for Hand Hygiene 3.2.2.4 changed when they are found to be wet or soiled. Hand Sanitizers 3.2.2.5 RATIONALE Containment of Soiled Diapers 5 . 2 . 7. 4 Frequency and severity of diaper dermatitis is lower when Handwashing Sinks 5. 4 .1.10 diapers are changed more often, regardless of the type of References diaper used (1). Diaper dermatitis occurs frequently in 1. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Children diapered children. Most common diaper dermatitis repre- in out-of-home child care. In: Red Book: 2015 Report of the Committee of sents an irritant contact dermatitis; the source of irritation Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. is prolonged contact of the skin with urine, feces, or both 2. American Academy of Pediatrics. Healthychildren.org. 2015. Diaper rash. (2). The action of fecal digestive enzymes on urinary urea https://www.healthychildren.org/English/ages-stages/baby/ and the resulting production of ammonia make the diapers-clothing/Pages/Diaper-Rash.aspx. 3. Counts, J.L., Helmes, C.T., Kenneally, D., Otts, D.R. Modern disposable diapered area more alkaline, which has been shown to diaper constructions: Innovations in performance help maintain healthy damage skin (1,2). diapered skin. 2014. Clinical Pediatrics. 53(9S):10S-13S. Damaged skin is more susceptible to other biological, NOTES chemical, and physical insults that can cause or aggravate Content in the STANDARD was modified on 8/9/2017. diaper dermatitis (2). Modern disposable diapers can be checked for wetness by 3.2.1.2 feeling the diaper through the clothing and fecal contents Handling Cloth Diapers can be assessed by odor. Nonetheless, since these methods If cloth diapers are used, soiled cloth diapers and/or soiled of checking may be inaccurate, the diaper should be opened training pants should never be rinsed or carried through the and checked visually at least every two hours. Even though child care area to place the fecal contents in a toilet. Reusable modern disposable diapers can continue to absorb moisture diapers should be laundered by a commercial diaper service. for an extended period of time when they are wet, they Soiled cloth diapers should be stored in a labeled container should be changed after two hours of wearing if they are with a tight-fitting lid provided by an accredited commercial found to be wet. This prevents rubbing of wet surfaces diaper service, or in a sealed plastic bag for removal from the against the skin, a major cause of diaper dermatitis. facility by an individual child’s family. The sealed plastic bag TYPE OF FACILITY should be sent home with the child at the end of the day. The Center, Large Family Child Care Home containers or sealed diaper bags of soiled cloth diapers should not be accessible to any child (1). RELATED STANDARDS RATIONALE 3.2.1.2 Handling Cloth Diapers Containing and minimizing the handling of soiled diapers Diaper Changing Procedure 3. 2 .1. 4 so they do not contaminate other surfaces is essential to 3. 2 .1. 5 Procedure for Changing Children’s Soiled prevent the spread of infectious disease. Putting stool into a Underwear/Pull-Ups and Clothing toilet in the child care facility increases the likelihood that Situations that Require Hand Hygiene 3.2.2.1 other surfaces will be contaminated during the disposal (2).

140 113 Chapter 3: Health Promotion and Protection does not contaminate these surfaces with stool or urine References 1. Healthy Children. 2010. Ages and stages: When diaper rash strikes. http:// during the diaper changing. www.healthychildren.org/English/ages-stages/baby/diapers-clothing/ Pages/When-Diaper-Rash-Strikes.aspx. : Clean the child’s diaper area. Step 3 2. Shelov, S. P., T. R. Altmann, eds. 2009. Caring for your baby and young Place the child on the diaper change surface and unfasten a. child: Birth to age 5. 5th ed. Elk Grove Village, IL: American Academy of the diaper, but leave the soiled diaper under the child; Pediatrics. If safety pins are used, close each pin immediately once b. it is removed and keep pins out of the child’s reach 3 . 2 .1. 4 (never hold pins in your mouth); Diaper Changing Procedure c. Lift the child’s legs as needed to use disposable wipes, or The following diaper changing procedure should be posted a dampened cloth or wet paper towel to clean the skin on in the changing area, should be followed for all diaper the child’s genitalia and buttocks and prevent recontami - changes, and should be used as part of staff evaluation of nation from a soiled diaper. Remove stool and urine from caregivers/teachers who diaper. The signage should be front to back and use a fresh wipe, or a dampened cloth simple and should be in multiple languages if caregivers/ or wet paper towel each time you swipe. Put the soiled teachers who speak multiple languages are involved in wipes or paper towels into the soiled diaper or directly diapering. All employees who will diaper should undergo into a plastic-lined, hands-free covered can. Reusable training and periodic assessment of diapering practices. cloths should be stored in a washable, plastic-lined, Caregivers/teachers should never leave a child unattended tightly covered receptacle (within arm’s reach of diaper on a table or countertop, even for an instant. A safety strap changing tables) until they can be laundered. The cover or harness should not be used on the diaper changing table. should not require touching with contaminated hands If an emergency arises, caregivers/teachers should bring or objects. any child on an elevated surface to the floor or take the : Remove the soiled diaper and clothing without Step 4 child with them. contaminating any surface not already in contact with Use a fragrance-free bleach that is EPA-registered as a s stool or urine. anitizing or disinfecting solution. If other products are a. Fold the soiled surface of the diaper inward; used for sanitizing or disinfecting, they should also be b. Put soiled disposable diapers in a covered, plastic-lined, fragrance-free and EPA-registered (1). hands-free covered can. If reusable cloth diapers are used, put the soiled cloth diaper and its contents (without All cleaning and disinfecting solutions should be stored to emptying or rinsing) in a plastic bag or into a plastic- be accessible to the caregiver/teacher but out of reach of any - lined, hands-free covered can to give to parents/guard child. Please refer to Appendix J: Selecting an Appropriate ians or laundry service; Sanitizer or Disinfectant and Appendix K: Routine c. Put soiled clothes in a plastic-lined, hands-free plastic Schedule for Cleaning, Sanitizing, and Disinfecting. bag; : Get organized. Before bringing the child to the diaper Step 1 Check for spills under the child. If there are any, use the d. changing area, perform hand hygiene, gather and bring corner of the paper to fold the paper that extends under supplies to the diaper changing area: the child’s feet over the soiled area so a fresh, unsoiled Non-absorbent paper liner large enough to cover the a. paper surface is now under the child’s buttocks; changing surface from the child’s shoulders to beyond If gloves were used, remove them using the proper tech - e. the child’s feet; ) and put them into a plastic-lined, Appendix D nique (see Unused diaper, clean clothes (if you need them); b. hands-free covered can; Wipes, dampened cloths or wet paper towels for clean c. - f. Whether or not gloves were used, use a fresh wipe to ing the child’s genitalia and buttocks readily available; wipe the hands of the caregiver/teacher and another fresh d. A plastic bag for any soiled clothes or cloth diapers; wipe to wipe the child’s hands. Put the wipes into the e. Disposable gloves, if you plan to use them (put gloves on plastic-lined, hands-free covered can. before handling soiled clothing or diapers) and remove : Put on a clean diaper and dress the child. Step 5 them before handling clean diapers and clothing; a. Slide a fresh diaper under the child; f. A thick application of any diaper cream (e.g., zinc oxide Use a facial or toilet tissue or wear clean disposable glove b. ointment), when appropriate, removed from the con- to apply any necessary diaper creams, discarding the tainer to a piece of disposable material such as facial or tissue or glove in a covered, plastic-lined, hands-free toilet tissue. covered can; : Carry the child to the changing table, keeping soiled Step 2 Note and plan to report any skin problems such as c. clothing away from you and any surfaces you cannot easily redness, skin cracks, or bleeding; clean and sanitize after the change. d. Fasten the diaper; if pins are used, place your hand a. Always keep a hand on the child; between the child and the diaper when inserting the pin. b. 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

141 114 Caring for Our Children: National Health and Safety Performance Standards available on this issue. Wet paper towels or a damp cloth Step 6 : Wash the child’s hands and return the child to a may be used as an alternative to commercial baby wipes. supervised area. a. Use soap and warm water, between 60°F and 120°F, If the child’s clean buttocks are put down on a soiled at a sink to wash the child’s hands, if you can. surface, the child’s skin can be resoiled. Step 7 : Clean and disinfect the diaper-changing surface. Children’s hands often stray into the diaper area (the area Dispose of the disposable paper liner used on the a. of the child’s body covered by diaper) during the diapering diaper changing surface in a plastic-lined, hands-free process and can then transfer fecal organisms to the envi - covered can; ronment. Washing the child’s hands will reduce the number If clothing was soiled, securely tie the plastic bag used b. of organisms carried into the environment in this way. to store the clothing and send home; Infectious organisms are present on the skin and diaper Remove any visible soil from the changing surface with c. even though they are not seen. To reduce the contamina - a disposable paper towel saturated with water and tion of clean surfaces, caregivers/teachers should use a fresh detergent, rinse; wipe to wipe their hands after removing the gloves, or, if no d. Wet the entire changing surface with a disinfectant that gloves were used, before proceeding to handle the clean is appropriate for the surface material you are treating. diaper and the clothing. Follow the manufacturer’s instructions for use; Some states and credentialing organizations may recom - e. Put away the disinfectant. Some types of disinfectants mend wearing gloves for diaper changing. Although gloves may require rinsing the change table surface with fresh may not be required, they may provide a barrier against water afterwards. surface contamination of a caregiver/teacher’s hands. This : Perform hand hygiene according to the procedure in Step 8 may reduce the presence of enteric pathogens under the Standard 3.2.2.2 and record the diaper change in the child’s fingernails and on hand surfaces. Even if gloves are used, daily log. caregivers/teachers must perform hand hygiene after each In the daily log, record what was in the diaper and a. child’s diaper changing to prevent the spread of disease- any problems (such as a loose stool, an unusual odor, causing agents. To achieve maximum benefit from use of blood in the stool, or any skin irritation), and report gloves, the caregiver/teacher must remove the gloves prop - as necessary (2). erly after cleaning the child’s genitalia and buttocks and removing the soiled diaper. Otherwise, retained contami - RATIONALE nated gloves could transfer organisms to clean surfaces. The procedure for diaper changing is designed to reduce - Note that sensitivity to latex is a growing problem. If care the contamination of surfaces that will later come in givers/teachers or children who are sensitive to latex are contact with uncontaminated surfaces such as hands, present in the facility, non-latex gloves should be used. See furnishings, and floors (3). Posting the multi-step proce - Appendix D, for proper technique for removing gloves. dure may help caregivers/teachers maintain the routine. A safety strap cannot be relied upon to restrain the child Assembling all necessary supplies before bringing the and could become contaminated during diaper changing. child to the changing area will ensure the child’s safety, Cleaning and disinfecting a strap would be required after make the change more efficient, and reduce opportunities every diaper change. Therefore safety straps on diaper for contamination. Taking the supplies out of their con- changing surfaces are not recommended. tainers and leaving the containers in their storage places reduces the likelihood that the storage containers will Prior to disinfecting the changing table, clean any visible become contaminated during diaper changing. soil from the surface with a detergent and rinse well with water. Always follow the manufacturer’s instructions for use, Commonly, caregivers/teachers do not use disposable paper application and storage. If the disinfectant is applied using that is large enough to cover the area likely to be contami - a spray bottle, always assume that the outside of the spray nated during diaper changing. If the paper is large enough, bottle could be contaminated. Therefore, the spray bottle there will be less need to remove visible soil from surfaces should be put away before hand hygiene is performed, later and there will be enough paper to fold up so the soiled (the last and essential part of every diaper change) (5). surface is not in contact with clean surfaces while dressing the child. Diaper-changing areas should never be located in food preparation areas and should never be used for temporary If the child’s foot coverings are not removed during diaper placement of food, drinks, or eating utensils. changing, and the child kicks during the diaper changing procedure, the foot coverings can become contaminated If parents/guardians use the diaper changing area, they and subsequently spread contamination throughout the should be required to follow the same diaper changing child care area. procedure to minimize contamination of the diaper changing area and child care. Some experts believe that commercial baby wipes may cause irritation of a baby’s sensitive tissues, such as inside TYPE OF FACILITY the labia, but currently there is no scientific evidence Center, Large Family Child Care Home

142 115 Chapter 3: Health Promotion and Protection with steps that allow the child to climb with the caregiver/ RELATED STANDARDS teacher’s help and supervision are a good idea. This would 3. 2 .1.1 Type of Diapers Worn help reduce the risk of back injury for the adults that may Handling Cloth Diapers 3.2.1.2 occur from lifting the child onto the table (1). 3. 2 .1. 3 Checking for the Need to Change Diapers Caregivers/teachers should never leave a child unattended 3.2.2.1 Situations that Require Hand Hygiene on a table or countertop, even for an instant. A safety strap Handwashing Procedure 3.2.2.2 or harness should not be used on the changing surface. If 3.3.0.1 Routine Cleaning, Sanitizing, and an emergency arises, caregivers/teachers should bring any Disinfecting child on an elevated surface to the floor or take the child 5 . 2 . 7. 4 Containment of Soiled Diapers with them. Location of Laundry Equipment and Water 5.4.4.2 Use fragrance-free bleach that is EPA-registered as a sani - Temperature for Laundering tizing or disinfecting solution. If other products are used Gloving Appendix D: for sanitizing or disinfecting, they should also be fragrance- free and EPA-registered (2). Selecting an Appropriate Sanitizer or Appendix J: Disinfectant All cleaning and disinfecting solutions should be stored to Appendix K: Routine Schedule for Cleaning, Sanitizing, be accessible to the caregiver/teacher but out of reach of any and Disinfecting child. Please refer to Appendix J: Selecting an Appropriate Sanitizer or Disinfectant and Appendix K: Routine References Schedule for Cleaning, Sanitizing, and Disinfecting. 1. Children’s Environmental Health Network. 2016. Household chemicals. http://www.cehn.org/wp-content/uploads/Household_chemicals_1_16.pdf. : Get organized and determine whether to change the Step 1 2. National Association for the Education of Young Children. 2012. Healthy child lying down or standing up. Before bringing the child to Young Children, A Manual for Programs. Fifth edition. Editor. Susan the changing area, perform hand hygiene, and gather and Aronson Washington, DC. 3. Red Book: 2015 Report of the Committee on Infectious Diseases, 30th bring supplies to the changing area. Edition American Academy of Pediatrics Committee on Infectious a. Non-absorbent paper liner large enough to cover the Diseases; Editor: David W. Kimberlin, MD, FAAP; Associate Editors: changing surface; Michael T. Brady, MD, FAAP; Mary Anne Jackson, MD, FAAP; and Sarah S. Long, MD, FAAP. Unused pull-up or underwear, clean clothes (if you need b. 4. Early Childhood Education Linkage System. Healthy Child Care them); Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa. - c. Wipes, dampened cloths or wet paper towels for clean org/tools/posters/item/279-diapering-poster. 5. University of California, San Francisco School of Nursing’s Institute for ing the child’s genitalia and buttocks readily available; Health & Aging, University of California, Berkeley’s Center for - d. A plastic bag for any soiled clothes, including under Environmental Research and Children’s Health, and Informed Green wear, or pull-ups; Solutions, California Department of Pesticide Regulation. 2013. Green cleaning, sanitizing, and disinfecting: A checklist for early care and Disposable gloves, if you plan to use them (put gloves on e. education. https://www.epa.gov/sites/production/files/2013-08/documents/ before handling soiled clothing or pull-ups) and remove checklist_8.1.2013.pdf. them before handling clean pull-ups or underwear and NOTES clothing. Content in the STANDARD was modified on 1/2012, : Avoid contact with soiled items. Step 2 7/2012, 5/13/2013 and on 8/23/2016. a. If the child is standing, it may cause the clothing, shoes and socks to become soiled. The caregiver/teacher must 3 . 2 .1. 5 remove these items before the change begins; Procedure for Changing Children’s Soiled To avoid contaminating the child’s clothes, have the b. child hold their shirt, sweater, etc. up above their waist Underwear/Pull-Ups and Clothing during the change. This keeps the child’s hands busy The following changing procedure for soiled pull-ups or and the caregiver/teacher knows where the child’s hands underwear and clothing should be posted in the changing are during the changing process. Caregivers/teachers area, should be followed for all changes, and should be used can also use plastic clothes pins that can be washed and as part of staff evaluation of caregivers/teachers who change sanitized to keep the clothing out of the way; pull-ups or underwear and clothing. The signage should be c. If disposable pull-ups were used, pull the sides apart, simple and should be in multiple languages if caregivers/ rather than sliding the garment down the child’s legs. If teachers who speak multiple languages are involved in - underwear is being changed, remove the soiled under changing pull-ups or underwear. All employees who will wear and any soiled clothing, doing your best to avoid change pull-ups or underwear and clothing should undergo contamination of surfaces; training and periodic assessment of these practices. d. To avoid contamination of the environment and/or the Changing a child from the floor level or on a chair puts the increased risk of spreading germs to the other children adult in an awkward position and increases the risk of in the room, do not rinse the soiled clothing in the toilet - contamination of the environment. Using a toddler chang or elsewhere. Place all soiled garments in a plastic-lined, ing table helps establish a well-organized changing area for hands-free plastic bag to be cleaned at the child’s home; both the child and the caregiver/teacher. Changing tables

143 116 Caring for Our Children: National Health and Safety Performance Standards e. If the child’s shoes are soiled, the caregiver/teacher : Perform hand hygiene according to the procedure in Step 7 must wash and sanitize them before putting them back Standard 3.2.2.2 and record the change in the child’s daily log. on the child. It is a good idea for the child care facility In the daily log, record what was in the pull-up or a. to request a few extra pair of socks and shoes from the underwear and any problems (such as a loose stool, an parent/caregiver to be kept at the facility in case these unusual odor, blood in the stool, or any skin irritation), items become soiled (1). and report as necessary (3). : Clean the child’s skin and check for spills. Step 3 RATIONALE Lift the child’s legs as needed to use disposable wipes, or a. Children who are learning to use the toilet may still wet/soil a dampened cloth or wet paper towel to clean the skin their pull-ups or underwear and clothing. Changing these on the child’s genitalia and buttocks. Remove stool and undergarments can lead to risk for spreading infection due urine from front to back and use a fresh wipe, damp - to the contamination of surfaces from urine or feces (1). The ened cloth or wet paper towel each time you swipe. Put procedure for changing a child’s soiled undergarment and the soiled wipes or paper towels into the soiled pull-up clothing is designed to reduce the contamination of or directly into a plastic-lined, hands-free covered can. surfaces that will later come in contact with uncontami - Reusable cloths should be stored in a washable, plastic- nated surfaces such as hands, furnishings, and floors (4,5). lined, tightly covered receptacle (within arm’s reach of Posting the multi-step procedure may help caregivers/ diaper changing tables) until they can be laundered. The teachers maintain the routine. cover should not require touching with contaminated Assembling all necessary supplies before bringing the child hands or objects; to the changing area will ensure the child’s safety, make the b. Check for spills under the child. If there are any, use the change more efficient, and reduce opportunities for paper that extends beyond or under the child’s feet to contamination. Taking the supplies out of their containers fold over the soiled area so a fresh, unsoiled paper and leaving the containers in their storage places reduces surface is now under the child; the likelihood that the storage containers will become c. If gloves were used, remove them using the proper contaminated during changing. technique (see Appendix D) and put them into a Commonly, caregivers/teachers do not use disposable paper plastic-lined, hands-free covered can; - that is large enough to cover the area likely to be contami Whether or not gloves were used, use a fresh wipe to d. nated during changing. If the paper is large enough, there wipe the hands of the caregiver/teacher and another will be less need to remove visible soil from surfaces later fresh wipe to wipe the child’s hands. Put the wipes into and there will be enough paper to fold up so the soiled the plastic-lined, hands-free covered can; surface is not in contact with clean surfaces while dressing : Put on a clean pull-up or underwear and clothing, if Step 4 the child. necessary. - If the child’s foot coverings are not removed during chang a. Assist the child, as needed, in putting on a clean dis- ing, and the child kicks during the changing procedure, the posable pull-up or underwear, then in re-dressing (1); foot coverings can become contaminated and subsequently b. Note and plan to report any skin problems such as spread contamination throughout the child care area. redness, skin cracks, or bleeding; c. Put the child’s socks and shoes back on if they were If the child’s clean buttocks are put down on a soiled removed during the changing procedure (1). surface, the child’s skin can be resoiled. : Wash the child’s hands and return the child to a Step 5 Children’s hands often stray into the changing area (the supervised area. area of the child’s body covered by the soiled pull-ups or Use soap and warm water, between 60°F and 120°F, a. underwear) during the changing process and can then at a sink to wash the child’s hands, if you can. transfer fecal organisms to the environment. Washing the child’s hands will reduce the number or organisms carried Step 6 : Clean and disinfect the changing surface. into the environment in this way. Infectious organisms are - Dispose of the disposable paper liner used on the chang a. present on the skin and pull-ups or underwear even though ing surface in a plastic-lined, hands-free covered can; they are not seen. To reduce the contamination of clean If clothing was soiled, securely tie the plastic bag used b. surfaces, caregivers/teachers should use a fresh wipe to to store the clothing and send home; wipe their hands after removing the gloves or, if no gloves Remove any visible soil from the changing surface c. were used, before proceeding to handle the clean pull-up or with a disposable paper towel saturated with water underwear and the clothing. and detergent, rinse; Wet the entire changing surface with a disinfectant that d. - Some states and credentialing organizations may recom is appropriate for the surface material you are treating. mend wearing gloves for changing. Although gloves may Follow the manufacturer’s instructions for use; not be required, they may provide a barrier against surface e. Put away the disinfectant. Some types of disinfectants contamination of a caregiver/teacher’s hands. This may may require rinsing the change table surface with fresh reduce the presence of enteric pathogens under the water afterwards.

144 117 Chapter 3: Health Promotion and Protection fingernails and on hand surfaces. Even if gloves are used, toward self-regulation of their bodies is a component of caregivers/teachers must perform hand hygiene after each teaching young children. child’s changing to prevent the spread of disease-causing TYPE OF FACILITY agents. To achieve maximum benefit from use of gloves, the Center, Large Family Child Care Home caregiver/teacher must remove the gloves properly after RELATED STANDARDS cleaning the child’s genitalia and buttocks and removing the soiled pull-up or underwear. Otherwise, retained con- Toilet Learning/Training 2.1.2.5 taminated gloves could transfer organisms to clean surfaces. 3. 2 .1.1 Type of Diapers Worn - Note that sensitivity to latex is a growing problem. If care 3.2.1.2 Handling Cloth Diapers givers/teachers or children who are sensitive to latex are Checking for the Need to Change Diapers 3. 2 .1. 3 present in the facility, non-latex gloves should be used. See 3.2.2.1 Situations that Require Hand Hygiene Appendix D for proper technique for removing gloves. 3.2.2.2 Handwashing Procedure A safety strap cannot be relied upon to restrain the child Routine Cleaning, Sanitizing, and 3.3.0.1 and could become contaminated during changing. Clean- Disinfecting ing and disinfecting a strap would be required after every change. Therefore safety straps on changing surfaces are Containment of Soiled Diapers 5 . 2 . 7. 4 not recommended. 5.4.4.2 Location of Laundry Equipment and Water Temperature for Laundering Prior to disinfecting the changing table, clean any visible soil from the surface with a detergent and rinse well with Gloving Appendix D: water. Always follow the manufacturer’s instructions for Selecting an Appropriate Sanitizer or Appendix J: use, application and storage. If the disinfectant is applied Disinfectant using a spray bottle, always assume that the outside of the Appendix K: Routine Schedule for Cleaning, Sanitizing, spray bottle could be contaminated. Therefore, the spray and Disinfecting bottle should be put away before hand hygiene is performed References (the last and essential part of every change) (6). 1. Early Childhood Education Linkage Systems. Healthy Child Care Pennsylvania. 2016. Changing soiled underwear. http://www.ecels- Changing areas should never be located in food preparation healthychildcarepa.org/publications/fact-sheets/item/116-changing-soiled- areas and should never be used for temporary placement of under wear? highlight=WyJzb2lsZWQi XQ. food, drinks, or eating utensils. 2. Children’s Environmental Health Network. 2016. Household chemicals. http://www.cehn.org/wp-content/uploads/Household_chemicals_1_16.pdf. COMMENTS 3. National Association for the Education of Young Children. 2012. Healthy Young Children, A Manual for Programs. Fifth edition. Editor. Susan Children with disabilities may require diapering and the Aronson Washington, DC. method of diapering will vary according to their abilities. 4. Red Book: 2015 Report of the Committee on Infectious Diseases, 30th However, principles of hygiene should be consistent regard - Edition American Academy of Pediatrics Committee on Infectious Diseases; Editor: David W. Kimberlin, MD, FAAP; Associate Editors: - less of method. Toddlers and preschool age children with Michael T. Brady, MD, FAAP; Mary Anne Jackson, MD, FAAP; and Sarah out physical disabilities frequently have toileting issues as S. Long, MD, FAAP. well. These soiling/wetting episodes can be due to rapid 5. University of California, San Francisco School of Nursing’s Institute for Health & Aging, University of California, Berkeley’s Center for onset gastroenteritis, distraction due to the intensity of Environmental Research and Children’s Health, and Informed Green their play, and emotional disruption secondary to new Solutions, California Department of Pesticide Regulation. 2013. Green transition. These include new siblings, stress in the family, cleaning, sanitizing, and disinfecting: A checklist for early care and education. https://www.epa.gov/sites/production/files/2013-08/documents/ or anxiety about changing classrooms or programs, all of checklist_8.1.2013.pdf. - which are based on their inability to recognize and articu 6. Early Childhood Education Linkage System. Healthy Child Care late their stress and to manage a variety of impulses. Pennsylvania. 2013. Diapering poster. http://www.ecels-healthychildcarepa. org/tools/posters/item/279-diapering-poster. Development is not a straight trajectory, but rather a cycle NOTES of forward and backward steps as children gain mastery over their bodies in a wide variety of situations. It is normal Content in the STANDARD was modified on 1/2012, and developmentally appropriate for children to revert to 7/13/2012, 1/5/2013, and 8/23/2016. immature behaviors as they gain developmental milestones while simultaneously dealing with immediate struggles which they are internalizing. Even for preschool and kin- dergarten aged children, these accidents happen and these incidents are called ‘accidents’ because of the frequency of these episodes among normally developing children. It is important for caregivers/teachers to recognize that the need to assist young children with toileting is a critical part of their work and that their attitude regarding the incident and their support of children as they work

145 118 Caring for Our Children: National Health and Safety Performance Standards sanitizer is an alternative to traditional handwashing with 3.2.2 soap and water when visible soiling is not present. HAND HYGIENE Hand sanitizer products may be dangerous or toxic if ingested in amounts greater than the residue left on hands 3.2.2.1 after cleaning. It is important for caregivers/teachers to Situations that Require Hand Hygiene monitor children’s use of hand sanitizers to ensure the All staff, volunteers, and children should follow the product is being used appropriately (6). procedure in Standard 3.2.2.2 for hand hygiene at the Alcohol-based hand sanitizers have the potential to be following times: toxic due to the alcohol content if ingested in a significant Upon arrival for the day, after breaks, or when moving a. amount (6). As with any hand hygiene product, supervision from one child care group to another; of children is required to monitor effective use and to avoid Before and after: b. potential ingestion or inadvertent contact with eyes and 1. Preparing food or beverages; mucous membranes (6). Infectious organisms may be 2. Eating, handling food, or feeding a child; spread in a variety of ways: 3. Giving medication or applying a medical ointment a. In human waste (urine, stool); or cream in which a break in the skin (e.g., sores, b. In body fluids (saliva, nasal discharge, secretions from cuts, or scrapes) may be encountered; open injuries; eye discharge, blood); Playing in water (including swimming) that is used 4. c. Cuts or skin sores; by more than one person; By direct skin-to-skin contact; d. 5. Diapering; e. By touching an object that has live organisms on it; c. After: f. In droplets of body fluids, such as those produced by 1. Using the toilet or helping a child use a toilet; sneezing and coughing, that travel through the air. 2. Handling bodily fluid (mucus, blood, vomit), from Since many infected people carry infectious organisms sneezing, wiping and blowing noses, from mouths, without symptoms and many are contagious before they or from sores; experience a symptom, caregivers/teachers routine hand 3. Handling animals or cleaning up animal waste; hygiene is the safest practice (1). Playing in sand, on wooden play sets, and outdoors; 4. 5. Cleaning or handling the garbage; COMMENTS Applying sunscreen and/or insect repellent. 6. While alcohol-based hand sanitizers are helpful in reducing Situations or times that children and staff should perform the spread of disease when used correctly, there are some hand hygiene should be posted in all food preparation, hand common diarrhea-causing germs that are not killed (e.g. hygiene, diapering, and toileting areas. Also, if caregivers/ norovirus, spore-forming organisms) (1). These germs are teachers smoke off premises before starting work, they common in child care settings, and children less than 2 should wash their hands before caring for children to years are at the greatest risk of spreading diarrheal disease prevent children from receiving third-hand smoke due to frequent diaper changing. Even though alcohol- e x p o s u re (1). based hand sanitizers are not prohibited for children under the age of 2 years, hand washing with soap and RATIONALE water is always the preferred method for hand hygiene. Hand hygiene is the most important way to reduce the TYPE OF FACILITY spread of infection. Many studies have shown that improp - erly cleansed hands are the primary carriers of infections. Center, Large Family Child Care Home Deficiencies in hand hygiene have contributed to many RELATED STANDARDS outbreaks of diarrhea among children and caregivers/ Handwashing Procedure 3.2.2.2 teachers in child care centers (2). Assisting Children with Hand Hygiene 3.2.2.3 Child care centers that have implemented good hand 3.2.2.4 Training and Monitoring for Hand Hygiene hygiene techniques have consistently demonstrated a 3.2.2.5 Hand Sanitizers reduction in diseases transmission (2). When frequent 3. 4 .1.1 Use of Tobacco, Electronic Cigarettes, Alcohol, and proper hand hygiene practices are incorporated into and Drugs a child care center’s curriculum, there is a decrease in the incidence of acute respiratory tract diseases (3). References 1. Mayo Clinic. 2010. Secondhand smoke: Avoid dangers in the air. Hand hygiene after exposure to soil and sand will reduce http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/ opportunities for the ingestion of zoonotic parasites that second hand-smoke/ar t-20043914. 2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child could be present in contaminated sand and soil (4). care and schools: A quick reference guide, 4 th Edition.Elk Grove Village, Thorough handwashing with soap for at least twenty seconds IL: American Academy of Pediatrics. 3. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Children using clean running water at a comfortable temperature in out-of-home child care. In: Red book: 2015 report of the committee on removes organisms from the skin and allows them to be infectious diseases. 30th Ed. Elk Grove Village, IL: American Academy of rinsed away (5). Hand hygiene with an alcohol- based Pediatrics.

146 119 Chapter 3: Health Promotion and Protection Palmer, S. R., L. Soulsby, D. I. H. Simpson, eds. 1998. Zoonoses: Biology, 4. Children and staff who need to open a door to leave a bath - clinical practice, and public health control. New York: Oxford University room or diaper changing area should open the door with a Press. disposable towel to avoid possibly re-contaminating clean 5. Centers for Disease Control and Prevention. 2015. Handwashing: Clean hands save lives. http://www.cdc.gov/handwashing/. hands. If a child cannot open the door or turn off the Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported 6. faucet, they should be assisted by an adult. adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep RATIONALE 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5. Running clean water over the hands removes visible soil. NOTES Wetting the hands before applying soap helps to create a Content in the STANDARD was modified on 8/23/2016 lather that can loosen soil. The soap lather loosens soil and and 8/9/2017. 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. Acceptable forms of 3.2.2.2 soap include liquid and powder. Handwashing Procedure Alcohol-based hand sanitizers do not kill norovirus and Children and staff members should wash their hands using spore-forming organisms which are common causes of the following method: diarrhea in child care settings (4). This is sufficient reason to Check to be sure a clean, disposable paper (or single-use a. limit or even avoid the use of hand sanitizers with infants cloth) towel is available; and toddlers (children less than 2 years of age) because they Turn on clean, running water to a comfortable b. are the age group at greatest risk of spreading diarrheal temperature (1); disease due to frequent diaper changing. Hand washing is Moisten hands with water and apply soap (not antibac - c. the preferred method. However, while hand sanitizers are terial) to hands; not recommended for children under the age of 2, they are d. Rub hands together vigorously until a soapy lather . not prohibited appears, hands are out of the water stream, and continue COMMENTS for at least twenty seconds (sing Happy Birthday silently twice) (2). Rub areas between fingers, around nail beds, Pre-moistened cleansing towelettes do not effectively clean under fingernails, jewelry, and back of hands. Nails hands and should not be used as a substitute for washing should be kept short; acrylic nails should not be worn (3); hands with soap and running water. When running water Rinse hands under clean, running water that is at a e. is unavailable or impractical, the use of alcohol-based hand comfortable temperature until they are free of soap and sanitizer (Standard 3.2.2.5) is a suitable alternative. dirt. Leave the water running while drying hands; Outbreaks of disease have been linked to shared wash f. Dry hands with the clean, disposable paper or single use water and wash basins (7). Water basins should not be used cloth towel; - as an alternative to running water. Camp sinks and porta If taps do not shut off automatically, turn taps off with a g. ble commercial sinks with foot or hand pumps dispense disposable paper or single use cloth towel; water as for a plumbed sink and are satisfactory if filled Throw the disposable paper towel into a lined trash h. with fresh water daily. The staff should clean and disinfect container; or place single-use cloth towels in the laundry the water reservoir container and water catch basin daily. hamper; or hang individually labeled cloth towels to dry. Single-use towels should be used unless an automatic Use hand lotion to prevent chapping of hands, if desired. electric hand-dryer is available. The use of alcohol based hand sanitizers is an alternative to The use of cloth roller towels is not recommended because traditional handwashing (with soap and water) if soap and - children often use cloth roll dispensers improperly, result water is not available and if hands are not visibly dirty (4,5). ing in more than one child using the same section of towel. A single pump of an alcohol-based sanitizer should be dispensed. Hands should be rubbed together, distributing TYPE OF FACILITY sanitizer to all hand and finger surfaces and hands should Center, Large Family Child Care Home be permitted to air dry. Alcohol based hand sanitizer dis- RELATED STANDARDS pensers should be kept out of reach of children, and active 3.2.2.1 Situations that Require Hand Hygiene supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact with 3.2.2.3 Assisting Children with Hand Hygiene eyes and mucous membranes (6). Hand Sanitizers 3.2.2.5 Situations/times that children and staff should wash their 5. 4 .1.10 Handwashing Sinks hands should be posted in all handwashing areas. Appendix K: Routine Schedule for Cleaning, Sanitizing, and Disinfecting Use of antimicrobial soap is not recommended in child care settings. There are no data to support use of antibacterial soaps over other liquid soaps.

147 120 Caring for Our Children: National Health and Safety Performance Standards References 3.2.2.4 1. Centers for Disease Control and Prevention. Handwashing: Clean hands Training and Monitoring for Hand Hygiene save lives. CDC.gov Web site. http://www.cdc.gov/handwashing/. Updated September 27, 2017. Accessed October 23, 2017. The program should ensure that staff members and 2. American Academy of Pediatrics. Children in out-of-home child care. In: children who are developmentally able to learn personal Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 hygiene are instructed in, and monitored on performing 30th Ed. Elk Grove Village, Report of the Committee on Infectious Diseases. IL: American Academy of Pediatrics; 2015. hand hygiene as specified in Standard 3.2.2.2. 3. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings recommendations of the healthcare infection control RATIONALE practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand Education of the staff and children regarding hand hygiene MMWR . 20 02;51(R R16). hygiene task force. and other cleaning procedures can reduce the occurrence Managing infectious diseases in child care American Academy of Pediatrics. 4. and schools: A quick reference guide . Aronson SS, Shope TR, eds. 2017. 4th of illness in the group of children in care (1,2). ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017. 5. U.S. Department of Health and Human Services, Centers for Disease Staff training and monitoring of hand hygiene has been Control and Prevention. Show me the science-When and how to use hand shown to reduce transmission of organisms that cause sanitizer. CDC.gov Web site. http://www.cdc.gov/handwashing/show-me- disease (3-6). Periodic training and monitoring is needed the-science-hand-sanitizer.html. Updated July 13, 2017. Accessed October 23, 2017. to result in sustainable changes in practice (7). Santos C, Kieszak S, Wang A, Law R, Schier J, Wolkin A. Reported adverse 6. COMMENTS health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Rep 2017;66:223–226. DOI: http://dx. Training programs may utilize some type of verbal cue doi.org/10.15585/mmwr.mm6608a5. such as singing the alphabet song, twinkle, twinkle little 7. Ogunsola FT, Adesiji YO. Comparison of four methods of hand washing in situations of inadequate water supply. West Afr J Med . 2008(27):24-28. star or the birthday song during handwashing. NOTES TYPE OF FACILITY Content in the STANDARD was modified on 8/9/2017. Center, Large Family Child Care Home RELATED STANDARDS 3.2.2.3 3.2.2.1 Situations that Require Hand Hygiene Assisting Children with Hand Hygiene Handwashing Procedure 3.2.2.2 Caregivers/teachers should provide assistance with hand - References washing at a sink for infants who can be safely cradled in 1. Hawks, D., J. Ascheim, G. S. Giebink, S. Graville, A. J. Solnit. 1994. Science, one arm and for children who can stand but not wash their prevention, and practice VII: Improving child day care, a concurrent summary of the American Public Health Association/American Academy hands independently. A child who can stand should either of Pediatrics national health and safety guidelines for child-care programs; use a child-height sink or stand on a safety step at a height featured standards and implementation. Pediatrics 95:1110-12. at which the child’s hands can hang freely under the Roberts, L., E. Mapp, W. Smith, L. Jorm, M. Pate, R. M. Douglas, C. 2. McGilchrist. 2000. Effect of infection control measures on the frequency of running water. After assisting the child with handwashing, upper respiratory infection in child care: A randomized, controlled trial. the staff member should wash his or her own hands. Hand Pediatrics 105:738-42. hygiene with an alcohol-based sanitizer is an alternative to 3. Black, R. E., A. C. Dykes, K. E. Anderson. 1981. Handwashing to prevent diarrhea in day care centers. Am J Epidemiol 113:445-51. - handwashing with soap and water by children over twen Roberts, L., L. Jorm, M. Patel, W. Smith, R. M. Douglas, C. McGilchrist. 4. ty-four months of age and adults when there is no visible 2000. Effect of infection control measures on the frequency of diarrheal soiling of hands (1). episodes in child care: A randomized, controlled trial. Pediatrics 105:743-46. 5. Carabin, H., T. W. Gyorkos, J. C. Soto, L. Joseph, P. Payment, J. P. Collet. RATIONALE 1999. Effectiveness of a training program in reducing infections in toddlers attending daycare centers. Epidemiol 10:219-27. Encouraging and teaching children good hand hygiene 6. Bartlett, A. V., B. A. Jarvis, V. Ross, T. M. Katz, M. A. Dalia, S. J. Englender, practices must be done in a safe manner. A “how to” poster L. J. Anderson. 1988. Diarrheal illness among infants and toddlers in day that is developmentally appropriate should be placed wher - care centers: Effects of active surveillance and staff training without subsequent monitoring. Am J Epidemiol 127:808-17. ever children wash their hands. 7. Alkon, A., J. Bernzweig, K. To, M. Wolff, J. F. Mackie. 2009. Child care health consultation improves health and safety policies and practices. For examples of handwashing posters, see: Academic Pediatrics 9:366-70. California Childcare Health Program at http://www.ucsf - childcarehealth.org; 3.2.2.5 North Carolina Child Care Health and Safety Resource Hand Sanitizers Center at http://www.healthychildcarenc.org/training_ The use of hand sanitizers by children and adults in child materials.htm. care programs is an appropriate alternative to the use of RELATED STANDARDS traditional handwashing if soap and water is not available and if hands are not visibly dirty (1,2). 3.2.2.1 Situations that Require Hand Hygiene Handwashing Procedure 3.2.2.2 Supervision of children is required to monitor effective use and to avoid potential ingestion or inadvertent contact of 3.2.2.5 Hand Sanitizers hand sanitizers with eyes and mucous membranes (3). Reference 1. Centers for Disease Control and Prevention. 2013. Information for schools and childcare providers. http://www.cdc.gov/flu/school/index.htm

148 121 Chapter 3: Health Promotion and Protection The technique for using hand sanitizers is: COMMENTS Even in health care settings, the Centers for Disease • For visibly dirty hands and soap is not available, rinsing Control and Prevention (CDC) guidelines recommend under running water or wiping with a water-saturated washing hands that are visibly soiled or contaminated with towel should be used to remove as much dirt as possible organic material with soap and water as an adjunct to the before using a hand sanitizer. use of alcohol-based sanitizers (6). • Apply the product to the palm of one hand (read the label to learn the correct amount); While alcohol-based hand sanitizers are helpful in reducing • Rub hands together; and the spread of disease when used correctly, there are some • Rub the product over all surfaces of the hands and common diarrhea-causing germs that are not killed (e.g. fingers until hands are dry (4). norovirus, spore-forming organisms) (1). These germs are common in child care settings, and children less than 2 Hand sanitizers using an alcohol-based active ingredient years are at the greatest risk of spreading diarrheal disease must contain 60% to 95% alcohol to be effective in killing due to frequent diaper changing. Even though alcohol- most germs including multi-drug resistant pathogens. based hand sanitizers are not prohibited for children under Child care programs should follow the manufacturer’s the age of 2 years, hand washing with soap and water is instructions for use, check instructions to determine how always the preferred method for hand hygiene. much product and how long the hand sanitizer needs to remain on the skin surface to be effective. Some hand sanitizing products contain non-alcohol and - “natural” ingredients. The efficacy of non-alcohol contain Where alcohol-based hand sanitizer dispensers are used: ing hand sanitizers is variable and therefore a non-alcohol- a. The maximum individual dispenser fluid capacity based product is not recommended for use. should be as follows: TYPE OF FACILITY b. 0.32 gal (1.2 L) for dispensers in individual rooms, Center, Large Family Child Care Home corridors, and areas open to corridors; c. 0.53 gal (2.0 L) for dispensers in suites of rooms; RELATED STANDARDS Where aerosol containers are used, the maximum d. 3.2.2.1 Situations that Require Hand Hygiene capacity of the aerosol dispenser should be 18 oz. (0.51 3.2.2.2 Handwashing Procedure kg) and should be limited to Level 1 aerosols as defined 5.5.0.5 Storage of Flammable Materials in NFPA 30B: Code for the Manufacture and Storage of Aerosol Products; References 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child e. Wall mounted dispensers should be separated from , 4th Edition.Elk Grove Village, IL: care and schools: A quick reference guide each other by horizontal spacing of not less than American Academy of Pediatrics. 48 in. (1,220 mm); U.S. Department of Health and Human Services, Centers for Disease 2. Control and Prevention. 2016. Show me the science-When and how to use Wall mounted dispensers should not be installed above f. hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science- or adjacent to ignition sources such as electrical outlets; hand-sanitizer.html. g. Wall mounted dispensers installed directly over 3. Centers for Disease Control and Prevention. When & how to wash your hands. 2015. https://www.cdc.gov/handwashing/when-how-handwashing. carpeted floors should be permitted only in child care html. facilities protected by automatic sprinklers (5). 4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported adverse health effects in children from ingestion of alcohol-based hand When alcohol based hand sanitizers are offered in a child sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep care facility, the facility should encourage parents/guard - 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5. ians to teach their children about their use at home. 5. National Fire Protection Association (NFPA). 2009. NFPA 101: Life safety code. 2009 ed. Quincy, MA: NFPA. RATIONALE Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. 6. Red Book: 2015 Report of the Summaries of Infectious Diseases. In: Studies have demonstrated that using an alcohol-based . 30th Ed. Elk Grove Village, IL: American Committee on Infectious Diseases hand sanitizer after washing hands with soap and water is Academy of Pediatrics. effective in reducing illness transmission in the home, in 7. Vessey, J. A., J. J. Sherwood, D. Warner, D. Clark. 2007. Comparing hand washing to hand sanitizers in reducing elementary school students’ child care centers and in health care settings (6-8). absenteeism. 33:368-72. Pediatric Nurs U.S. Department of Health and Human Services, Centers for Disease 8. Hand sanitizer products may be dangerous or toxic if Control and Prevention. 2016. Handwashing: Clean hands save lives! http:// ingested in amounts greater than the residue left on hands www.cdc.gov/handwashing/. after cleaning. It is important for caregivers/teachers to Additional Reference monitor children’s use of hand sanitizers to ensure the American Association of Poison Control Centers. 2016. Hand sanitizer. product is being used appropriately (5). http://www.aapcc.org/alerts/hand-sanitizer/. Alcohol-based hand sanitizers have the potential to be NOTES toxic due to the alcohol content if ingested in a significant Content in the STANDARD was modified on 4/5/2017 amount (1,3,4). and 8/9/2017.

149 122 Caring for Our Children: National Health and Safety Performance Standards COMMENTS 3.2.3 Multi-lingual videos, posters, and handouts should be part EXPOSURE TO BODY FLUIDS of an active educational effort of caregivers/teachers and children to reinforce this practice. For free downloadable 3.2.3.1 posters and flyers in multiple languages, go to http://www. Procedure for Nasal Secretions and cdc.gov/flu/protect/covercough.htm. Use of Nasal Bulb Syringes TYPE OF FACILITY Staff members and children should blow or wipe their Center, Large Family Child Care Home noses with disposable, single use tissues and then discard RELATED STANDARDS them in a plastic-lined, covered, hands-free trash container. Situations that Require Hand Hygiene 3.2.2.1 After blowing the nose, they should practice hand hygiene, 3.2.2.2 Handwashing Procedure as specified in Standards 3.2.2.1 and 3.2.2.2.Use of nasal bulb syringes is permitted. Nasal bulb syringes should be 3.2.2.3 Assisting Children with Hand Hygiene pro- vided by the parents/guardians for individual use 3.2.2.5 Hand Sanitizers and shotuld be labeled with the child’s name.If nasal bulb Reference syringes are used, facilities should have a written policy 1. Centers for Disease Control and Prevention. 2010. Seasonal flu: Cover your that indicates: cough. http://www.cdc.gov/flu/protect/covercough.htm. a. Rationale and protocols for use of nasal bulb syringes; Written permission and any instructions or preferences b. 3.2.3.3 from the child’s parent/guardian; Cuts and Scrapes c. Staff should inspect each nasal bulb syringe for tears or Cuts or sores that are actively dripping, oozing, or drain- cracks (and to see if there is unknown fluid in the nasal ing body fluids should be covered with a dressing to avoid bulb syringe) before each use; contamination of surfaces in child care. The caregiver/ d. Nasal bulb syringes should be cleaned with warm soapy teacher should wear gloves if there is contact with any water and stored open to air. wound (cut or scrape) that has material that could be RATIONALE transmitted to another surface. Hand hygiene is the most effective way to reduce the spread A child or caregiver/teacher with a cut or sore that is leak - of infection (1,2). ing a body fluid that cannot be contained or cannot be TYPE OF FACILITY covered with a dressing, should be excluded from the facility until the cut or sore is scabbed over or healed. Center, Large Family Child Care Home RATIONALE RELATED STANDARDS Touching a contaminated object or surface may spread 3.2.2.1 Situations that Require Hand Hygiene infectious organisms (1,2). Body fluids may contain Handwashing Procedure 3.2.2.2 infectious organisms (1,2). 3.2.2.3 Assisting Children with Hand Hygiene Gloves can provide a protective barrier against infectious References organisms that may be present in body fluids (1,2). 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove COMMENTS Village, IL: American Academy of Pediatrics. 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Covering sores on lips and on eyes is difficult. Children or Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. Elk caregivers/teachers who are unable to prevent contact with Grove Village, IL: American Academy of Pediatrics. these exposed lesions should be excluded until lesions do not present a risk of transmission of a pathogen. 3.2.3.2 TYPE OF FACILITY Cough and Sneeze Etiquette Center, Large Family Child Care Home Staff members and children should be taught to cover their RELATED STANDARDS mouths and noses with a tissue when they cough or sneeze. Staff members and children should also be taught to cough 1.4. 2. 3 Orientation Topics or sneeze into their inner elbow/upper sleeve and to avoid 3.2.3.4 Prevention of Exposure to Blood and Body covering the nose or mouth with bare hands. Hand hygiene, Fluids as specified in Standards 3.2.2.1 and 3.2.2.2, should follow a 3. 6 .1.1 Inclusion/Exclusion/Dismissal of Children - cough or sneeze that could result in the spread of respira 5. 6 . 0.1 First Aid and Emergency Supplies tory droplets to the skin. Appendix D: Gloving RATIONALE Proper respiratory etiquette can prevent transmission of respiratory pathogens (1).

150 123 Chapter 3: Health Promotion and Protection 2. For spills of blood or other potentially infectious References 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child body fluids, including injury and tissue discharges, care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove the area should be cleaned and disinfected. Care Village, IL: American Academy of Pediatrics. should be taken and eye protection used to avoid 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. Elk splashing any contaminated materials onto any Grove Village, IL: American Academy of Pediatrics. mucus membrane (eyes, nose, mouth); 3. Blood-contaminated material and diapers should be 3.2.3.4 disposed of in a plastic bag with a secure tie; Prevention of Exposure to Blood 4. - Floors, rugs, and carpeting that have been contami nated by body fluids should be cleaned by blotting and Body Fluids - to remove the fluid as quickly as possible, then disin Child care facilities should adopt the use of Standard fected by spot-cleaning with a detergent-disinfectant. Precautions developed for use in hospitals by The Centers Additional cleaning by shampooing or steam clean- for Disease Control and Prevention (CDC). Standard Pre- ing the contaminated surface may be necessary. cautions should be used to handle potential exposure to Caregivers/teachers should consult with local health blood, including blood-containing body fluids and tissue departments for additional guidance on cleaning discharges, and to handle other potentially infectious fluids. contaminated floors, rugs, and carpeting. In child care settings: Prior to using a disinfectant, clean the surface with a deter- a. Use of disposable gloves is optional unless blood or gent and rinse well with water. Facilities should follow the blood containing body fluids may contact hands. Gloves - manufacturer’s instruction for preparation and use of disin are not required for feeding human milk, cleaning up of fectant (3,4). For guidance on disinfectants, refer to Appendix spills of human milk, or for diapering; J, Selecting an Appropriate Sanitizer or Disinfectant. Gowns and masks are not required; b. c. Barriers to prevent contact with body fluids include If blood or bodily fluids enter a mucous membrane (eyes, moisture-resistant disposable diaper table paper, nose, mouth) the following procedure should occur. Flush disposable gloves, and eye protection. the exposed area thoroughly with water. The goal of washing or flushing is to reduce the amount of the pathogen to which Caregivers/teachers are required to be educated regarding an exposed individual has contact. The optimal length of - Standard Precautions to prevent transmission of blood time for washing or flushing an exposed area is not known. borne pathogens before beginning to work in the facility - Standard practice for managing mucous membrane(s) expo and at least annually thereafter. Training must comply with sures to toxic substances is to flush the affected area for at requirements of the Occupational Safety and Health least fifteen to twenty minutes. In the absence of data to Administration (OSHA). support the effectiveness of shorter periods of flushing it Procedures for Standard Precautions should include: seems prudent to use the same fifteen to twenty minute a. Surfaces that may come in contact with potentially standard following exposure to bloodborne pathogens (5). - infectious body fluids must be disposable or of a mate RATIONALE rial that can be disinfected. Use of materials that can be Some children and adults may unknowingly be infected with sterilized is not required. HIV or other infectious agents, such as hepatitis B virus, as b. The staff should use barriers and techniques that: these agents may be present in blood or body fluids. Thus, the 1. Minimize potential contact of mucous membranes staff in all facilities should adopt Standard Precautions for all or openings in skin to blood or other potentially blood spills. Bacteria and viruses carried in the blood, such infectious body fluids and tissue discharges; and as hepatitis B, pose a small but specific risk in the child care Reduce the spread of infectious material within the 2. setting (3). Blood and body fluids containing blood (such as child care facility. Such techniques include avoiding watery discharges from injuries) pose a potential risk, because touching surfaces with potentially contaminated bloody body fluids contain the highest concentration of materials unless those surfaces are disinfected before viruses. In addition, hepatitis B virus can survive in a dried further contact occurs with them by other objects or state in the environment for at least a week and perhaps even individuals. longer. Some other body fluids such as saliva contaminated When spills of body fluids, urine, feces, blood, saliva, c. with blood or blood-associated fluids may contain live virus nasal discharge, eye discharge, injury or tissue dis- (such as hepatitis B virus) but at lower concentrations than are charges occur, these spills should be cleaned up found in blood itself. Other body fluids, including urine and immediately, and further managed as follows: feces, do not pose a risk for bloodborne infections unless they 1. For spills of vomit, urine, and feces, all floors, walls, are visibly contaminated with blood, although these fluids bathrooms, tabletops, toys, furnishings and play may pose a risk for transmission of other infectious diseases. - equipment, kitchen counter tops, and diaper-chang ing tables in contact should be cleaned and disin - Touching a contaminated object or surface may spread fected as for the procedure for diaper changing tables illnesses. Many types of infectious germs may be contained in Standard 3.2.1.4, Step 7; in human waste (urine, feces) and body fluids (saliva, nasal discharge, tissue and injury discharges, eye discharges, blood,

151 124 Caring for Our Children: National Health and Safety Performance Standards Use non-latex gloves for activities that are not likely to and vomit). Because many infected people carry infectious a. diseases without having symptoms, and many are conta involve contact with infectious materials (food prepara - - gious before they experience a symptom, staff members - tion, diapering, routine housekeeping, general mainte need to protect themselves and the children they serve by nance, etc.); - Use appropriate barrier protection when handling infec adhering to Standard Precautions for all activities. b. tious materials. Avoid using latex gloves BUT if latex Gloves have proven to be effective in preventing transmission gloves are chosen, use powder-free gloves with reduced of many infectious diseases to health care workers. Gloves protein content; are used mainly when people knowingly contact or suspect 1. Such gloves reduce exposures to latex protein and they may contact blood or blood-containing body fluids, thus reduce the risk of latex allergy; including blood-containing tissue or injurydischarges. These 2. Hypoallergenic latex gloves do not reduce the risk of fluids may contain the viruses that transmit HIV, hepatitis B, latex allergy. However, they may reduce reactions to and hepatitis C. While human milk can be contaminated chemical additives in the latex (allergic contact with blood from a cracked nipple, the risk of transmission of dermatitis); infection to caregivers/teachers who are feeding expressed Use appropriate work practices to reduce the chance of c. - human milk is almost negligible and this represents a theo reactions to latex; retical risk. Wearing of gloves to feed or clean up spills of d. When wearing latex gloves, do not use oil-based hand expressed human milk is unnecessary, but caregivers/ creams or lotions (which can cause glove deterioration); teachers should avoid getting expressed human milk on After removing latex gloves, wash hands with a mild e. their hands, if they have any open skin or sores on their soap and dry thoroughly; hands. If caregivers/teachers have open wounds they should f. Practice good housekeeping, frequently clean areas and be protected by waterproof bandages or disposable gloves. equipment contaminated with latex-containing dust; Cleaning and disinfecting rugs and carpeting that have Attend all latex allergy training provided by the facility g. been contaminated by body fluids is challenging. Extracting and become familiar with procedures for preventing as much of the contaminating material as possible before it latex allergy; penetrates the surface to lower layers helps to minimize this Learn to recognize the symptoms of latex allergy: h. challenge. Cleaning and disinfecting the surface without skin rash; hives; flushing; itching; nasal, eye, or sinus damaging it requires use of special cleaning agents designed symptoms; asthma; and (rarely) shock. for use on rugs, or steam cleaning (3). Therefore, alternatives - Natural fingernails that are long or wearing artificial finger to the use of carpeting and rugs are favored in the child nails or extenders is not recommended. Child care facilities care environment. should develop an organizational policy on the wearing of COMMENTS non-natural nails by staff (2). The sanctions for failing to comply with OSHA require - For more information on safety with blood and body fluids, - ments can be costly, both in fines and in health conse consult Healthy Child Care Pennsylvania’s “Keeping Safe quences. Regional offices of OSHA are listed at http://www. When Touching Blood or Other Body Fluids” at http:// epa.gov/aboutepa/index.html#regional/ and in the telephone www.ecels-healthychildcarepa.org/content/Keeping Safe directory with other federal offices. 07-27-10.pd f. Either single-use disposable gloves or utility gloves should TYPE OF FACILITY be used when disinfecting. Single-use disposable gloves Center, Large Family Child Care Home should be used only once and then discarded immediately without being handled. If utility gloves are used, they should RELATED STANDARDS be cleaned after every use with soap and water and then 3. 2 .1. 4 Diaper Changing Procedure dipped in disinfectant solution up to the wrist. The gloves Staff Education on Prevention of Bloodborne 7. 6 .1. 3 should then be allowed to air dry. The wearing of gloves Diseases does not prevent contamination of hands or of surfaces Appendix D: Gloving touched with contaminated gloved hands. Hand hygiene Cleaning Up Body Fluids Appendix L: and sanitizing of contaminated surfaces is required when gloves are used. References 1. De Queiroz, M., S. Combet, J. Berard, A. Pouyau, H. Genest, P. Ongoing exposures to latex may result in allergic reactions Mouriquand, D. Chassard. 2009. Latex allergy in children: Modalities and prevention. 19:313-19. Pediatric Anesthesia - in both the individual wearing the latex glove and the indi Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection 2. vidual who contacts the latex glove. Reports of such reac - Control Practices Advisory Committee. 2007. 2007 Guideline for isolation tions have increased (1). precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/Isolation/Isolation2007.pdf. Caregivers/teachers should take the following steps to 3. Kotch, J. B., P. Isbell, D. J. Weber, et al. 2007. Hand-washing and diapering protect themselves, children, volunteers, and visitors from equipment reduces disease among children in out-of-home child care centers. Pediatrics 120: e29-e36. latex exposure and allergy in the workplace (6):

152 125 Chapter 3: Health Promotion and Protection Each term has a specific purpose and there are many 4. Rutala, W. A., D. J. Weber, HICPAC. 2008. Guideline for disinfection and sterilization in healthcare facilities. Centers for Disease Control and methods that may be used to achieve such purpose. Prevention. https://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_ Nov_2008.pdf. Task Purpose 5. Email communication from Amy V. Kindrick, MD, MPH, Senior Consultant, National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline), UCSF Clean To remove dirt and debris by scrubbing and washing with School of Medicine at San Francisco General Hospital to Elisabeth L.M. a detergent solution and rinsing with water. The friction of Miller, BSN, RN, BC, PA Chapter American Academy of Pediatrics, Early cleaning removes most germs and exposes any remaining Childhood Education Linkage System – Healthy Child Care Pennsylvania. germs to the effects of a sanitizer or disinfectant used later. November 11, 2009. American Latex Allergy Association. Creating a safe school for latex-sensitive 6. To reduce germs on inanimate surfaces to levels considered Sanitize children. 1996-2016. http://latexallergyresources.org/articles/web-article- safe by public health codes or regulations. creating-safe-school-latex-sensitive-children. To destroy or inactivate most germs on any inanimate Disinfect object, but not bacterial spores. 3.3 Note: The term “germs” refers to bacteria, viruses, fungi and molds that may cause infectious disease. Bacterial spores are dormant bacteria that have formed a protective CLEANING, SANITIZING, shell, enabling them to survive extreme conditions for years. The spores reactivate after entry into a host (such as a person), where conditions are favorable for them to AND DISINFECTING live and reproduce (5). Only U.S. Environmental Protection Agency (EPA)- registered products that have an EPA registration number 3.3.0.1 on the label can make public health claims that can be relied on for reducing or destroying germs. The EPA registration Routine Cleaning, Sanitizing, and Disinfecting label will also describe the product as a cleaner, sanitizer, or Keeping objects and surfaces in a child care setting as clean . In addition, some manufacturers of disinfectant cleaning and free of pathogens as possible requires a combination of: products have developed “green cleaning products”. As new a. Frequent cleaning; and environmentally-friendly cleaning products appear in the b. When necessary, an application of a sanitizer or market, check to see if they are 3rd party certified by Green disinfectant. Seal: http://www.greenseal.org, UL/EcoLogic: http://www. Facilities should follow a routine schedule of cleaning, sani - ecologo.org, and/or EPA’s Safer Choice: http://www.epa.gov/ tizing, and disinfecting as outlined in Appendix K: Routine saferchoice. Use fragrance-free bleach that is EPA-registered Schedule for Cleaning, Sanitizing, and Disinfecting. as a sanitizing or disinfecting solution (6). If other products are used for sanitizing or disinfecting, they should also be Cleaning, sanitizing and disinfecting products should not fragrance-free and EPA-registered (7). All products must be - be used in close proximity to children, and adequate ventila used accordining to manufacturer’s instructions. The fol- tion should be maintained during any cleaning, sanitizing lowing resource may be useful: Green Cleaning, Sanitizing, or disinfecting procedure to prevent children and caregivers/ and Disinfecting: A Toolkit for Early Care and Education. teachers from inhaling potentially toxic fumes. Employers should provide staff with hazard information, RATIONALE including access to and review of the Safety Data Sheets Young children sneeze, cough, drool, use diapers and are (SDS) as required by the Occupational Safety and Health just learning to use the toilet. They hug, kiss, and touch Administration (OSHA), about the presence of toxic sub- everything and put objects in their mouths. Illnesses may stances such as, cleaning, sanitizing and disinfecting supplies be spread in a variety of ways, such as by coughing, sneez- in use in the facility. The SDS explain the risk of exposure to ing, direct skin-to-skin contact, or touching a contaminated products so that appropriate precautions may be taken. object or surface. Respiratory tract secretions that can con- tain viruses (including respiratory syncytial virus and TYPE OF FACILITY rhinovirus) contaminate environmental surfaces and may Center, Large Family Child Care Home present an opportunity for infection by contact (1-3). RELATED STANDARDS COMMENTS 3.3.0.2 Cleaning and Sanitizing Toys The terms are sometimes disinfecting and cleaning, sanitizing Cleaning and Sanitizing Objects Intended for 3.3.0.3 used interchangeably which can lead to confusion and result the Mouth in cleaning procedures that are not effective (4). 5. 2 .1. 6 Ventilation to Control Odors For example, if there is visible soil on a diaper changing or Appendix J: Selecting an Appropriate Sanitizer or - it with detergent and water before spray clean table surface, Disinfectant ing the surface with a sanitizer or disinfectant. Using a sani - Appendix K: Routine Schedule for Cleaning, Sanitizing, tizer or disinfectant as this “first step” is not effective because and Disinfecting . disinfect or sanitize the purpose of the solution is to either

153 126 Caring for Our Children: National Health and Safety Performance Standards References RELATED STANDARDS 1. Thompson, S. C. 1994. Infectious diarrhoea in children: Controlling 3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting J Paediatric Child Health transmission in the child care setting. 30:210 -19. Butz, A. M., P. Fosarelli, D. Dick, et al. 1993. Prevalence of rotavirus on 2. 4 . 9. 0 .11 Dishwashing in Centers 92:202-5. high-risk fomites in day-care facilities. Pediatrics Dishwashing in Small and Large Family 4 . 9. 0.12 3. D. Leduc, eds. 2015. . 3rd ed. Well beings: A guide to health in child care (revised) Ottawa, Ontario: Canadian Paediatric Society. Child Care Homes 4. U.S. Centers for Disease Control and Prevention. 2014. How to clean and 4 . 9. 0.13 Methods for Washing Dishes by Hand disinfect schools to help slow the spread of flu. http://www.cdc.gov/flu/ school/cleaning.htm Microbiology Procedure. Sporulation in bacteria. Routine Schedule for Cleaning, Sanitizing, Appendix K: http://www.microbiologyprocedure.com/microorganisms/sporulation-in- and Disinfecting bacteria.htm. 5. Children’s Environmental Health Network Fragrances. Retrieved from: Reference http://www.cehn.org/our-work/eco-healthy-child-care/ehcc-faqs/ 1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well beings. fragrances/. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society 6. Children’s Environmental Health Network 2016. Household chemicals. http://cehn.org/wp-content/uploads/2015/12/ Household_chemicals_1_16.pdf. 3.3.0.3 Cleaning and Sanitizing Objects Intended 3.3.0.2 for the Mouth Cleaning and Sanitizing Toys Thermometers, pacifiers, teething toys, and similar objects Toys that cannot be cleaned and sanitized should not be should be cleaned, and reusable parts should be sanitized used. Toys that children have placed in their mouths or that between uses. Pacifiers should not be shared. are otherwise contaminated by body secretion or excretion RATIONALE should be set aside until they are cleaned by hand with water and detergent, rinsed, sanitized, and air-dried or in Contamination of hands, toys and other objects in child care a mechanical dishwasher that meets the requirements of areas has played a role in the transmission of diseases in Standard 4.9.0.11 through Standard 4.9.0.13. Play with plas - child care settings (1). tic or play foods, play dishes and utensils, should be closely TYPE OF FACILITY supervised to prevent shared mouthing of these toys. Center, Large Family Child Care Home Machine washable cloth toys should be used by one indi - RELATED STANDARDS vidual at a time. These toys should be laundered before 3.1. 4 . 3 Pacifier Use being used by another child. 3.3.0.1 Routine Cleaning, Sanitizing, and Disinfecting Indoor toys should not be shared between groups of infants Thermometers for Taking Human 3. 6 .1. 3 or toddlers unless they are washed and sanitized before Temperatures being moved from one group to the other. Routine Schedule for Cleaning, Sanitizing, Appendix K: RATIONALE and Disinfecting Contamination of hands, toys and other objects in child care areas has played a role in the transmission of diseases Reference 1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well beings. in child care settings (1). All toys can spread disease when 3rd ed. Ottawa, Ontario: Canadian Paediatric Society. children put the toys in their mouths, touch the toys after putting their hands in their mouths during play or eating, 3.3.0.4 or after toileting with inadequate hand hygiene. Using a mechanical dishwasher is an acceptable labor-saving Cleaning Individual Bedding - approach for sanitizing plastic toys as long as the dish Bedding (sheets, pillows, blankets, sleeping bags) should be washer can wash and sanitize the surfaces and dishes and of a type that can be washed. Each child’s bedding should be cutlery are not washed at the same time (1). kept separate from other children’s bedding, on the bed or stored in individually labeled bins, cubbies, or bags. Bedding COMMENTS that touches a child’s skin should be cleaned weekly or Small toys with hard surfaces can be set aside for cleaning before use by another child. by putting them into a dish pan labeled “soiled toys.” This dish pan can contain soapy water to begin removal of soil, RATIONALE or it can be a dry container used to bring the soiled toys to a Toddlers often nap or sleep on mats or cots and the mats toy cleaning area later in the day. Having enough toys to or cots are taken out of storage during nap time, and then rotate through cleaning makes this method of preferred placed back in storage. Providing bedding for each child cleaning possible. and storing each set in individually labeled bins, cubbies, or bags in a manner that separates the personal articles of one TYPE OF FACILITY individual from those of another are appropriate hygienic Center, Large Family Child Care Home practices (1). TYPE OF FACILITY Center, Large Family Child Care Home

154 127 Chapter 3: Health Promotion and Protection - infections when they experience common respiratory infec RELATED STANDARD tions; and Sudden Infant Death Syndrome (SIDS) (1-6). Sleeping Equipment and Supplies 5.4.5.1 Separation of smokers and nonsmokers within the same Reference air space does not eliminate or minimize exposure of non- 1. Pickering, L. K., C. J. Baker, D. W. Kimberlin, S. S. Long, eds. 2009. - smokers to secondhand smoke. Tobacco smoke contamina Red book: 2009 report of the Committee on Infectious Diseases, 153. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics. tion lingers after a cigarette is extinguished and children come in contact with the toxins (7). Thirdhand smoke 3.3.0.5 exposure also presents hazards. Thirdhand smoke refers to Cleaning Crib Surfaces gases and particles clinging to smokers’ hair and clothing, Cribs and crib mattresses should have a nonporous, easy- cushions and carpeting, and outdoor equipment, after to-wipe surface. All surfaces should be cleaned as recom - tobacco smoke has dissipated (8). The residue includes mended in Appendix K, Routine Schedule for Cleaning, heavy metals, carcinogens and radioactive materials that Sanitizing, and Disinfecting. young children can get on their hands and ingest, especially if they’re crawling or playing on the floor. Residual toxins RATIONALE from smoking at times when the children are not using the Contamination of hands, toys and other objects in child space can trigger asthma and allergies when the children do care areas has played a role in the transmission of diseases use the space (2,3). in child care settings (1). Cigarettes and materials used to light them also present a TYPE OF FACILITY risk of burn or fire. In fact, cigarettes used by adults are the Center, Large Family Child Care Home leading cause of ignition of fatal house fires (9). RELATED STANDARDS Alcohol use, illegal and legal drug use, and misuse of pre- 5.4.5.1 Sleeping Equipment and Supplies scription or over-the-counter (OTC) drugs prevent caregiv - Cribs 5.4.5.2 ers/teachers from providing appropriate care to infants and children by impairing motor coordination, judgment, and Reference response time. Safe child care necessitates alert, unimpaired 1. Grenier, D., D. Leduc, eds. 2008. Preventing infections. In Well beings. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society. caregivers/teachers. The use of alcoholic beverages and legal drugs in family child care homes after children are not in care is not pro- 3.4 hibited, but these items should be safely stored at all times. HEALTH PROTECTION IN CHILD CARE COMMENTS 3 . 4 .1 The age, defenselessness, and dependence upon the judg - TOBACCO AND DRUG USE ment of caregivers/teachers of the children under care make this prohibition an absolute requirement. 3 . 4 .1.1 As more states move toward legalizing marijuana use for Use of Tobacco, Electronic Cigarettes, recreational and/or medicinal purposes, it is important for Alcohol, and Drugs caregivers/teachers to be aware of the impact marijuana - The use of tobacco, electronic cigarettes (e-cigarettes), alco used medicinally and/or recreationally has on their ability hol, and drugs should be prohibited on the premises of the to provide safe care. Staff modeling of healthy and safe program (both indoor and outdoor environments), during behavior at all times is essential to the care and education work hours including breaks, and in any vehicles used by of young children. the program at all times. Caregivers/teachers should be TYPE OF FACILITY prohibited from wearing clothing that smells of smoke Center, Large Family Child Care Home when working or volunteering. The use of legal drugs (e.g. marijuana, prescribed narcotics, etc.) that have side effects RELATED STANDARDS that diminish the ability to property supervise and care for 5. 2 . 9.1 Use and Storage of Toxic Substances children or safely drive program vehicles should also be 9. 2 . 3.15 Policies Prohibiting Smoking, Tobacco, Alcohol, prohibited. Illegal Drugs, and Toxic Substances RATIONALE References Scientific evidence has linked respiratory health risks 1. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: Updated 2016 to secondhand smoke. No children, especially those with recommenations for a safe infant sleeping environment. Pediatrics . respiratory problems, should be exposed to additional 2016;138(6):e20162938. http://pediatrics.aappublications.org/content/ risk from the air they breathe. Infants and young children early/2016/10/20/peds.2016-2938. 2. Centers for Disease Control and Prevention. 2016. Health effects of exposed to secondhand smoke are at risk of severe asthma; secondhand smoke. http://www.cdc.gov/tobacco/data_statistics/fact_ developing bronchitis, pneumonia, and middle ear sheets/secondhand_smoke/health_effects/.

155 128 Caring for Our Children: National Health and Safety Performance Standards 3. American Academy of Pediatrics. Healthychildren.org. 2015. The dangers Fish are permissible but must be inaccessible to children. of secondhand smoke. https://www.healthychildren.org/English/ health-issues/conditions/tobacco/Pages/Dangers-of-Secondhand-Smoke. Any animal present at the facility, indoors or outdoors, aspx. should be trained/adapted to be with young children, in 4. Children and U.S. Department of Health and Human Services. 2007. good health, show no evidence of carrying any disease, secondhand smoke exposure . Excerpts from the health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. fleas or ticks, be fully immunized, and be maintained Atlanta, GA: U.S. Department of Health and Human Services, Centers for on an intestinal parasite control program. A current Disease Control and Prevention, Coordinating Center for Health (time-specified) certificate from each animal’s attending Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. veterinarian should be on file in the facility, stating that 5. Schwartz, J., K. L. Timonen, J. Pekkanen. 2000. Respiratory effects of all animals on the facility premises meet these conditions environmental tobacco smoke in a panel study of asthmatic and and meet local and state requirements. symptomatic children. 161:802-6. Am J Resp Crit Care Med U.S. Department of Health and Human Services. The Health Consequences 6. Only animals that do not pose a health or safety risk will be of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon allowed on the premises of the facility. General. Secondhand Smoke What It Means to You. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, The caregiver/teacher should instruct children on the Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, humane and safe procedures to follow when in close prox - 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke- imity to animals (for example, not to provoke or startle consumer.pdf. animals or touch them when they are near food). 7. U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon - All contact between animals and children should be super General. Secondhand Smoke What It Means to You. U.S. Department of vised by a caregiver/teacher who is close enough to remove Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic the child immediately if the animal shows signs of distress Disease Prevention and Health Promotion, Office on Smoking and Health, (e.g., growling, baring teeth, tail down, ears back) or the 2006. http://www.surgeongeneral.gov/library/reports/secondhand-smoke- child shows signs of treating the animal inappropriately. consumer.pdf. 8. Winickoff, J. P., J. Friebely, S. E. Tanski, C. Sherrod, G. E. Matt, M. F. Hovell, Children should not be allowed to feed animals directly R. C. McMillen. 2009. Beliefs about the health effects of “thirdhand” smoke Pediatrics and home smoking bans. 123: e74-e79. from their hands. 9. Dale, L. 2014. What is thirdhand smoke, and why is it a concern? http:// No food and beverages should be allowed in animal areas. www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/ t hird-hand-smoke/faq-20057791 In addition, adults and children should not carry toys, use pacifiers, cups, and infant bottles in animal areas. Additional References: Centers for Disease Control and Prevention. 2009. Facts: Preventing residential The animals should be housed within some “barrier” that fire injuries. http://www.cdc.gov/injury/pdfs/Fires2009CDCFactSheet- protects them from competition by other animals while FINAL-a.pdf. - being fed which would also provide protection for the chil American Lung Association. E-cigarettes and Lung Health. 2016. http://www. lung.org/stop-smoking/smoking-facts/e-cigarettes-and-lung-health. dren yet they could still observe the animals eating. Animal html?referrer=https://www.google.com/. food dishes should not be placed in areas accessible to chil - Children’s Hospital Colorado. 2016. Acute marijuana intoxication. https:// dren during hours when children are present. www.childrenscolorado.org/conditions-and-advice/conditions-and- symptoms/conditions/acute-marijuana-intoxication/. Children should be discouraged from “kissing” animals or having them in close contact with their faces. NOTES All children and caregivers/teachers who handle animals or Content in the STANDARD was modified on 1/12/2017. animal-related equipment (e.g., leashes, dishes, toys, etc.) should be instructed to use hand hygiene immediately after handling. 3.4.2 Immunocompromised children, such as children with ANIMALS organ transplants, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), or currently 3 . 4 . 2 .1 receiving cancer chemotherapy or radiation therapy, and/ Animals that Might Have Contact with or children with allergies, should have an individualized Children and Adults health care plan in place that specifies if there are precau - The following domestic animals may have contact with tionary measures to be taken before the child has direct children and adults if they meet the criteria specified in this or indirect contact with animals or equipment. standard: Uncaged animals, such as dogs and cats, should wear a Dog; a. proper collar, harness, and/or leash when on the facility Cat; b. premises and the owner or responsible adult should stay Ungulate (e.g., cow, sheep, goat, pig, horse); c. - with the animal at all times. Animals should not be permit Rabbit; d. ted in food preparation or service areas at any time. Rodent (e.g., mice, rats, hamsters, gerbils, guinea pigs, e. chinchillas).

156 129 Chapter 3: Health Promotion and Protection RATIONALE RELATED STANDARDS The risk of injury, infection, and aggravation of allergy 3.2.2.1 Situations that Require Hand Hygiene from contact between children and animals is significant. 3.2.2.2 Handwashing Procedure The staff must plan carefully when having an animal in the Assisting Children with Hand Hygiene 3.2.2.3 facility and when visiting a zoo or local pet store (5,9,10). Training and Monitoring for Hand Hygiene 3.2.2.4 Children should be brought into direct contact only with 3.2.2.5 Hand Sanitizers animals known to be friendly and comfortable in the Prohibited Animals 3.4.2.2 company of children. 3.4.2.3 Care for Animals Dog bites to children under four years of age usually occur at home, and the most common injury sites are the head, References 1. Gilchrist, J., J. J. Sacks, D. White, M. J. Kresnow. 2008. Dog bites: Still a face, and neck (1-4). Many human illnesses can be acquired problem? Injury Prevention 14:296-301. from animals (5,7,8,11). Many allergic children have 2. Reisner, I. R., F. S. Shofer. 2008. Effects of gender and parental status on symptoms when they are around animals. knowledge and attitudes of dog owners regarding dog aggression toward children. J Am Vet Med Assoc 233:1412-19. Special precautions may be needed to minimize the risk of 3. Information from Your Family Doctor. 2004. Dog bites: Teaching your disease transmission to immunocompromised children (13). child to be safe. Am Family Physician 69:2653. Bernardo, L. M., M. J. Gardner, R. L. Rosenfield, B. Cohen, R. Pitetti. 2002. 4. When animals are taken out of their natural environment A comparison of dog bite injuries in younger and older children treated in a pediatric emergency department. Pediatric Emergency Care 18:247-49. and are in situations unusual to them, the stress that the 5. National Association of State Public Health Veterinarians. 2007. animals experience may cause them to act aggressively or Compendium of measures to prevent disease associated with animals in attempt to escape (the “flight or fight” phenomenon). Appro- public settings. MMWR 56:1-13. 6. U.S. Department of Health and Human Services, Centers for Disease priate restraint devices will allow the holder to react quickly, Control and Prevention. 2009. Appendix D: Guidelines for animals in prevent harm to children and/or the escape of the animal (9). school and child-care settings. MMWR 58:20-21. 7. U.S. Department of Health and Human Services, Centers for Disease Pregnant women need to be aware of a potential risk asso- Control and Prevention. 2000. Compendium of measures to control ciated with contact with cats’ feces (stool). Toxoplasmosis is Chlamydia psittaci infection among humans (psittacosis) and pet birds an infection caused by a parasite called Toxoplasma gondii. (avian chlamydiosis). MMWR 49:3-17. 8. U.S. Department of Health and Human Services, Centers for Disease This parasite is carried by cats and is passed in their feces. Control and Prevention. Pregnant women and Toxoplasmosis. Toxoplasmosis can cause problems with pregnancy, includ - http://www.cdc.gov/healthypets/pregnant.htm. ing abortion (8). The CDC advises pregnant women to 9. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. avoid pet rodents because of the risk of lymphocytic http://www.kdheks.gov/pdf/hef/ ab1007.pdf. choriomeningitis virus (6,12). 10. Massachusetts Department of Public Health Division of Epidemiology and Immunization. 2001. Recommendations for petting zoos, petting farms, COMMENTS animal fairs, and other events and exhibits where contact between animals Bringing animals and children together has both risks and and people is permitted. http://www.mass.gov/Eeohhs2/docs/dph/cdc/ rabies/reduce_zoos _risk.pdf. benefits. Animals teach children about how to be gentle and 11. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to responsible, about life and death, and about unconditional nontraditional pets at home and to animals in public settings: risks to love (9). Nevertheless, animals can pose serious health and children. Pediatrics 122:876-86. 12. Centers for Disease Control and Prevention. 2010. Lymphocytic safety risks. choriomeningitis (LCMV). http://www.cdc.gov/ncidod/dvrd/spb/mnpages/ dispages/lcmv.htm. Special accommodations for children with allergies may be 13. Hemsworth, S., B. Pizer. 2006. Pet ownership in immunocompromised necessary. Cleaning air filters more often if animals are in children – A review of the literature and survey of existing guidelines. childcare areas may be helpful in reducing animal dander. Eur J Oncol Nurs 10:117-27. Some dogs complete training and are certified as part of “dog-assisted therapy programs.” Certification requires that 3.4.2.2 dogs meet specific criteria, complete screening/training, and Prohibited Animals be a member of Therapy Dogs International for liability The following animals should not be kept at or brought onto purposes. Although these programs are typically based in the grounds of the child care facility (4,6,7): hospitals, certified therapy animals also help with disaster a. Bats; - relief and other efforts. Facilities that want to offer educa b. Hermit crabs; - tional information to staff or hands-on learning opportuni c. Poisonous animals - Inclusive of spiders, venomous ties for children may find it helpful to contact their local insects, venomous reptiles (including snakes), and hospital to identify a trainer for dog-assisted therapy venomous amphibians; programs. For more information on this program and d. Wolf-dog hybrids - These animals are crosses between a resources, contact Therapy Dogs International at http:// wolf and a domestic dog and have shown a propensity for www.tdi-dog.org. aggression, especially toward young children; TYPE OF FACILITY e. Stray animals - Stray animals should never be present at Center, Large Family Child Care Home a child care facility because the health and vaccination status of these animals is unknown;

157 130 Caring for Our Children: National Health and Safety Performance Standards Chickens and ducks - These animals excrete E. coli f. 3.4.2.3 O157:H7, Salmonella, Campylobacter, S. paratyphoid; Care for Animals Aggressive animals - Animals which are bred or trained g. The facility should care for all animals as recommended by to demonstrate aggression towards humans or other the health department and in consultation with licensed animals, or animals which have demonstrated such veterinarian. When animals are kept on the premises, the aggressive behavior in the past, should not be permitted facility should write and adhere to procedures for their on the grounds of the child care facility. Exceptions may humane care and maintenance. When animals are kept be sentry or canine corps dogs for a demonstration. in the child care facility, the following conditions should These dogs must be under the control of trained be met: military or law enforcement officials; Humane Care: An environment will be maintained in Reptiles and amphibians - Inclusive of non-venomous h. which animals experience: snakes, lizards, and iguanas, turtles, tortoises, terrapins, crocodiles, alligators, frogs, tadpoles, salamanders, Good health; a. and newts; b. Are able to effectively cope with their environment; Psittacine birds unless tested for psittacosis - Inclusive of i. c. Are able to express a diversity of species specific parrots, parakeets, budgies, and cockatiels. Psittacine behaviors. birds can carry diseases that can be transferred to Health Care: Proof of appropriate current veterinary certifi - humans; cate meeting local and state health requirement is kept on Ferrets - Ferrets have a propensity to bite when startled; j. file at the facility for each animal kept on the premises or k. Animals in estrus - Female dogs and cats should be visiting the child care facility. determined not to be in estrus (heat) when at the child Animal care: Specific areas should be designated for care facility; animal contact. l. Animals less than one year of age - Incorporating young animals (animal that are less than one year of age) into Live animals should be prohibited from: child care programs is not permitted because of issues Food preparation, food storage, and dining areas; a. regarding unpredictable behavior and elimination con- The vicinity of sinks where children wash their hands; b. trol. Additionally, the immune systems of very young Clean supply rooms; c. puppies and kittens are not completely developed, d. Areas where children routinely play or congregate thereby placing the health of these animals at risk. (e.g., sandboxes, child care facility playgrounds). RATIONALE The living quarters of animals should be enclosed and kept Animals, including pets, are a source of illness for people, clean of waste to reduce the risk of human contact with and people may be a source of illness for animals (1-2,4-5). this waste. Reptiles usually carry salmonella and pose a risk to chil - Animal food supplies should be kept out of reach of dren who are likely to put unwashed hands in their children. mout hs (3, 5). Animal litter boxes should not be located in areas accessible TYPE OF FACILITY to children. Children and food handlers should not handle Center, Large Family Child Care Home or clean up any form of animal waste (feces, urine, RELATED STANDARDS blood, etc). Animals that Might Have Contact with 3. 4 . 2 .1 All animal waste and litter should be removed immediately Children and Adults from children’s areas and will be disposed of in a way where Care for Animals 3.4.2.3 children cannot come in contact with the material, such as References in a plastic bag or container with a well-fitted lid or via the 1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections transmitted sewage waste system for feces. from animals. Infect Dis Clin North Am 5:649-61. 2. National Association of State Public Health Veterinarians. 2007. Used fish tank water should be disposed of in sinks that are Compendium of measures to prevent disease associated with animals in not used for food preparation or used for obtaining water public settings. MMWR 56:1-13. for human consumption. 3. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and resident pets. Topeka, KS: Kansas Department of Health and Environment. Disposable gloves should be used when cleaning aquariums http://www.kdheks.gov/pdf/hef/ ab1007.pdf. 4. U.S. Department of Health and Human Services, Centers for Disease and hands should be washed immediately after cleaning is Control and Prevention. 2009. Appendix D: Guidelines for animals in finished. Eye and oral contamination by splashing of school and child-care settings. MMWR 58:20-21. contaminated water during the cleaning process should be 5. Pickering, L. K., N. Marano, J. A. Bocchini, F. J. Angulo. 2008. Exposure to nontraditional pets at home and to animals in public settings: risks to prevented. Children should not be involved in the cleaning children. Pediatrics 122:876-86. of aquariums. PETCO Animal Supplies. 2006. Hermit crab: Care sheet. http://www.petco. 6. com/caresheets/invertebrates/HermitCrab.pdf. Areas where feeders, water containers, and cages are 7. Kahn, C. M., S. Line, eds. 2010. The Merck veterinary manual. 10th ed. cleaned should be disinfected after cleaning activity is Whitehouse Station, NJ: Merck. finished.

158 131 Chapter 3: Health Promotion and Protection 5. U.S. Department of Health and Human Services, Centers for Disease Pregnant persons should not handle cat waste or litter. Cat Control and Prevention. 2009. Appendix D: Guidelines for animals in litter boxes should be cleaned daily. school and child-care settings. MMWR 58:20-21. 6. American Veterinary Medical Association. Animal welfare principles. All persons who have contact with animals, animal prod - https://www.avma.org/public/animalwelfare/pages/default.aspx. ucts, or animal environments should wash their hands immediately after the contact. RATIONALE 3.4.3 Animals, including pets, are a source of illness for people; EMERGENCY PROCEDURES likewise, people may be a source of illness for animals (1). All contact with animals, and animal wastes should occur 3.4.3.1 in a fashion that minimizes staff and children’s risk of Emergency Procedures injury, infection and aggravation of allergy (2,4,5). Hand When an immediate emergency medical response is hygiene is the most important way to reduce the spread required, the following emergency procedures should of infection. Unwashed or improperly washed hands are be utilized: primary carriers of germs which may lead to infections. a. First aid should be employed and an emergency medical Just as food intended for human consumption may become response team should be called such as 9-1-1 and/or the contaminated, an animal’s food can become contaminated poison center if a poison emergency (1-800-222-1222); by standing at room temperature, or by being exposed to The program should implement a plan for emergency b. animals, insects, or people. transportation to a local emergency medical facility; The parent/guardian or parent/guardian’s emergency c. Pregnant woman can acquire toxoplasmosis from infected contact person should be called as soon as practical; cat waste. The infection can be transmitted to her unborn d. A staff member should accompany the child to the child. Congenital toxoplasmosis infection can lead to mis- hospital and will stay with the child until the parent/ carriage or an array of malformations of the developing guardian or emergency contact person arrives. Child to child prior to birth. Cat litter boxes should be cleaned daily staff ratio must be maintained, so staff may need to be - since it takes one to five days for feces containing toxo called in to maintain the required ratio. plasma oocysts to become infectious with toxoplasmosis (3). Programs should develop contingency plans for emergencies COMMENTS or disaster situations when it may not be possible or feasible Ensuring animal welfare is a human responsibility that to follow standard or previously agreed upon emergency includes consideration for all aspects of animal well-being, procedures (see also Standard 9.2.4.3, Disaster Planning, inclusive of secure housing, suitable temperature, adequate Training, and Communication). Children with known exercise and proper diet, disease prevention and treatment, medical conditions that might involve emergent care - humane handling, and, when necessary, humane euthana require a Care Plan created by the child’s primary care sia (6). Animal well-being also includes continued care of - provider. All staff need to be trained to manage an emer animals during the days that child care is not in session gency until emergency medical care becomes available. and in the event of an emergency evacuation. RATIONALE TYPE OF FACILITY The staff must know how to carry out the written disaster Center, Large Family Child Care Home and emergency plans as described in Standard 9.2.4.3 to RELATED STANDARDS help prevent or minimize severe injury to children and 3.2.2.1 Situations that Require Hand Hygiene other staff. The staff should review and practice the 3.2.2.2 Handwashing Procedure emergency plan regularly (1). Assisting Children with Hand Hygiene 3.2.2.3 COMMENTS 3.2.2.4 Training and Monitoring for Hand Hygiene First aid instructions are available from the American Hand Sanitizers 3.2.2.5 Academy of Pediatrics (AAP) and the American Red Cross. Animals that Might Have Contact with 3. 4 . 2 .1 TYPE OF FACILITY Children and Adults Center, Large Family Child Care Home 3.4.2.2 Prohibited Animals RELATED STANDARDS References Disaster Planning, Training, and 9.2.4.3 1. Weinberg, A. N., D. J. Weber, eds. 1991. Respiratory infections transmitted Communication from animals. Infect Dis Clin North Am 5:649-61. National Association of State Public Health Veterinarians. 2007. 2. Appendix P: Situations that Require Medical Attention Compendium of measures to prevent disease associated with animals in R ig ht Away public settings. MMWR 56:1-13. 3. Centers for Disease Control and Prevention (CDC). Pregnant women and Reference toxoplasmosis. http://www.cdc.gov/healthypets/pregnant.htm. 1. Aronson, S. 2005. Pediatric first aid for caregivers and teachers. Sudbury, 4. Hansen, G. R. 2004. Animals in Kansas schools: Guidelines for visiting and MA: Jones and Bartlett; Elk Grove Village, IL: American Academy of resident pets. Topeka, KS: Kansas Department of Health and Environment. Pediatrics. http://www.kdheks.gov/pdf/hef/ ab1007.pdf.

159 132 Caring for Our Children: National Health and Safety Performance Standards COMMENTS 3.4.3.2 For resources for children: see Stop, Drop, and Roll – Use of Fire Extinguishers A Jessica Worries Book: Fire Safety . The staff should demonstrate the ability to locate and oper - ate the fire extinguishers. Facilities should develop a plan TYPE OF FACILITY for responding in the event of a fire in or near the facility Center, Large Family Child Care Home that includes staff responsibilities and protocols regarding RELATED STANDARD evacuation, notifying emergency personnel, and using fire Situations that Require Medical Attention Appendix P: extinguishers. The staff should demonstrate the ability to R ig ht Away recognize a fire that is larger than incipient stage and should not be fought with a portable fire extinguisher. Reference 1. American Academy of Pediatrics, Committee on Injury and Poison RATIONALE Prevention. 2000. Reducing the number of deaths and injuries from residential fires. Pediatrics 105:1355-57. A fire extinguisher may be used to put out a small fire or to clear an escape path (1). Developing a plan that includes staff use of fire extinguishers and conducting fire drills/ exercises can increase preparedness and help staff better 3.4.4 understand what to do to respond to a fire. It is just as CHILD ABUSE AND NEGLECT important that staff know when not to try to fight a fire with portable fire extinguishers. 3.4.4.1 COMMENTS Recognizing and Reporting Suspected Staff should be trained that the first priority is to remove Child Abuse, Neglect, and Exploitation the children from the facility safely and quickly. Putting Caregivers/teachers should receive initial and ongoing out the fire is secondary to the safe exit of the children and training to assist them in preventing child abuse and staff. However, depending upon the situation at hand and neglect and in recognizing signs of child abuse and neglect. the number of available staff, the facility’s plan could iden - Programs are encouraged to partner with primary health tify which caregivers/teachers evacuate the children, where care providers, child care health consultants, and/or child they will all meet outside, who should call emergency per- protection advocates to provide training and to be available sonnel, and who should locate/use the fire extinguishers. for consultation. Caregivers/teachers are mandated report - These efforts can take place simultaneously. ers of child abuse and neglect. Each facility should have a written policy for reporting child abuse and neglect. TYPE OF FACILITY Center, Large Family Child Care Home The facility should report any instance in which there is reasonable cause to believe that child abuse and/or neglect RELATED STANDARD has occurred to the child abuse reporting hotline, depart - 9.2.4.3 Disaster Planning, Training, and Communication ment of social services, child protective services, or police Reference as required by state and local laws. Every staff member 1. American Academy of Pediatrics, Committee on Injury and Poison should be oriented to what and how to report. Phone Prevention. 2000. Reducing the number of deaths and injuries from residential fires. Pediatrics 105:1355-57. numbers and reporting system, as required by state or local agencies, should be clearly posted in a location accessible to caregivers/teachers. 3.4.3.3 Employees and volunteers in centers and large family child Response to Fire and Burns care homes should receive an instruction sheet about child Children who are developmentally able to understand, abuse and neglect reporting that contains a summary of should be instructed to STOP, DROP, and ROLL when the state child abuse reporting statute and a statement that garments catch fire. Children should be instructed to crawl they will not be discharged or disciplined because they have - on the floor under the smoke if necessary when they evacu made a child abuse and neglect report. Some states have ate the building. This instruction is part of ongoing health specific forms that are required to be completed when abuse and safety education and fire drills/exercise. and neglect is reported. Some states have forms that are not Cool water should be applied to burns immediately. The required but assist mandated reporters in documenting injury should be covered with a loose bandage or clean, accurate and thorough reports. In those states, facilities dry cloth. Medical assessment/care should be immediate. should have such forms on hand and all staff should be RATIONALE trained in the appropriate use of those forms. Running when garments have been ignited will fan the Parents/guardians should be notified on enrollment of the fire. Removing heat from the affected area will prevent facility’s child abuse and neglect reporting requirement continued burning and aggravation of tissue damage. and procedures. Asphyxiation causes more deaths in house fires than does thermal injury (1).

160 133 Chapter 3: Health Promotion and Protection RATIONALE References 1. 1. Rheingold AA, Zajac K, Chapman JE, et al. Child sexual abuse prevention While caregivers/teachers are not expected to diagnose or training for childcare professionals: an independent multi-site randomized investigate child abuse and neglect, it is important that they controlled trial of Stewards of Children. Prev Sci. 2015;16(3):374–385 2. 2. Smith M, Robinson L, Segal J. Child abuse and neglect: how to spot the be aware of common physical and emotional signs and symp - signs and make a difference. Helpguide.org Web site. https://www. toms of child maltreatment (see Appendix M, Recognizing helpguide.org/articles/abuse/child-abuse-and-neglect.htm. Updated Child Abuse and Neglect: Signs and Symptoms) (1,2). October 2017. Accessed January 11, 2018 3. 3. Darkness to Light. Reporting child sexual abuse. https://www.d2l.org/ All states have laws mandating the reporting of child abuse get-help/reporting. Accessed January 11, 2018 4. Child Welfare Information Gateway. What Is Child Abuse and Neglect? 4. and neglect to child protection agencies and/or police. Laws Recognizing the Signs and Symptoms. Washington, DC: Child Welfare about when and to whom to report vary by state (3). Failure Information Gateway; 2013. https://www.childwelfare.gov/pubpdfs/ to report abuse and neglect is a crime in all states and may whatiscan.pdf. Accessed January 11, 2018 lead to legal penalties. NOTES COMMENTS Content in the STANDARD was modified on 05/29/2018. Child abuse includes physical, sexual, psychological, and emotional abuse. Other components of abuse include 3.4.4.2 shaken baby syndrome/acute head trauma and repeated Immunity for Reporters of Child Abuse exposure to violence, including domestic violence. Neglect and Neglect occurs when the parent/guardian/caregiver does not meet Caregivers/teachers who report suspected abuse and neglect the child’s basic needs and includes physical, medical, in the settings where they work should be immune from educational, and emotional neglect (4). Caregivers/teachers discharge, retaliation, or other disciplinary action for that and health professionals may contact individual state hot- reason alone, unless it is proven that the report was lines where available. While almost all states have hotlines, malicious. they may not operate 24 hours a day, and some toll-free numbers may only be accessible within that particular state. RATIONALE Childhelp provides a national hotline: 1-800-4-A-CHILD Cases which are reported suggest that sometimes workers (80 0/422- 4 453). are intimidated by superiors in the centers where they work, Many health departments will be willing to provide contact and for that reason, fail to report abuse and neglect (1). In - for experts in child abuse and neglect prevention and recog some cases the abuser may be a staff member or superior. nition. The American Academy of Pediatrics (www.aap.org) TYPE OF FACILITY can also assist in recruiting and identifying physicians who Center, Large Family Child Care Home are skilled in this work. RELATED STANDARDS Caregivers/teachers are still liable for reporting even when 1.7.0.5 Stress their supervisor indicates they don’t need to or says that some- 3.4.4.1 Recognizing and Reporting Suspected Child one else will report it. Caregivers/teachers who report in good Abuse, Neglect, and Exploitation faith may do so confidentially and are protected by law. Preventing and Identifying Shaken Baby 3.4.4.3 For more information about specific state laws on mandated Syndrome/Abusive Head Trauma reporting, go to the Child Welfare Information Gateway Care for Children Who Have Been Abused/ 3.4.4.4 Mandated Reporting Web site, https://www. Neglected childwelfare.gov/topics/responding/reporting/mandated. 9. 4 .1. 9 Records of Injury TYPE OF FACILITY Recognizing Child Abuse and Neglect: Signs Appendix M: Center, Large Family Child Care Home, Small Family Child and Symptoms Care Home Protective Factors Regarding Child Abuse Appendix N: RELATED STANDARDS and Neglect 1. 6 . 0.1 Child Care Health Consultants Reference 1.7.0.5 Stress 1. Goldman, R. 1990. An educational perspective on abuse. In Children at risk: An interdisciplinary approach to child abuse and neglect. Ed. R. Goldman, 3.4.4.2 Immunity for Reporters of Child Abuse R. Gargiulo. Austin, TX: Pro-Ed. and Neglect Preventing and Identifying Shaken Baby 3.4.4.3 3.4.4.3 Syndrome/Abusive Head Trauma Preventing and Identifying Shaken Baby 3.4.4.4 Care for Children Who Have Been Abused/ Syndrome/Abusive Head Trauma Neglected All childcare facilities should have a policy and procedure Records of Injury 9. 4 .1. 9 to identify and prevent shaken baby syndrome/abusive head Recognizing Child Abuse and Neglect: Signs Appendix M: trauma. All caregivers/teachers who are in direct contact and Symptoms with children, including substitute caregivers/teachers and Protective Factors Regarding Child Abuse Appendix N: volunteers, should receive training on preventing shaken and Neglect

161 134 Caring for Our Children: National Health and Safety Performance Standards 4. American Academy of Pediatrics. Abusive head trauma: how to protect baby syndrome/abusive head trauma; recognizing potential your baby. HeathyChildren.org Web site. https://www.healthychildren.org/ signs and symptoms of shaken baby syndrome/abusive English/safety-prevention/at-home/Pages/Abusive-Head-Trauma-Shaken- head trauma; creating strategies for coping with a crying, Baby-Syndrome.aspx. Updated November 21, 2015. Accessed January 11, 2018 - fussing, or distraught child; and understanding the devel opment and vulnerabilities of the brain in infancy and NOTES early childhood. Content in the STANDARD was modified on 05/30/2018. RATIONALE Shaken baby syndrome/abusive head trauma is the occur - 3.4.4.4 rence of brain injury in newborns, infants, and children Care for Children Who Have Been younger than 3 years caused by shaking a child. Even mild Abused/Neglected shaking can result in serious, permanent brain damage or Caregivers/teachers should have access to specialized death. The brain of the young child may bounce inside of training and expert advice for children with behavioral - the skull, resulting in brain damage, hemorrhaging, blind abnormalities related to abuse or neglect. ness, or other serious injuries or death. There have been RATIONALE several reported incidents in child care (1). All children who have been abused or neglected have had Caregivers/teachers care for young children who may be their physical and emotional boundaries violated and fussy or constantly crying. It is important for caregivers/ crossed. With this violation often comes a breach of the teachers to be educated about the risks of shaking and pro- child’s sense of security and trust. Abused and neglected vided with strategies to cope if they are frustrated(2). Many children may come to believe that the world is not a safe states have passed legislation requiring education and train - place and that adults are not trustworthy. Abused and ing for caregivers/teachers. Caregivers/teachers should neglected children may have more emotional needs and check their individual state’s specific requirements (3). Staff may require more individual staff time and attention than should be knowledgeable about and be able to recognize the children who are not maltreated. Children who are victims signs and symptoms of shaken baby syndrome/abusive head of abuse or neglect, in addition to having more develop - trauma in children in their care. mental problems, also have behavior problems such as COMMENTS emotional lability, depression, and aggressive behaviors (3). Victims of shaken baby syndrome/abusive head trauma These problems may persist long after the maltreatment may exhibit one or more of the following symptoms (4): occurred and may have significant psychiatric and medical consequences into adulthood. In particular, children who 1. Irritability have suffered abuse or neglect or been exposed to violence, 2. Trouble staying awake including domestic violence, often have excessive responses 3. Trouble breathing to environmental stress. Their responses are often misinter - - preted by caregivers/teachers and responded to inappropri 4. Vomiting ately which, in turn, reinforces their hyper-vigilance and 5. Unable to be woken up maladaptive behavior in a counter-productive feedback cycle (1,2). Child care staff may need to work closely with For more information and resources on shaken baby the child’s primary care provider, therapist, social worker, syndrome/abusive head trauma, contact the National and parents/guardians to formulate a more personalized Center on Shaken Baby Syndrome at www.dontshake.org. behavior management plan. TYPE OF FACILITY COMMENTS Center, Large Family Child Care Home, Small Family Centers serving children with a history of maltreatment Child Care Home related behavior problems may require professionally RELATED STANDARD trained staff. Resources on caring for a child who has 3.4.4.1 Recognizing and Reporting Suspected Child been abused or neglected are available from the National Abuse, Neglect, and Exploitation Children’s Advocacy Center at http://www.nationalcac.org/ References professionals/. 1. Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: TYPE OF FACILITY characteristic features, diagnosis, and management. Neurol Med Chir (Tok yo). 2017;57(2):82–93 Center Fortson BL, Klevens J, Merrick MT, Gilbert LK, Alexander SP. Preventing 2. Child Abuse and Neglect: A Technical Package for Policy, Norm, and RELATED STANDARD Programmatic Activities. Atlanta, GA: National Center for Injury Child Care Health Consultants 1. 6 . 0.1 Prevention and Control, Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical- Package.pdf. Accessed January 11, 2018 3. Child Care Aware. Health and safety training. http://childcareaware.org/ providers/training-essentials/health-and-safety-training. Accessed January 11, 2018

162 135 Chapter 3: Health Promotion and Protection References Preventing Entry to Toilet Rooms by Infants 5.4.1.4 1. American Academy of Pediatrics. 2008. Understanding the behavioral and a n d To d d l e r s emotional consequences of child abuse. Pediatrics 122:667-73. Chemical Toilets 5. 4 .1. 5 2. Felitti, V. J., R. F. Anda, P. Nordenber, D. F. Williamson, A. M. Spitz, V. Edwards, M. P. Koss, J. S. Marks. 1998. Relationship of childhood abuse and Ratios of Toilets, Urinals, and Hand Sinks to 5. 4 .1. 6 household dysfunction to many of the leading causes of death in adults. The Children Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14:245-58. 3. Child Welfare Information Gateway. 2008. Parenting a child who has been Toilet Learning/Training Equipment 5. 4 .1.7 sexually abused: A guide for foster and adoptive parents – factsheet for families. Washington, DC: U.S. Department of Health and Human Services. 5. 4 .1. 8 Cleaning and Disinfecting Toileting Equipment https://www.childwelfare.gov/pubs/f-abused/ 5. 4 .1. 9 Waste Receptacles in the Child Care Facility and in NOTES Child Care Facility Toilet Room(s) Content in the STANDARD was modified on 03/07/2013. References 1. Goldman, R. 1990. An educational perspective on abuse. In Children at risk: An interdisciplinary approach to child abuse and neglect. R. Goldman, R. 3.4.4.5 Gargiulo, eds. Austin, TX: Pro-Ed. Child Development Institute. 2010. Child development. http:// 2. Facility Layout to Reduce Risk of childdevelopmentinfo.com/development/. Child Abuse and Neglect The physical layout of facilities should be arranged so that there is a high level of visibility in the inside and outside 3.4.5 areas as well as diaper changing areas and toileting areas SUN SAFETY AND INSECT REPELLENT used by children. All areas should be viewed by at least one other adult in addition to the caregiver/teacher at all times 3.4.5.1 when children are in care. For center-based programs, rooms should be designed so that there are windows to Sun Safety Including Sunscreen the hallways to keep classroom activities from being too Caregivers/teachers should implement the following private. Ideally each area of the facility should have two procedures to ensure sun safety for themselves and the adults at all times. Such an arrangement reduces the risk children under their supervision: of child abuse and neglect and the likelihood of extended Keep infants younger than six months out of direct a. periods of time in isolation for individual caregivers/ sunlight. Find shade under a tree, umbrella, or the teachers with children, especially in areas where stroller canopy; children may be partially undressed or in the nude. Wear a hat or cap with a brim that faces forward to b. Caregivers/teachers should have increased awareness shield the face; regarding risk of abuse and neglect when a caregiver/ c. Limit sun exposure between 10 AM and 4 PM, when teacher is alone with a child. Other caregivers/teachers UV rays are strongest; should periodically walk into a room with one caregiver/ d. Wear child safe shatter resistant sunglasses with at teacher to ensure there is no abuse and neglect. least 99% UV protection; e. Apply sunscreen (1). RATIONALE Over-the-counter ointments and creams, such as sun- The presence of multiple caretakers greatly reduces the screen that are used for preventive purposes do not require risk of serious abusive injury. Maltreatment tends to occur a written authorization from a primary care provider with in privacy and isolation, and especially in toileting areas (1). prescriptive authority. However, parent/guardian written A significant number of cases of abuse have been found permission is required, and all label instructions must be involving young children being diapered in diaper followed. If the skin is broken or an allergic reaction is changing areas (1). observed, caregivers/teachers should discontinue use COMMENTS and notify the parent/guardian. - This standard does not mean to disallow privacy for chil If parents/guardians give permission, sunscreen should be dren who are developmentally able to toilet independently applied on all exposed areas, especially the face (avoiding and who may need privacy (2). the eye area), nose, ears, feet, and hands and rubbed in TYPE OF FACILITY well especially from May through September. Sunscreen is Center, Large Family Child Care Home needed on cloudy days and in the winter at high altitudes. Sun reflects off water, snow, sand, and concrete. “Broad RELATED STANDARDS spectrum” sunscreen will screen out both UVB and UVA Toilet Learning/Training 2.1.2.5 rays. Use sunscreen with an SPF of 15 or higher, the higher General Requirements for Toilet and Handwashing 5. 4 .1.1 the SPF the more UVB protection offered. UVA protection Areas is designated by a star rating system, with four stars the 5. 4 .1. 2 Location of Toilets and Privacy Issues highest allowed in an over-the-counter product. Ability to Open Toilet Room Doors 5. 4 .1. 3 Sunscreen should be applied thirty minutes before going outdoors as it needs time to absorb into the skin. If the

163 136 Caring for Our Children: National Health and Safety Performance Standards Pennsylvania’s Self Learning Module “Sun Safety” at http:// children will be out for more than one hour, sunscreen will need to be reapplied every two hours as it can wear off. www.ecels-healthychildcarepa.org/content/Sun Safey SLM If children are playing in water, reapplication will be 6-23-10 v5 .pdf. needed more frequently. Children should also be protected TYPE OF FACILITY from the sun by using shade and sun protective clothing. Center, Large Family Child Care Home Sun exposure should be limited between the hours of 10 RELATED STANDARDS AM and 4 PM when the sun’s rays are the strongest. Situations that Require Hand Hygiene 3.2.2.1 Sunscreen should be applied to the child at least once by Insect Repellent and Protection from 3.4.5.2 the parents/guardians and the child observed for a reaction Vector-Borne Diseases to the sunscreen prior to its use in child care. 3.6.3.1 Medication Administration RATIONALE 6.1.0.7 Shading of Play Area Sun exposure from ultraviolet rays (UVA and UVB) causes visible and invisible damage to skin cells. Visible damage References 1. American Academy of Pediatrics. 2008. Sun safety. http://www. consists of freckles early in life. Invisible damage to skin healthychildren.org/english/safety-prevention/at-play/pages/Sun-Safety.aspx. cells adds up over time creating age spots, wrinkles, and American Academy of Dermatology. 2010. Skin, hair and nail care: 2. even skin cancer (2,4). Exposure to UV light is highest near Protecting skin from the sun. Kids Skin Health.http://www.kidsskinhealth. org/grownups/skin_habits_sun.html. the equator, at high altitudes, during midday (10 AM to 3. Kenfield, S., A. Geller, E. Richter, S. Shuman, D. O’Riordan, H. Koh, G. 4 PM), and where light is reflected off water or snow (5). Colditz. 2005. Sun protection policies and practices at child care centers in Massachusetts. J Comm Health 30:491-503. COMMENTS Maguire-Eisen, M., K, Rothman, M. F. Demierre. 2005. The ABCs of sun 4. Protective clothing must be worn for infants younger than protection for children. Dermatology Nurs 17:419-22,431-33. 5. Weinberg, N., M. Weinberg, S. Maloney. Traveling safely with infants six months. For infants older than six months, apply sun- and children. Medic8. http://wwwnc.cdc.gov/travel/yellowbook/2012/ screen to all exposed areas of the body, but be careful to chapter-7-international-travel-infants-children/traveling-safely-with- keep away from the eyes (3). If an infant rubs sunscreen infants-and-children. 6. Yan, X. S., G. Riccardi, M. Meola, A. Tashjian, J. SaNogueira, T. Schultz. into her/his eyes, wipe the eyes and hands clean with a 2008. A tear-free, SPF50 sunscreen product. Cutan Ocul Toxicol 27:231-39. damp cloth. Unscented sunblocks or sunscreen with tita - 7. Norval, M., H. C. Wulf. 2009. Does chronic sunscreen use reduce vitamin D nium dioxide or zinc oxide are generally safer for children production to insufficient levels? British J Dermatology 161:732-36. Misra, M., D. Pacaud, A. Petryk, P. F. Collett-Solberg, M. Kappy. 2008. 8. and less likely to cause irritation problems (6). If a rash Vitamin D deficiency in children and its management: Review of current develops, have parents/guardians talk with the child’s knowledge and recommendations. Pediatrics 122:398-417. primary care provider (1). NOTES Sunscreen needs to be applied every two hours because it Content in the STANDARD was modified on 8/8/2013. wears off after swimming, sweating, or just from absorbing into the skin (1). 3.4.5.2 There is a theoretical concern that daily sunscreen use will Insect Repellent and Protection from lower vitamin D levels. UV radiation from sun exposure Vector-Borne Diseases causes the important first step in converting vitamin D in Most insects do not carry human disease and most insect the skin into a usable form for the body. Current medical bites only cause mild irritation. Insect repellents may be research on this topic is not definitive, but there does not used with children older than 2 months in child care where appear to be a link between daily normal sunscreen use and there are specific disease outbreaks and alerts. As with all lower vitamin D levels (7). This is probably because the vita - pesticides, care should be taken to limit children’s exposure min D conversion can still occur with sunscreen use at to insect repellents (1). Caregivers/teachers should consult lower levels of UV exposure, before the skin becomes pink with a child care health consultant, the primary care pro- - or tan. However, vitamin D levels can be influenced signifi vider, or the local health department about the appropriate cantly by amount of sun exposure, time of the day, amount use of repellents based on the likelihood that local insects of protective clothing, skin color and geographic location are carrying potentially dangerous diseases (e.g., local (8). These factors make it difficult to apply a safe sunscreen cases of meningitis from mosquito bites). This information policy for all settings. A health consultant may assist the should be shared with parents/guardians, and collective program develop a local sunscreen policy that may differ decisions made about use. from above if there is a significant public health concern regarding low vitamin D levels. Insect repellent requires the written permission of parents/ guardians and label instructions must be followed. It does EPA provides specific UV Index information by City Name, not require written permission from a primary care Zip Code or by State, to view go to http://www.epa.gov/ provider. sunwise/uvindex.html. REPELLENTS CONTAINING DEET A good resource for reading materials for young children Repellents with 10%-30% DEET offer the broadest pro- and parents/guardians can be found at Healthy Child Care tection against mosquitoes, ticks, flies, chiggers, and fleas.

164 137 Chapter 3: Health Promotion and Protection Caregivers/teachers should read product labels and confirm PROTECTION FROM TICKS that the product is 1) safe for children and 2) contains no In places where ticks are likely to be found (6), caregivers/ more than 30% DEET. Most product labels for registrations teachers should take the following steps to protect children containing DEET recommend consultation with a physi - in their care from ticks: cian if applying to a child less than six months of age. Remove leaf litter and clear tall grasses and brush a. The use of DEET should reflect how much time the child around homes and buildings and at the edges of lawns; will be exposed to biting insects (2): b. Place wood chips or gravel between lawns and wooded areas to restrict tick migration to recreational areas; • 10% DEET is generally effective for two hours. c. Mow the lawn and clear brush and leaf litter frequently; • 24% DEET is generally effective for five hours. Keep playground equipment, decks, and patios away d. • Products with more than 30% DEET should never be from yard edges and trees; used on children. Ensure that children wear light colored clothing, long e. • Do not use products that combine insect repellent and sleeves and pants, tuck pants into socks; and sunscreen. This is because sunscreen may need to be f. Conduct tick checks of children when returning re-applied more often and in larger amounts than indoors (7). repellent. • If sunscreen is also used, apply sunscreen FIRST. How to Remove a Tick (8): DEET may decrease the SPF of sunscreens by one-third. It is important to remove the tick as soon as possible. Sunscreens may increase absorption of DEET through Use the following steps: t he sk in). If possible, clean the area with an antiseptic solution or a. OTHER TYPES OF INSECT REPELLENTS soap and water. Take care not to scrub the tick too hard. Picaridin and IR3535 are other products registered at the Just clean the skin around it; Environmental Protection Agency (EPA) identified as Use blunt, fine tipped tweezers or gloved fingers to grasp b. providing repellent activity sufficient to help people avoid the tick as close to the skin as possible; the bites of disease carrying mosquitoes (4). Para-menthane- Pull slowly and steadily upwards to allow the tick to c. diol (PMD) or pil of lemon eucalyptus products, according release; to their product labels, should NOT be used on children If the tick’s head breaks off in the skin, use tweezers to d. under three years of age (4,5). remove it like you would a splinter; GENERAL GUIDELINES FOR USE OF INSECT Wash the area around the bite with soap; e. REPELLENTS WITH CHILDREN f. Following the removal of the tick, wash your hands, the tweezers, and the area thoroughly with soap and As noted above, insect repellents may be applied to warm water. children older than two months. In addition to consult- ing label instructions, teachers/caregivers may follow Take care not to do the following: these guidelines: a. Do not use sharp tweezers. Apply insect repellent to the caregiver/teacher’s hands a. b. Do not crush, puncture, or squeeze the tick’s body. first. Do not use a twisting or jerking motion to remove c. b. When applying insect repellent on a child, use just the tick. enough to cover exposed skin. d. Do not handle the tick with bare hands. Do not apply under clothing. c. e. Do not try to make the tick let go by holding a hot Do not use on children’s hands. d. match or cigarette close to it. e. Avoid applying to areas around the eyes and mouth. f. Do not try to smother the tick by covering it with f. Do not use over cuts or irritated skin. petroleum jelly or nail polish. g. Do not use near food. RATIONALE h. After returning indoors, wash treated skin immediately Mosquitoes and ticks can carry pathogens that may cause with soap and water. serious diseases (i.e., vector-borne diseases such as West i. Caregivers/teachers should wash their hands after Nile virus and Lyme disease) (7). applying insect repellent to the children in the group. If the child gets a rash or other skin reaction from j. Zika is a mosquito-borne virus that usually causes mild an insect repellent, stop using the repellent, wash the illness that lasts from several days to a week. The mosquito repellent off with mild soap and water, and call a local that spreads Zika virus is found everywhere in the world poison center (1-800-222-1222) for further guidance (4). including the United States. Zika can be passed from a If repellent is used on broken skin or an allergic reac- pregnant woman to her fetus. Infection during pregnancy tion is observed, discontinue use and notify the can cause certain birth defects (9). Information and recom - parent/guardian. mendations regarding Zika are rapidly evolving. Please visit the Centers for Disease Control and Prevention (CDC) Zika updates page for the most recent information: http://www.cdc.gov/zika/index.html (9).

165 138 Caring for Our Children: National Health and Safety Performance Standards 7. Centers for Disease Control and Prevention, Division of Vector- COMMENTS Borne Infectious Diseases. 2010. Lyme disease: Protect yourself Insect repellents should be EPA-registered and labeled as from tick bites.http://www.cdc.gov/ncidod/dvbid/lyme/Prevention/ ld_Prevention_Avoid.htm. approved for use in the child’s age range. Centers for Disease Control and Prevention. 2015. Tick removal. 8. Aerosol sprays are not recommended. Pump sprays are https://www.cdc.gov/ticks/removing_a_tick.html. 9. Centers for Disease Control and Prevention. 2016. About zika. a better choice. Regardless of the type of spray used, https://www.cdc.gov/zika/about/index.html. caregivers/teachers should spray the insect repellent into Additional Reference - her/his hand and then apply to the child. It is not recom U.S. Environmental Protection Agency. 2016. Find the insect repellent mended to directly spray the child with the insect repellent that is right for you. https://www.epa.gov/insect-repellents/ to prevent unintentional injury to eyes and mouth. Pre- find-insect-repellent-right-you. school children, toddlers, and infants should not apply NOTES insect repellent to themselves. School age children can Content in the STANDARD was modified on 4/5/2017. apply insect repellent to themselves if they are supervised to make sure that they are applying it correctly. Parents/guardians should be notified when insect repellent 3.4.6 is applied to their child since it is recommended that treated STRANGULATION skin is washed with soap and water. If a product gets in the eyes, flush with water and consult 3 . 4 . 6 .1 the poison center at 1-800-222-1222. Several resources are Strangulation Hazards available on reducing exposure to ticks and mosquitoes Strings and cords (such as those that are parts of toys and based on habits, protective attire, and insect repellent use. those found on window coverings) long enough to encircle The following resources offer detailed information on pre- a child’s neck should not be accessible to children in child venting exposure to ticks and mosquitoes in early care and care. Miniblinds and venetian blinds should not have education settings: looped cords. Vertical blinds, continuous looped blinds, • Preventing Tick Bites on People by the Centers for and drapery cords should have tension or tie-down devices Disease Control and Prevention at http://www.cdc.gov/ to hold the cords tight. Inner cord stops should be installed. lyme/prev/on_people.html. Shoulder straps on guitars and chin straps on hats should UCSF California Childcare Health Program’s (CCHP) • be removed (1). Health and Safety Note for child care centers: Straps/handles on purses/bags used for dramatic play 1. Integrated Pest Management: Mosquitoes: should be removed or shortened. Ties, scarves, necklaces, http://cchp.ucsf.edu/sites/cchp.ucsf.edu/files/ and boas used for dramatic play should not be used for ipm_mosquitoes.pdf children under three years. If used by children three years 2. CCHP IPM Handout for Family Child Care Homes: and over, children should be supervised. Mosquitoes: http://cchp.ucsf.edu/sites/cchp.ucsf.edu/ files/Mosquitoes_FCCH_IPM.pdf Pacifiers attached to strings or ribbons should not be placed around infants’ necks or attached to infants’ clothing. TYPE OF FACILITY Hood and neck strings from all children’s outerwear, Center, Large Family Child Care Home including jackets and sweatshirts, should be removed. RELATED STANDARDS Drawstrings on the waist or bottom of garments should Situations that Require Hand Hygiene 3.2.2.1 not extend more than three inches outside the garment 3. 4 . 5.1 Sun Safety Including Sunscreen when it is fully expanded. These strings should have no 5. 2 . 8 .1 Integrated Pest Management knots or toggles on the free ends. The drawstring should be sewn to the garment at its midpoint so the string References cannot be pulled out through one side. 1. National Pesticide Information Center. 2015. Pesticides and children. http:// npic.orst.edu/health/child.html. RATIONALE Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child 2. care and schools: A quick reference guide, 4th Edition. Elk Grove Village, Window covering cords are associated with strangulation IL: American Academy of Pediatrics. of young children under (2,4). Infants can become entan - 3. Centers for Disease Control and Prevention. 2015. Chapter 2 - Protection gled in cords from window coverings near their cribs. Since against mosquitos, ticks, & other anthropods. https://wwwnc.cdc.gov/ travel/yellowbook/2016/the-pre-travel-consultation/sun-exposure. 1990, more than 200 infants and young children have died Centers for Disease Control and Prevention, Division of Vector-Borne 4. from unintentional strangulation in window cords (5). Infectious Diseases. 2015. West nile virus: Insect repellent use and safety. http://www.cdc.gov/westnile/faq/repellent.html. Cords and ribbons tied to pacifiers can become tightly 5. Centers for Disease Control and Prevention. 2016. Avoid bug bites. twisted, or can catch on crib cornerposts or other protru - https://wwwnc.cdc.gov/travel/page/avoid-bug-bites. 6. Centers for Disease Control and Prevention. 2015. Geographic sions, causing strangulation. distribution of ticks that bite humans. https://www.cdc.gov/ticks/ Clothing strings on children’s clothing, necklaces and geographic_distribution.html. scarves can catch on playground equipment and strangle children. The U.S. Consumer Product Safety Commission

166 139 Chapter 3: Health Promotion and Protection (CPSC) has reported deaths and injuries involving the Medications to be administered on an emergent basis d. entanglement of children’s clothing drawstrings (3). with clearly stated parameters, signs, and symptoms that warrant giving the medication written in lay language; COMMENTS Procedures to be performed; e. Children’s outerwear that has alternative closures (e.g., Allergies; f. - snaps, buttons, hook and loop, and elastic) are recom Dietary modifications required for the health of the child; g. mended (3). It is advisable that caregivers avoid wearing Activity modifications; h. necklaces or clothing with drawstrings that could cause i. Environmental modifications; entanglement. Stimulus that initiates or precipitates a reaction or series j. For additional information regarding the prevention of reactions (triggers) to avoid; of strangulation from strings on toys, window cover- k. Symptoms for caregiver/teachers to observe; ings, clothing, contact the CPSC. See http://www. Behavioral modifications; l. windowcoverings.org for the latest blind cord safety Emergency response plans – both if the child has a m. information. medical emergency and special factors to consider in programmatic emergency, like a fire; TYPE OF FACILITY n. Suggested special skills training and education for staff. Center, Large Family Child Care Home A template for a Care Plan for children with special health RELATED STANDARD care needs is provided in Appendix O. 5. 3.1.1 Safety of Equipment, Materials, and Furnishings The Care Plan should be updated after every hospitaliza- References tion or significant change in health status of the child. The 1. U.S. Consumer Products Safety Commission. Strings and straps on toys can Care Plan is completed by the primary care provider in the strangle young children. http://www.cpsc.gov//PageFiles/122499/5100.pdf Window Covering Safety Council. 2011. New study released on window 2. medical home with input from parents/guardians, and it is covering safety awareness. http://www.windowcoverings.org/about-2/ implemented in the child care setting. The child care health 3. U.S. Consumer Product Safety Commission (CPSC). 1999. Guidelines for consultant should be involved to assure adequate informa - drawstrings on children’s outerwear. Bethesda, MD: CPSC. http://www. cpsc.gov/cpscpub/pubs/208.pdf. tion, training, and monitoring is available for child care staff. 4. U.S. Consumer Product Safety Commission (CPSC). Are your window coverings safe? Washington, DC: CPSC. RATIONALE 5. Window Covering Safety Council. Basic cord safety. http://www. Children with special health care needs could have a variety prnewswire.com/news-releases/new-study-released-on-window-cord- - of different problems ranging from asthma, diabetes, cere safety-awareness-115561629.html. bral palsy, bleeding disorders, metabolic problems, cystic fibrosis, sickle cell disease, seizure disorder, sensory disor - 3.5 ders, autism, severe allergy, immune deficiencies, or many other conditions (2). Some of these conditions require daily CARE PLANS AND ADAPTATIONS treatments and some only require observation for signs of impending illness and ability to respond in a timely ma n ner (3). 3.5.0.1 COMMENTS Care Plan for Children with Special Health A collaborative approach in which the primary care pro- Care Needs vider and the parent/guardian complete the Care Plan and Reader’s Note: Children with special health care needs are the parent/guardian works with the child care staff to imple - defined as “...those who have or are at increased risk for a ment the plan is helpful. Although it is usually the primary chronic physical, developmental, behavioral, or emotional care provider in the medical home completing the Care Plan, condition and who also require health and related services sometimes management is shared by specialists, nurse prac - of a type or amount beyond that required by children titioners, and case managers, especially with conditions generally” (1). such as diabetes or sickle cell disease. Any child who meets these criteria should have a Routine Child care health consultants are very helpful in assisting and Emergent Care Plan completed by their primary care in implementing Care Plans and in providing or finding provider in their medical home. In addition to the informa - training resources. The child care health consultant may tion specified in Standard 9.4.2.4 for the Health Report, help in creating the care plan, through developing a draft there should be: and/or facilitate the primary care provider to provide specific a. A list of the child’s diagnosis/diagnoses; directives to follow within the child care environment. The Contact information for the primary care provider and b. child care health consultant should write out directives into any relevant sub-specialists (i.e., endocrinologists, a “user friendly” language document for caregivers/teachers oncologists, etc.); and/or staff to implement with ease. c. Medications to be administered on a scheduled basis; Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical

167 140 Caring for Our Children: National Health and Safety Performance Standards information (4). Confidentiality should be maintained at primary care provider who prescribed the special treatment each step in compliance with any laws or regulations that (such as a urologist for catheterization). Often, the child’s are pertinent to all parties such as the Family Educational primary care provider may be able to provide this informa - Rights and Privacy Act (commonly known as FERPA) and/ tion. This plan of care should address any special prepara - tion to perform routine and/or urgent procedures (other or the Health Insurance Portability and Accountability than those that might be required in an emergency for Act (commonly known as HIPAA) (4). any typical child, such as cardiopulmonary resuscitation For additional information on care plans and approaches [CPR]). This plan of care should include instructions for for the most prevalent chronic diseases in child care see the how to receive training in performing the procedure, following resources: performing the procedure, a description of common and Asthma: How Asthma-Friendly Is Your Child-Care Setting? uncommon complications of the procedure, and what to do at http://www.nhlbi.nih.gov/health/public/lung/asthma/ and who to notify if complications occur. Specific/relevant chc_chk.htm; training for the child care staff should be provided by a qualified health care professional in accordance with at http://www.cdc.gov/ Autism: Learn the Signs/ACT Early state practice acts. Facilities should follow state laws where ncbddd/autism/actearly/; such laws require RNs or LPNs under RN supervision to at Food Allergies: Guides for School, Childcare, and Camp perform certain medical procedures. Updated, written http://www.foodallergy.org/section/guidelines1/; medical orders are required for nursing procedures. Diabetes: “Diabetes Care in the School and Day Care RATIONALE Setting” at http://care.diabetesjournals.org/content/29/ The specialized skills required to implement these proce - suppl_1/s49.full; - dures are not traditionally taught to early childhood care at ht t p:// Seizures: Seizure Disorders in the ECE Setting givers/teachers, or educational assistants as part of their www.ucsfchildcarehealth.org/pdfs/healthandsafety/ academic or practical experience. Skilled nursing care SeizuresEN032707_adr.pdf. may be necessary in some circumstances. TYPE OF FACILITY COMMENTS Center, Large Family Child Care Home Parents/guardians are responsible for supplying the required equipment. The facility should offer staff training RELATED STANDARDS and allow sufficient staff time to carry out the necessary Medication Administration 3.6.3.1 procedures. Caring for children who require intermittent Care for Children with Food Allergies 4 . 2 . 0.10 catheterization or maintaining supplemental oxygen is not Contents of Child’s Primary Care Provider’s 9.4.2.4 as demanding as it first sounds, but the implication of this Assessment standard is that facilities serving children who have Appendix P: Situations that Require Medical Attention complex medical problems need special training, R ig ht Away consultation, and monitoring. References Before enrolling a child who will need this type of care, 1. McPherson, M., P. Arango, H. Fox, C. Lauver, M. McManus, P. Newacheck, caregivers/teachers can request and review fact sheets, J. Perrin, J. Shonkoff, B. Strickland. 1998. A new definition of children with instructions, and training by an appropriate health care special health care needs. Pediatrics 102:137-40. 2. U.S. Department of Health and Human Services, Health Resources and professional that includes a return demonstration of com- Services Administration. The national survey of children with special petence of the caregivers/teachers for handling specific pro- health care needs: Chartbook 2005-2006. http://mchb.hrsa.gov/cshcn05/. cedures. Often, the child’s parents/guardians or clinicians 3. American Association of Nurse Anesthetists. 2003. Creating a latex-safe school for latex-sensitive children. http://www .anesthesiapatientsafety. have these materials and know where training is available. com/patients/latex/school.asp. If possible, parents/guardians should be present and take Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in 4. part in the training. The primary care provider is respon- child care and schools: A quick reference guide. Elk Grove Village, IL: American Academy of Pediatrics. sible for providing the health care plan for the child; the plan can be communicated to the caregiver/teacher by the parent/guardian with the help of the child care health con- 3.5.0.2 sultant who can then assist in training the staff. When the Caring for Children Who Require specifics are known, caregivers/teachers can make a more Medical Procedures responsible decision about what would be required to serve A facility that enrolls children who require the following the child. A caregiver/teacher should not assume care for a - medical procedures: tube feedings, endotracheal suction child with special medical needs unless comfortable with - ing, supplemental oxygen, postural drainage, or catheter training received and approved for that role by the child ization daily (unless the child requiring catheterization can care health consultant or consulting primary care provider. perform this function on his/her own), checking blood Communication between parents/guardians, the child sugars or any other special medical procedures performed care program and the primary care provider (medical routinely, or who might require special procedures on an home) requires the free exchange of protected medical urgent basis, should receive a written plan of care from the

168 141 Chapter 3: Health Promotion and Protection information (1). Confidentiality should be maintained at should objectively determine if the child is ill or well. Staff should determine which children with mild illnesses can each step in compliance with any laws or regulations that remain in care and which need to be excluded. are pertinent to all parties such as the Family Educational Rights and Privacy Act (commonly known as FERPA) and/ Staff should notify the parent/guardian when a child develops or the Health Insurance Portability and Accountability Act new signs or symptoms of illness. Parent/guardian notifica - (commonly known as HIPAA) (1). tion should be immediate for emergency or urgent issues. TYPE OF FACILITY Staff should notify parents/guardians of children who have Center, Large Family Child Care Home symptoms that require exclusion and parents/guardians should remove the child from the child care setting as RELATED STANDARDS soon as possible. 1. 4 . 3.1 First Aid and CPR Training for Staff For children whose symptoms do not require exclusion, 1. 6 . 0.1 Child Care Health Consultants verbal or written notification of the parent/guardian at Care Plan for Children with Special Health 3. 5. 0.1 the end of the day is acceptable. Care Needs Most conditions that require exclusion do not require a Reference primary health care provider visit before reentering care. 1. 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: CONDITIONS/SYMPTOMS THAT DO NOT American Academy of Pediatrics. REQUIRE EXCLUSION a. Common colds, runny noses (regardless of color or 3.6 consistency of nasal discharge) A cough not associated with fever, rapid or difficult b. MANAGEMENT OF ILLNESS breathing, wheezing or cyanosis (blueness of skin or 3.6.1 mucous membra nes) INCLUSION/EXCLUSION DUE TO ILLNESS Pinkeye (bacterial conjunctivitis) indicated by pink or c. red conjunctiva with white or yellow eye mucous drainage 3 . 6 .1.1 and matted eyelids after sleep. This may be thought of as a cold in the eye. Exclusion is no longer required for this Inclusion/Exclusion/Dismissal of Children condition. Health professionals may vary on whether or (Adapted from: Aronson, S. S., T. R. Shope, eds. 2017. not to treat pinkeye with antibiotic drops. The role of anti- Managing infectious diseases in child care and schools: - biotics in treatment and preventing spread of conjuncti A quick reference guide, pp. 43-48. 4th Edition. Elk vitis is unclear. Most children with pinkeye get better Grove Village, IL: American Academy of Pediatrics.) after 5 or 6 days without antibiotics. Parents/guardians PREPARING FOR MANAGING ILLNESS should discuss care of this condition with their child’s Caregivers/teachers should: primary care provider, and follow the primary care pro- a. With a child care health consultant, develop protocols vider’s advice. Some primary care providers do not think - and procedures for handling children’s illnesses, includ it is necessary to examine the child if the discussion with ing care plans and an inclusion/exclusion policy. the parents/guardians sug- gests that the condition is b. Review with all families the inclusion/exclusion criteria. likely to be self-limited. If no treatment is provided, the Clarify that the program staff (not the families) will child should be allowed to remain in care. If the child’s make the final decision about whether children who eye is painful, a health care [provider should examine the are ill may attend. The decision will be based on the child. If 2 or more children in a group develop pinkeye in program’s inclusion/exclusion criteria and their ability the same period, the program should seek advice from to care for the child who is ill without compromising the program’s health consultant or a public health agency. the care of other children in the program. d. Watery, yellow or white discharge or crusting eye Encourage all families to have a backup plan for child c. discharge without fever, eye pain, or eyelid redness care in the event of short- or long-term exclusion. e. Yellow or white eye drainage that is not associated with d. Consider the family’s description of the child’s behavior pink or red conjunctiva (i.e., the whites of the eyes) to determine whether the child is well enough to return, Fever without any signs or symptoms of illness in chil- f. unless the child’s status is unclear from the family’s dren who are older than four months regardless of report. whether acetaminophen or ibuprofen was given. For e. A primary health care provider’s note may be required this purpose, fever is defined as temperature above to readmit a child to determine whether the child is a 101 degrees F (38.3 degrees C) by any method. These health risk to others, or if guidance is needed about any temperature readings do not require adjustment for special care the child requires. the location where they are made. They are simply reported with the temperature and the location, as Daily health checks as described in Standard 3.1.1.1 should in “101 degrees in the armpit/axilla”; be performed upon arrival of each child each day. Staff

169 142 Caring for Our Children: National Health and Safety Performance Standards Fever is an indication of the body’s response to something, KEY CRITERIA FOR EXCLUSION OF CHILDREN but is neither a disease nor a serious problem by itself. Body WHO ARE ILL temperature can be elevated by overheating caused by over - When a child becomes ill but does not require immediate dressing or a hot environment, reactions to medications, and medical help, a determination must be made regarding response to infection. If the child is behaving normally but whether the child should be sent home (i.e., should be has a fever, the child should be monitored, but does not need temporarily “excluded” from child care). Most illnesses to be excluded for fever alone. For example, an infant with do not require exclusion. The caregiver/teacher should a fever after an immunization who is behaving normally determine if the illness: does not require exclusion. Prevents the child from participating comfortably in a. Rash without fever and behavioral changes. Exception: g. activities; call EMS (911) for rapidly spreading bruising or small b. Results in a need for care that is greater than the staff blood spots under the skin. can provide without compromising the health and h. Impetigo lesions should be covered, but treatment may safety of other children; be delayed until the end of the day. As long as treatment c. Poses a risk of spread of harmful diseases to others. is started before return the next day, no exclusion is If any of the above criteria are met, the child should be needed; excluded, regardless of the type of illness. Decisions about i. Lice or nits treatment may be delayed until the end of the caring for the child while awaiting parent/guardian pick-up day. As long as treatment is started before returning the should be made on a case-by-case basis providing care that next day, no exclusion is needed; is comfortable for the child considering factors such as the Ringworm treatment may be delayed until the end of the j. child’s age, the surroundings, potential risk to others and the day. As long as treatment is started before returning the type and severity of symptoms the child is exhibiting. The next day, no exclusion is needed; child should be supervised by someone who knows the child Scabies treatment may be delayed until the end of the k. well and who will continue to observe the child for new or day. As long as treatment is started before returning the worsening symptoms. If symptoms allow the child to remain next day, no exclusion is needed; in their usual care setting while awaiting pick-up, the child l. Molluscum contagiosum (does not require covering should be separated from other children by at least 3 feet of lesions); until the child leaves to help minimize exposure of staff and Thrush (i.e., white spots or patches in the mouth or on m. children not previously in close contact with the child. All the cheeks or gums); who have been in contact with the ill child must wash their n. Fifth disease (slapped cheek disease, parvovirus B19) hands. Toys, equipment, and surfaces used bythe ill child once the rash has appeared; should be cleaned and disinfected after the child leaves. Staphylococcus aureus, o. or MRSA, Methicillin-resistant Temporary exclusion is recommended when the child has without an infection or illness that would otherwise any of the following conditions: require exclusion. Known MRSA carriers or colonized individuals should not be excluded; The illness prevents the child from participating a. p. Cytomegalovirus infection; comfortably in activities; Chronic hepatitis B infection; q. The illness results in a need for care that is greater than b. Human immunodeficiency virus (HIV) infection; r. the staff can provide without compromising the health Asymptomatic children who have been previously eval- s. and safety of other children; uated and found to be shedding potentially infectious A severely ill appearance - this could include lethargy/ c. organisms in the stool. Children who are continent of lack of responsiveness, irritability, persistent crying, stool or who are diapered with formed stools that can difficult breathing, or having a quickly spreading rash; be contained in the diaper may return to care. For some d. Fever (temperature above 101°F [38.3°C] by any method) infectious organisms, exclusion is required until certain with a behavior change in infants older than 2 months guidelines have been met. Note: These agents are not of age. For infants younger than 2 months of age, a fever common and caregivers/teachers will usually not (above 100.4°F [38°C] by any method) with or without a know the cause of most cases of diarrhea; behavior change or other signs and symptoms (e.g., sore t. Children with chronic infectious conditions that can throat, rash, vomiting, diarrhea) requires exclusion and be accommodated in the program according to the immediate medical attention; legal requirement of federal law in the Americans e. Diarrhea is defined by stools that are more frequent with Disabilities Act. The act requires that child care or less formed than usual for that child and not asso- programs make reasonable accommodations for cIated with changes in diet. Exclusion is required for all children with disabilities and/or chronic illnesses, diapered children whose stool is not contained in the dia- considering each child individually. per and toilet-trained children if the diarrhea is causing ”accidents”. In addition, diapered children with diarrhea should be excluded if the stool frequency exceeds two stools above normal for that child during the time in the program day, because this may cause too much work for

170 143 Chapter 3: Health Promotion and Protection the caregivers/teachers, or those whose stool contains Scabies, only if the child has not been treated after i. blood or mucus. Readmission after diarrhea can occur notifying the family at the end of the prior program when diapered children have their stool contained by the day. (note: exclusion is not necessary before the end of the program day); diaper (even if the stools remain loose) and when toilet- Chickenpox (varicella), until all lesions have dried or j. trained children are not having “accidents” and when crusted (usually six days after onset of rash and no stool frequency is no more than 2 stools above normal new lesions have appeared for at least 24 hours); for that child during the time in the program day; Rubella, until seven days after the rash appears; k. Special circumstances that require specific exclusion l. Pertussis, until five days of appropriate antibiotic criteria include the following (2): treatment; A health care provider must clear the child or staff mem- m. Mumps, until five days after onset of parotid gland ber for readmission for all cases of diarrhea with blood or swelling; mucus. Readmission can occur following the requirements n. Measles, until four days after onset of rash; of the local health department authorities, which may in- Hepatitis A virus infection, until one week after onset o. clude testing for a diarrhea outbreak in which the stool cul- of illness or jaundice if the child’s symptoms are mild ture result is positive for Shigella, Salmonella serotype Typhi or as directed by the health department. (Note: Protec- and Paratyphi, or Shiga toxin–producing E coli. Children tion of the others in the group should be checked to be and staff members with Shigella should be excluded until sure everyone who was exposed has received the vaccine diarrhea resolves and test results from at least 1 stool culture or receives the vaccine immediately.); are negative (rules vary by state). Children and staff mem- p. Any child determined by the local health department bers with Shiga toxin–producing E coli (STEC) should be to be contributing to the transmission of illness during excluded until test results from 2 stool cultures are negative an outbreak. at least 48 hours after antibiotic treat- ment is complete (if PROCEDURES FOR A CHILD WHO REQUIRES EXCLUSION prescribed). Children and staff members with Salmonella The caregiver/teacher will: serotype Typhi and Paratyphi are excluded until test results from 3 stool cultures are negative. Stool should be collected Make decisions about caring for the child while await a. - at least 48 hours after antibiotics have stopped. State laws ing parent/guardian pick-up on a case-by-case basis may govern exclusion for these conditions and should be providing care that is comfortable for the child consid - followed by the health care provider who is clearing the ering factors such as the child’s age, the surroundings, child or staff member for readmission. potential risk to others and the type and severity of symptoms the child is exhibiting. The child should be a. Vomiting more than two times in the previous twenty- supervised by someone who knows the child well and four hours, unless the vomiting is determined to be - who will continue to observe the child for new or wors caused by a non-infectious condition and the child ening symptoms. If symptoms allow the child to remain remains adequately hydrated; in their usual care setting while awaiting pick-up, the b. Abdominal pain that continues for more than two hours child should be separated from other children by at least or intermittent pain associated with fever or other signs 3 feet until the child leaves to help minimize exposure of or symptoms of illness; staff and children not previously in close contact with c. Mouth sores with drooling that the child cannot the child. All who have been in contact with the ill child control unless the child’s primary care provider or local must wash their hands. Toys, equipment, and surfaces health department authority states that the child is used by the ill child should be cleaned and disinfected noninfectious; after the child leaves; Rash with fever or behavioral changes, until the primary d. Discuss the signs and symptoms of illness with the b. care provider has determined that the illness is not an - parent/guardian who is assuming care. Review guide infectious disease; lines for return to child care. If necessary, provide the Active tuberculosis, until the child’s primary care e. family with a written communication that may be given provider or local health department states child is on to the primary care provider. The communication appropriate treatment and can return; should include onset time of symptoms, observations - f. Impetigo, only if child has not been treated after notify about the child, vital signs and times (e.g., temperature ing family at the end of the prior program day. Exclusion 101.5°F at 10:30 AM) and any actions taken and the time is not necessary before the end of the day as long as the actions were taken (e.g., one children’s acetaminophen lesions can be covered; given at 11:00 AM). The nature and severity of symp - Streptococcal pharyngitis (i.e., strep throat or other g. toms and or requirements of the local or state health streptococcal infection), until the child has two doses department will determine the necessity of medical of antibiotic (one may be taken the day of exclusion consultation. Telephone advice, electronic transmissions and the second just before returning the next day); of instructions are acceptable without an office visit; Head lice, only if the child has not been treated after h. c. If the child has been seen by their primary health notifying the family at the end of the prior program provider, follow the advice of the provider for return to day. (note: exclusion is not necessary before the end of child care; the program day);

171 144 Caring for Our Children: National Health and Safety Performance Standards d. If the child seems well to the family and no longer meets unlikely to reduce the spread of most infectious agents (germs) caused by bacteria, viruses, parasites and fungi. criteria for exclusion, there is no need to ask for further Exposure to frequent mild infections helps the child’s information from the health professional when the child immune system develop in a healthy way. As a child gets returns to care. Children who had been excluded from older s/he develops immunity to common infectious agents care do not necessarily need to have an in-person visit and will become ill less often. Since exclusion is unlikely to with a health care provider; - reduce the spread of disease, the most important reason e. Contact the local health department if there is a ques for exclusion is the ability of the child to participate in tion of a reportable (harmful) infectious disease in a child or staff member in the facility. If there are con- activities and the staff to care for the child. flicting opinions from different primary care providers The terms contagious, infectious and communicable have about the management of a child with a reportable similar meanings. A fully immunized child with a conta - infectious disease, the health department has the gious, infectious or communicable condition will likely legal authority to make a final determination; not have an illness that is harmful to the child or others. Document actions in the child’s file with date, time, f. Children attending child care frequently carry contagious symptoms, and actions taken (and by whom); sign organisms that do not limit their activity nor pose a threat and date the document; to their contacts. Hand and personal hygiene is paramount In collaboration with the local health department, g. in preventing transmission of these organisms. Written notify the parents/guardians of contacts to the child or notes should not be required for return to child care for staff member with presumed or confirmed reportable common respiratory illnesses that are not specifically infectious infection. listed in the excludable condition list above. The caregiver/teacher should make the decision about For specific conditions, Managing Infectious Diseases whether a child meets or does not meet the exclusion crite - in Child Care and Schools: A Quick Reference Guide, ria for participation and the child’s need for care relative to 4th Edition has educational handouts that can be copied the staff ’s ability to provide care. If parents/guardians and and distributed to parents/guardians, health professionals, the child care staff disagree, and the reason for exclusion and caregivers/teachers. This publication is available from relates to the child’s ability to participate or the caregiver’s/ the American Academy of Pediatrics (AAP) at http://www. teacher’s ability to provide care for the other children, the aap.org. For more detailed rationale regarding inclusion/ - caregiver/teacher should not be required to accept responsi exclusion, return to care, when a health visit is necessary, bility for the care of the child. and health department reporting for children with REPORTABLE CONDITIONS specific symptoms, please see Appendix A: Signs and - The current list of infectious diseases designated as notifi Symptoms Chart. able in the United States at the national level by the Centers State licensing law or code defines the conditions or for Disease Control and Prevention (CDC) are listed at symptoms for which exclusion is necessary. States are https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/ increasingly using the criteria defined in Caring for Our infectious-diseases/. Managing Infectious Diseases in Child Children and the The caregiver/teacher should contact the local health Care and Schools publications. Usually, the criteria in these department: two sources are more detailed than the state regulations so can be incorporated into the local written policies without When a child or staff member who is in contact with a. conflicting with state law. others has a reportable disease; b. If a reportable illness occurs among the staff, children, COMMENTS or families involved with the program; When taking a child’s temperature, remember that: c. For assistance in managing a suspected outbreak. a. The amount of temperature elevation varies at different Generally, an outbreak can be considered to be two or body sites; more unrelated (e.g., not siblings) children with the The height of fever does not indicate a more or less b. same diagnosis or symptoms in the same group within severe illness. The child’s activity level and sense of - one week. Clusters of mild respiratory illness, ear infec well-being are far more important that the temperature tions, and certain dermatological conditions are reading; common and generally do not need to be reported. c. - If a child has been in a very hot environment and heat Caregivers/teachers should work with their child care stroke is suspected, a higher temperature is more health consultants to develop policies and procedures for serious; alerting staff and families about their responsibility to The method chosen to take a child’s temperature d. report illnesses to the program and for the program to depends on the need for accuracy, available equipment, report diseases to the local health authorities. the skill of the person taking the temperature, and the RATIONALE ability of the child to assist in the procedure; Most infections are spread by children who do not have e. Oral temperatures are difficult to take for children symptoms. Excluding children with mild illnesses is younger than four years of age;

172 145 Chapter 3: Health Promotion and Protection Rectal temperatures should be taken only by persons f. Chickenpox, until all lesions have dried and crusted, b. with specific health training in performing this pro- which usually occurs by six days; cedure and permission given by parents/guardians, Shingles, only if the lesions cannot be covered by c. however this method is not generally practiced due clothing or a dressing until the lesions have crusted; to concerns about proper procedure and risk of Rash with fever or joint pain, until diagnosed not to d. accusations of sexual abuse; be measles or rubella; g. Axillary (armpit) temperatures are accurate only when Measles, until four days after onset of the rash (if the e. the thermometer remains within the closed armpit for staff member or substitute has the capacity to develop the time period recommended by the device; an immune response following exposure); h. Any device used improperly may give inaccurate f. Rubella, until six days after onset of rash; results; and g. Diarrheal illness, stool frequency exceeds two or more i. Only digital thermometers, not mercury thermometers, stools above normal for that individual or blood in should be used. stools, until diarrhea resolves, or until a primary care provider determines that the diarrhea is not caused by a TYPE OF FACILITY germ that can be spread to others in the facility; For all Center, Large Family Child Care Home cases of bloody diarrhea and diarrhea caused by Shiga RELATED STANDARDS toxin–producing Escherichia coli (STEC), Shigella, or Salmonella serotype Typhi I, exclusion must continue Conduct of Daily Health Check 3.1.1.1 until the person is cleared to return by the primary Staff Exclusion for Illness 3. 6 .1. 2 health care provider. Exclusion is warranted for STEC, Thermometers for Taking Human 3. 6 .1. 3 until results of 2 stool cultures are negative (at least Temperatures 48 hours after antibiotic treatment is complete (if pre- 3. 6 .1. 4 Infectious Disease Outbreak Control scribed)); for Shigella species, until at least 1 stool Signs and Symptoms Chart Appendix A: culture is negative (varies by state); and for Salmonella Appendix J: Selecting an Appropriate Sanitizer or serotype Typhi, until 3 stool cultures are negative. Stool Disinfectant - samples need to be collected at least 48 hours after anti biotic treatment is complete. Other types of Salmonella Appendix K: Routine Schedule for Cleaning, Sanitizing, do not require negative test results from stool cultures. and Disinfecting Vomiting illness, two or more episodes of vomiting References during the previous twenty-four hours, until vomit- 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child ing resolves or is determined to result from non- care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics. infectious conditions; 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. h. Hepatitis A virus, until one week after symptom onset Recommendations for care of children in special circumstances. In: Red or as directed by the health department; Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. i. Pertussis, until after five days of appropriate antibiotic therapy or until 21 days after the onset of cough if the NOTES person is not treated with antibiotics; Content in the STANDARD was modified on 04/16/2015, j. Skin infection (such as impetigo), until treatment has on 8/2015, and on 4/4/2017. been initiated; exclusion should continue if lesion is draining AND cannot be covered; 3 . 6 .1. 2 k. Tuberculosis, until noninfectious and cleared by a Staff Exclusion for Illness health department official or a primary care provider; Please note that if a staff member has no contact with the Strep throat or other streptococcal infection, until l. children, or with anything with which the children has twenty-four hours after initial antibiotic treatment come into contact, this standard does not apply to that and end of fever; staff member. Head lice, from the end of the day of discovery until m. after the first treatment; A facility should not deny admission to or send home a Scabies, until after treatment has been completed; n. staff member or substitute with illness unless one or more o. type b (Hib), prophylaxis, Haemophilus influenzae of the following conditions exists: until cleared by the primary health care provider; Influenza, until fever free for 24 hours. (Health care pro- a. p. Meningococcal infection, until cleared by the primary viders can use a test to determine whether an ill person health care provider; has influenza rather than other symptoms. However, it q. Other respiratory illness, if the illness limits the staff is not practical to test all ill staff members to determine member’s ability to provide an acceptable level of child whether they have common cold viruses or influenza care and compromises the health and safety of the chil - infection. Therefore, exclusion decisions are based on dren. This includes a respiratory illness in which the the symptoms of the staff member); staff member is unable to consistently manage respira - tory secretions using proper cough and sneeze etiquette.

173 146 Caring for Our Children: National Health and Safety Performance Standards Caregivers/teachers who have herpes cold sores should not over age four. Individual plastic covers should be used on be excluded from the child care facility, but should: oral or rectal thermometers with each use or thermometers should be cleaned and sanitized after each use according to 1. Cover and not touch their lesions; the manufacturer’s instructions. Axillary (under the arm) 2. Carefully observe hand hygiene policies; and temperatures are less accurate, but are a good option for 3. infants and young children when the caregiver/teacher Not kiss any children. has not been trained to take a rectal temperature. RATIONALE RATIONALE Most infections are spread by children who do not When using tympanic thermometers, too much earwax can have symptoms. cause the reading to be incorrect. Tympanic thermometers The terms contagious, infectious and communicable have may fail to detect a fever that is actually present (1). There- - similar meanings. A fully immunized child with a conta fore, tympanic thermometers should not be used in chil - gious, infectious or communicable condition will likely dren under four months of age, where fever detection is not have an illness that is harmful to the child or others. most important. Children attending child care frequently carry contagious Mercury thermometers can break and result in mercury organisms that do not limit their activity nor pose a threat toxicity that can lead to neurologic injury. To prevent mer- to their contacts. cury toxicity, the American Academy of Pediatrics (AAP) Adults are as capable of spreading infectious disease as encourages the removal of mercury thermometers from children (1,2). Hand and personal hygiene is paramount homes. This includes all child care settings as well (1). in preventing transmission of these organisms. Although not a hazard, temporal thermometers are not as TYPE OF FACILITY accurate as digital thermometers (2). Center, Large Family Child Care Home COMMENTS RELATED STANDARDS The site where a child’s temperature is taken (rectal, oral, Situations that Require Hand Hygiene 3.2.2.1 axillary, or tympanic) should be documented along with 3.2.2.2 Handwashing Procedure the temperature reading and the time the temperature was taken, because different sites give different results Cough and Sneeze Etiquette 3.2.3.2 and affect interpretation of temperature. Inclusion/Exclusion/Dismissal of Children 3. 6 .1.1 More information about taking temperatures can be found Infectious Disease Outbreak Control 3. 6 .1. 4 on the AAP Website http://www.healthychildren.org/ References English/health-issues/conditions/fever/pages/ 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, How-to-Take-a -Childs-Temperature.aspx. IL: American Academy of Pediatrics. Safety and child abuse concerns may arise when using 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Recommendations for care of children in special circumstances. In: Red rectal thermometers. Caregivers/teachers should be aware Book: 2015 Report of the Committee on Infectious Diseases. 30th Ed. Elk of these concerns. If rectal temperatures are taken, steps Grove Village, IL: American Academy of Pediatrics. must be taken to ensure that all caregivers/teachers are NOTES trained properly in this procedure and the opportunity Content in the STANDARD was modified on 4/5/2017. for abuse is negligible (for example, ensure that more than one adult present during procedure). Rectal temperatures - should be taken only by persons with specific health train 3 . 6 .1. 3 ing in performing this procedure and permission given by Thermometers for Taking Human parents/guardians. Temperatures Many state or local agencies operate facilities that collect Digital thermometers should be used with infants and used mercury thermometers. Typically, the service is free. young children when there is a concern for fever. Tympanic For more information on household hazardous waste (ear) thermometers may be used with children four months collections in your area, call your State environmental and older. However, while a tympanic thermometer gives protection agency or your local health department. quick results, it needs to be placed correctly in the child’s ear to be accurate. TYPE OF FACILITY Glass or mercury thermometers should not be used. Mer- Center, Large Family Child Care Home cury containing thermometers and any waste created from References the cleanup of a broken thermometer should be disposed 1. Healthy Children. 2010. Health issues: How to take a child’s temperature. American Academy of Pediatrics. http://www.healthychildren.org/English/ of at a household hazardous waste collection facility. health-issues/conditions/fever/pages/How-to-Take-a-Childs-Temperature. Rectal temperatures should be taken only by persons with aspx. 2. Dodd, S. R., G. A. Lancaster, J. V. Craig, R. L. Smyth, P. R. Williamson. specific health training in performing this procedure. Oral 2006. In a systematic review, infrared ear thermometry for fever diagnosis (under the tongue) temperatures can be used for children in children finds poor sensitivity. J Clin Epidemiol 59:354-57.

174 147 Chapter 3: Health Promotion and Protection TYPE OF FACILITY 3 . 6 .1. 4 Center, Large Family Child Care Home Infectious Disease Outbreak Control - During the course of an identified outbreak of any report RELATED STANDARD able illness at the facility, a child or staff member should 5.5.0.1 Storage and Labeling of Personal Articles 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 3.6.2 not adequately immunized when there is an outbreak of CARING FOR CHILDREN WHO ARE ILL a vaccine preventable disease, or the circulating pathogen poses an increased risk to the individual. The child or staff 3 . 6 . 2 .1 member should be readmitted when the health department Exclusion and Alternative Care for official or primary care provider who made the initial Children Who Are Ill determination decides that the risk of transmission is At the discretion of the person authorized by the child care no longer present. provider to make such decisions, children who are ill should RATIONALE be excluded from the child care facility for the conditions Secondary spread of infectious disease has been proven defined in Standard 3.6.1.1. When children are not permitted to occur in child care. Control of outbreaks of infectious to receive care in their usual child care setting and cannot diseases in child care may include age-appropriate immuni - receive care from a parent/guardian or relative, they should zation, antibiotic prophylaxis, observing well children for - be permitted to receive care in one of the following arrange signs and symptoms of disease and for decreasing oppor- ments, if the arrangement meets the applicable standards: tunities for transmission of that may sustain an outbreak. Care in the child’s usual facility in a special area for a. Removal of children known or suspected of contributing care of children who are ill; to an outbreak may help to limit transmission of the Care in a separate small family child care home or b. disease by preventing the development of new cases center that serves only children with illness or of the disease (1). temporary disabilities; TYPE OF FACILITY c. Care by a child care provider in the child’s own home. Center, Large Family Child Care Home RATIONALE RELATED STANDARDS Young children who are developing trust, autonomy, and 3. 6 .1.1 Inclusion/Exclusion/Dismissal of Children initiative require the support of familiar caregivers and Staff Exclusion for Illness 3. 6 .1. 2 environments during times of illness to recover physically and avoid emotional distress (1). Young children enrolled Procedure for Parent/Guardian Notification About 3. 6 . 4 .1 in group care experience a higher incidence of mild illness Exposure of Children to Infectious Disease (such as upper respiratory infections or otitis media) and 3.6.4.2 Infectious Diseases That Require Parent/Guardian other temporary disabilities (such as exacerbation of asthma) Notification than those who have less interaction with other children. 9.2.4.4 Written Plan for Seasonal and Pandemic Influenza Sometimes, these illnesses preclude their participation in References the usual child care activities. To accommodate situations 1. Siegel, J. D., E. Rhinehart, M. Jackson, L. Chiarello, Healthcare Infection where parents/guardians cannot provide care for their Control Practices Advisory Committee. 2007. 2007 guideline for isolation own children who are ill, several types of alternative care precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. arrangements have been established. The majority of viruses are spread by children who are asymptomatic, therefore, exposure of children to others with active symptoms or 3 . 6 .1. 5 who have recently recovered, does not significantly raise Sharing of Personal Articles Prohibited the risk of transmission over the baseline (2). Combs, hairbrushes, toothbrushes, personal clothing, bedding, and towels should not be shared and should be TYPE OF FACILITY labeled with the name of the child who uses these objects. Center, Large Family Child Care Home RATIONALE RELATED STANDARDS Respiratory and gastrointestinal infections are common 3. 6 .1.1 Inclusion/Exclusion/Dismissal of Children - infectious diseases in child care. These diseases are trans 3.6.2.2 Space Requirements for Care of Children Who mitted by direct person-to-person contact or by sharing Are Ill personal articles such as combs, brushes, towels, clothing, 3.6.2.3 Qualifications of Directors of Facilities That Care and bedding. Prohibiting the sharing of personal articles for Children Who Are Ill and providing space so that personal items may be stored 3.6.2.4 Program Requirements for Facilities That Care for separately helps prevent these diseases from spreading. Children Who Are Ill

175 148 Caring for Our Children: National Health and Safety Performance Standards available at the handwashing sink at all times. A hand Caregiver/Teacher Qualifications for Facilities That 3.6.2.5 sanitizing dispenser is an alternative to traditional Care for Children Who Are Ill handwashing (3,4); 3.6.2.6 Child-Staff Ratios for Facilities That Care for ach room/home that is designated for the care of chil - f. Children Who Are Ill dren who are ill and are wearing diapers should have its Child Care Health Consultants for Facilities That 3.6.2.7 own diaper changing area adjacent to a handwashing Care for Children Who Are Ill sink and/or hand sanitizer dispenser. Licensing of Facilities That Care for Children 3.6.2.8 RATIONALE Who Are Ill Transmission of infectious diseases in early care and 3.6.2.9 Information Required for Children Who Are Ill education settings are influenced by the environmental 3. 6 . 2 .10 Inclusion and Exclusion of Children from sanitation and physical space of the facilities (5). Facilities That Serve Children Who Are Ill Handwashing sinks should be stationed in each room that References is designated for the care of ill children to promote hand 1. Crowley, A. 1994. Sick child care: A developmental perspective. J Pediatric Health Care. 8:261-67. hygiene and to give the caregivers/teachers an opportunity 2. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child for continuous supervision of the other children in care care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove when washing their hands. The sink must deliver a consis - Village, IL: American Academy of Pediatrics. tent flow of water for twenty seconds so that the user does not need to touch the faucet handles. Diaper changing 3.6.2.2 areas should be adjacent to sinks to foster cleanliness Space Requirements for Care of Children and to enable caregivers/teachers to provide continuous Who Are Ill supervision of other children in care. Environmental space utilized for the care of children who TYPE OF FACILITY are ill with infectious diseases and cannot receive care in Center, Large Family Child Care Home their usual child care group should meet all requirements RELATED STANDARDS for well children and include the following additional requirements: Situations that Require Hand Hygiene 3.2.2.1 Handwashing Procedure 3.2.2.2 Indoor space that the facility uses for children who are a. ill, including classrooms, hallways, bathrooms, and kit- Hand Sanitizers 3.2.2.5 chens, should be separate from indoor space used with Inclusion/Exclusion/Dismissal of Children 3. 6 .1.1 well children. This reduces the likelihood of mixing 5. 4 .1.10 Handwashing Sinks supplies, toys, and equipment. The facility may use a References single kitchen for ill and well children if the kitchen is 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child staffed by a cook who has no child care responsibilities care and schools: A quick reference guide, 4th Edition. Elk Grove Village, other than food preparation and who does not handle IL: American Academy of Pediatrics. 2. Centers for Disease Control and Prevention. 2015. Handwashing: Clean soiled dishes and utensils until after food preparation hands save lives. http://www.cdc.gov/handwashing/. and food service are completed for any meal; 3. U.S. Department of Health and Human Services, Centers for Disease If the program for children who are ill is in the same b. Control and Prevention. 2016. Show me the science-When and how to use hand sanitizer. http://www.cdc.gov/handwashing/show-me-the-science- facility as the well-child program, well children should hand-sanitizer.html. not use or share furniture, fixtures, equipment, or sup- 4. Santos, C., Kieszak, S., Wang, A., Law, R., Schier, J., Wolkin, A.. Reported plies designated for use with children who are ill unless adverse health effects in children from ingestion of alcohol-based hand sanitizers — United States, 2011–2014. MMWR Morb Mortal Wkly Rep they have been cleaned and sanitized before use by 2017;66:223–226. DOI: http://dx.doi.org/10.15585/mmwr.mm6608a5 well children; 5. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Children c. Children whose symptoms indicate infections of the in out-of-home child care. In: Red book: 2015 report of the committee on infectious diseases. 30th Ed. Elk Grove Village, IL: American Academy of gastrointestinal tract (often with diarrhea) should Pediatrics. receive their care in a space separate from other chil- NOTES - dren with other illnesses. Limiting child-to-child inter action, separating staff responsibilities, and not mixing Content in the STANDARD was modified on 8/9/2017. supplies, toys, and equipment reduces the likelihood of disease being transmitted between children 3.6.2.3 Children with chickenpox, pertussis, measles, mumps, d. Qualifications of Directors of Facilities rubella, or diphtheria, require a room with separate That Care for Children Who Are Ill ventilation including fresh outdoor air (1); The director of a facility that cares for children who are Each room/home that is designated for the care of chil- e. ill should have the following minimum qualifications, in dren who are ill should have a handwashing sink that addition to the general qualifications described in Director’s can provide a steady stream of clean, running water that Qualifications, Standards 1.3.1.1 and 1.3.1.2: is at a comfortable temperature at least for twenty seconds (2). Soap and disposable paper towels should be

176 149 Chapter 3: Health Promotion and Protection a. At least forty hours of training in prevention and regular child care arrangement, when the child care facility has the resources to adapt to the needs of such children. control of infectious diseases and care of children who are ill, including subjects listed in Standard 3.6.2.5; TYPE OF FACILITY b. At least two prior years of satisfactory performance as Center, Large Family Child Care Home a director of a regular facility; RELATED STANDARDS c. At least twelve credit hours of college-level training in child development or early childhood education. 3.6.2.2 Space Requirements for Care of Children Who Are Ill RATIONALE Procedure for Parent/Guardian Notification About 3. 6 . 4 .1 The director should be college-prepared in early childhood Exposure of Children to Infectious Disease education and have taken college-level courses in illness 3.6.4.2 Infectious Diseases That Require Parent/Guardian prevention and control, since the director is the person Notification responsible for establishing the facility’s policies and procedures and for meeting the training needs of new Notification of the Facility About Infectious 3.6.4.3 staff members (1). Disease or Other Problems by Parents/Guardians 3.6.4.4 List of Excludable and Reportable Conditions for TYPE OF FACILITY Parents/Guardians Center Death 3.6.4.5 RELATED STANDARDS State and Local Health Department Role 10.5.0.1 General Qualifications of Directors 1. 3.1.1 Mixed Director/Teacher Role 1. 3.1. 2 3.6.2.5 Caregiver/Teacher Qualifications for Facilities 3.6.2.5 Caregiver/Teacher Qualifications for Facilities That Care for Children Who Are Ill That Care for Children Who Are Ill Reference Each caregiver/teacher in a facility that cares for children 1. Fiene, R. 2002. 13 indicators of quality child care: Research update. who are ill should have at least two years of successful work Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http:// experience as a caregiver/teacher in a regular well-child aspe.hhs.gov/basic-report/13-indicators-quality-child-care. - facility prior to employment in the special facility. In addi tion, facilities should document, for each caregiver/teacher, 3.6.2.4 twenty hours of pre-service orientation training on care of children who are ill beyond the orientation training speci - Program Requirements for Facilities fied in Standards 1.4.2.1 through Standard 1.4.2.3. This That Care for Children Who Are Ill training should include the following subjects: Any facility that offers care for the child who is ill of any age should: a. Pediatric first aid and CPR, and first aid for choking; General infection-control procedures, including: b. a. Provide a caregiver/teacher who is familiar to the child; 1. Hand hygiene; b. Provide care in a place with which the child is familiar 2. Handling of contaminated items; and comfortable away from other children in care; 3. Use of sanitizing chemicals; Involve a caregiver/teacher who has time to give c. Food handling; 4. individual care and emotional support, who knows of 5. Washing and sanitizing of toys; the child’s interests, and who knows of activities that Education about methods of disease transmission. 6. appeal to the level of child development age group c. Care of children with common mild childhood and to a sick child; illnesses, including: d. Offer a program with trained personnel planned in 1. Recognition and documentation of signs and symp - consultation with qualified health care personnel and toms of illness including body temperature; with ongoing medical direction. 2. Administration and recording of medications; RATIONALE 3. Nutrition of children who are ill; When children are ill, they are stressed by the illness itself. 4. Communication with parents/guardians of children Unfamiliar places and caregivers/teachers add to the stress Knowledge of immunization who are ill; child is sick. Since illness tends to promote of illness when a requirements; regression and dependency, children who are ill need a 5. Recognition of need for medical assistance and how person who knows and can respond to the child’s cues to access; appropriately. Knowledge of reporting requirements for infectious 6. diseases; COMMENTS 7. Emergency procedures. Because children are most comfortable in a familiar place d. Child development activities for children who are ill; - with familiar people, the preferred arrangement for chil e. Orientation to the facility and its policies. dren who are ill will be the child’s home or the child’s

177 150 Caring for Our Children: National Health and Safety Performance Standards This training should be documented in the staff personnel - and recognition of children’s temporary emotional regres files, and compliance with the content of training routinely sion during times of illness (1-3); the lowest ratios used per evaluated. Based on these evaluations, the training on care age group seem appropriate. of children who are ill should be updated with a minimum COMMENTS of six hours of annual training for individuals who con- These ratios do not include other personnel, such as bus tinue to provide care to children who are ill. drivers, necessary for specialized functions such as RATIONALE transportation. Because meeting the physical and psychological needs TYPE OF FACILITY of children who are ill requires a higher level of skill and Center, Large Family Child Care Home understanding than caring for well children, a commitment References to children and an understanding of their general needs is 1. Davies, D. 1999. Child development: A practitioner’s guide. New York: essential (1). Work experience in child care facilities will The Guilford Press. help the caregiver/teacher develop these skills. States that 2. Schumacher, R. 2008. Charting progress for babies in child care: CLASP center ratios and group sizes – Research based rationale. http://www.clasp. have developed rules regulating facilities have recognized org/admin/site/babies/make_the_case/files/cp_rationale6.pdf. the need for training in illness prevention and control and 3. Crowley, A. A. 1994. Sick child care: A developmental perspective. management of medical emergencies. Staff members caring J Pediatric Health Care 8:261-67. for children who are ill in special facilities or in a get well room in a regular center should meet the staff qualifications 3.6.2.7 that are applied to child care facilities generally. Child Care Health Consultants for Facilities Caregivers/teachers have to be prepared for handling illness That Care for Children Who Are Ill and must understand their scope of work. Special training Each special facility that provides care for children who are is required of caregivers/teachers who work in special facili - ill should use the services of a child care health consultant ties for children who are ill because the director and the - for ongoing consultation on overall operation and develop caregivers/teachers are dealing with infectious diseases and ment of written policies relating to health care. The child need to know how to prevent the spread of infection. Each care health consultant should have the knowledge, skills caregiver/teacher should have training to decrease the risk and preparation as stated in Standard 1.6.0.1. of transmitting disease (1). The facility should involve the child care health consultant TYPE OF FACILITY in development and/or implementation, review, and sign- Center, Large Family Child Care Home off of the written policies and procedures for managing specific illnesses. The facility staff and the child care RELATED STANDARDS health consultant should review and update the written 1. 4 . 2 .1 Initial Orientation of All Staff pol icies a n nua l ly. 1.4.2.2 Orientation for Care of Children with The facility should assign the child care health consultant Special Health Care Needs - the responsibility for reviewing written policies and proce Orientation Topics 1.4. 2. 3 dures for the following: 10.5.0.1 State and Local Health Department Role Admission and readmission after illness, including a. Reference inclusion/exclusion criteria; 1. Heymann, S. J., P. Hong Vo, C. A. Bergstrom. 2002. Child care providers’ experiences caring for sick children: Implications for public policy. Early Health evaluation procedures on intake, including phy- b. Child Devel Care 172:1-8. sical assessment of the child and other criteria used to determine the appropriateness of a child’s attendance; 3.6.2.6 Plans for health care and for managing children with c. infectious diseases; Child-Staff Ratios for Facilities That d. Plans for surveillance of illnesses that are admissible and Care for Children Who Are Ill problems that arise in the care of children with illness; Each facility for children who are ill should maintain a e. Plans for staff training and communication with child-to-staff ratio no greater than the following: parents/guardians and primary care providers; Child to Staff Ratio Age of Children Plans for injury prevention; f. Situations that require medical care within an hour. g. 3 children to 1 staff member 3-35 months RATIONALE 36-71 months 4 children to 1 staff member Appropriate involvement of child care health consultants is 72 months and older 6 children to 1 staff member especially important for facilities that care for children who RATIONALE are ill. Facilities should use the expertise of primary care Some states stipulate the ratios for caring for children who providers to design and provide a child care environment are ill in their regulations. The expert consensus is based on with sufficient staff and facilities to meet the needs of chil - theories of child development including attachment theory dren who are ill (2,3). The best interests of the child and

178 151 Chapter 3: Health Promotion and Protection family must be given primary consideration in the care of capacity for facilities that care for children who are ill, the - child care health consultant with the local health authority children who are ill. Consultation by primary care provid should review these plans and procedures annually in an ers, especially those whose specialty is pediatrics, is critical advisory capacity. in planning facilities for the care of children who are ill (1). RATIONALE RATIONALE Appropriate involvement of child care health consultants is Facilities for children who are ill generally are required to especially important for facilities that care for children who meet the licensing requirements that apply to all facilities of a specific type, for example, small or large family child care are ill. Facilities should use the expertise of primary care homes or centers. Additional requirements should apply providers to design and provide a child care environment when children who are ill will be in care. - with sufficient staff and facilities to meet the needs of chil dren who are ill (2,3). The best interests of the child and This standard ensures that child care facilities are family must be given primary consideration in the care of continually reviewed by an appropriate state authority and children who are ill. Consultation by primary care provid - that facilities maintain appropriate standards in caring ers, especially those whose specialty is pediatrics, is critical for children who are ill. in planning facilities for the care of children who are ill (1). COMMENTS COMMENTS If a child care health consultant is not available, than the Caregivers/teachers should seek the services of a child care local health authority should review plans and procedures health consultant through state and local professional a n nua l ly. organizations, such as: TYPE OF FACILITY a. Local chapters of the American Academy of Pediatrics Center, Large Family Child Care Home (A AP); RELATED STANDARDS b. Local Children’s hospital; c. American Nurses Association (ANA); Inclusion and Exclusion of Children from Facilities 3. 6 . 2 .10 d. Visiting Nurse Association (VNA); That Serve Children Who Are Ill American Academy of Family Physicians (AAFP); e. Regulation of All Out-of-Home Child Care 10.2.0.1 f. National Association of Pediatric Nurse Practitioners 10. 3.1.1 Operation Permits (NAPNAP); g. National Association for the Education of Young 3.6.2.9 Children (NAEYC); Information Required for Children Who National Association for Family Child Care (NAFCC); h. Are Ill i. National Association of School Nurses (NASN); For each day of care in a special facility that provides care j. Emergency Medical Services for Children (EMSC) for children who are ill, the caregiver/teacher should have National Resource Center; the following information on each child: k. State or local health department (especially public health nursing, infectious disease, and epidemiology The child’s specific diagnosis and the individual a. departments). providing the diagnosis (primary care provider, parent/guardian); TYPE OF FACILITY Current status of the illness, including potential for b. Center, Large Family Child Care Home contagion, diet, activity level, and duration of illness; RELATED STANDARD Health care, diet, allergies (particularly to foods or c. 1. 6 . 0.1 Child Care Health Consultants medication), and medication and treatment plan, including appropriate release forms to obtain References 1. Donowitz, L. G., ed. 1996. Infection control in the child care center and emergency health care and administer medication; preschool, 18-19, 68. 2nd ed. Baltimore, MD: Williams and Wilkins. d. Communication with the parent/guardian on the 2. Churchill, R. B., L. K. Pickering. 1997. Infection control challenges in child child’s progress; care centers. Infect Dis Clin North Am 11:347-65. 3. Crowley A. A. 2000. Child care health consultation: The Connecticut Name, address, and telephone number of the child’s e. experience. Matern Child Health J 4:67-75. source of primary health care; Communication with the child’s primary care provider. f. 3.6.2.8 Communication between parents/guardians, the child care Licensing of Facilities That Care for program and the primary care provider (medical home) Children Who Are Ill requires the free exchange of protected medical informa - A facility may care for children with symptoms requiring tion (2). Confidentiality should be maintained at each step exclusion provided that the licensing authority has given in compliance with any laws or regulations that are perti - approval of the facility, written plans describing symptoms nent to all parties such as the Family Educational Rights and conditions that are admissible, and procedures for daily and Privacy Act (commonly known as FERPA) and/or care. In jurisdictions that lack regulations and licensing the Health Insurance Portability and Accountability Act (commonly known as HIPAA) (2).

179 152 Caring for Our Children: National Health and Safety Performance Standards exceeds 2 stools above normal frequency) and one or RATIONALE more of the following: The caregiver/teacher must have child-specific information 1. Signs of dehydration, such as dry mouth, no tears, to provide optimum care for each child who is ill and to lethargy, sunken fontanelle (soft spot on the head); make appropriate decisions regarding whether to include Blood or mucus in the stool until it is evaluated for 2. or exclude a given child. The caregiver/teacher must have organisms that can cause dysentery; contact information for the child’s source of primary health 3. Diarrhea caused by Salmonella, Campylobacter, care or specialty health care (in the case of a child with Giardia, Shigella or E.coli 0157:H7 until specific asthma, diabetes, etc.) to assist with the management criteria for treatment and return to care are met. of any situation that arises. Vomiting 2 or more times in the previous 24 hours, d. COMMENTS unless vomiting is determined to be caused by a non- For school-age children, documentation of the care of the communicable or noninfectious condition and the child during the illness should be provided to the parent to child is not in danger of dehydration; deliver to the school health program upon the child’s return Contagious stages of pertussis, measles, mumps, e. to school. Coordination with the child’s source of health chickenpox, rubella, or diphtheria, unless the child is care and school health program facilitates the overall appropriately isolated from children with other illnesses care of the child (1). and cared for only with children having the same illness; f. Untreated infestation of scabies or head lice; exclusion TYPE OF FACILITY not necessary before the end of the program day; Center, Large Family Child Care Home Untreated infectious tuberculosis; g. References h. Undiagnosed rash WITH fever or behavior change; 1. Beierlein, J. G., J. E. Van Horn. 1995. Sick child care. National Network for Abdominal pain that is intermittent or persistent and is i. Child Care. http://www.nncc.org/eo/emp.sick.child .care.html. Donoghue, E. A., C. A. Kraft, eds. 2010. Managing chronic health needs in 2. accompanied by fever, diarrhea, vomiting, or other signs child care and schools: A quick reference guide. Elk Grove Village, IL: and symptoms; American Academy of Pediatrics. j. An acute change in behavior; k. Undiagnosed jaundice (yellow skin and whites of eyes); 3 . 6 . 2 .10 Upper or lower respiratory infection in which signs or l. Inclusion and Exclusion of Children from symptoms require a higher level of care than can be Facilities That Serve Children Who Are Ill appropriately provided; and Facilities that care for children who are ill who have condi - Severely immunocompromised children and other m. tions that require additional attention from the caregiver/ conditions as may be determined by the primary health teacher, should arrange for a clinical health evaluation prior care provider and/or child care health consultant (1,2). to admission, by a licensed primary care provider, for each RATIONALE child who is admitted to the facility. A child care health These signs and symptoms may indicate a significant sys- consultant can assist in arranging the evaluation. Facilities - temic infection that requires professional medical manage who serve children who are ill should include children with ment and parental care (1,2). Diarrheal illnesses that require conditions listed in Standard 3.6.1.1: Inclusion/Exclusion/ an intensity of care that cannot be provided appropriately by Dismissal of Children if their policies and plans address the a caregiver/teacher could result in temporary exclusion (1,2). management of these conditions, except for the following TYPE OF FACILITY conditions which require exclusion from all types of child care facilities: Center, Large Family Child Care Home a. A severely ill appearance. This could include lethargy or RELATED STANDARDS lack of responsiveness, irritability, persistent crying, Child Care Health Consultants 1. 6 . 0.1 difficulty breathing, or having a quickly spreading rash; 3. 6 .1.1 Inclusion/Exclusion/Dismissal of Children Fever (temperature for an infant or child older than b. Infectious Disease Outbreak Control 3. 6 .1. 4 2 months that is above 101° F [38.3° C] or, in infants References younger than 2 months, a temperature above 100.4° F 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child [38.0° F] by any method) and behavior change or other care and schools: A quick reference guide, pp. 43-48. 4th Edition. Elk Grove signs and symptoms; Village, IL: American Academy of Pediatrics. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red Book: 2. c. Diarrhea (Defined by stool that is occurring with more 2015 Report of the Committee on Infectious Diseases. 30th Ed. Elk Grove frequency or is less formed in consistency than usual Village, IL: American Academy of Pediatrics. in the child and not associated with changes in diet.) NOTES Exclusion is required for all diapered children whose Content in the STANDARD was modified on 8/9/2017. stool is not contained in the diaper. For toilet-trained children, exclusion is required when diarrhea is causing “accidents”. Exclude children whose stool frequency

180 153 Chapter 3: Health Promotion and Protection All medicines require clear, accurate instruction and medi - 3.6.3 cal confirmation of the need for the medication to be given while the child is in the facility. Prescription medications MEDICATIONS can often be timed to be given at home and this should be 3.6.3.1 encouraged. Because of the potential for errors in medica - tion administration in child care facilities, it may be safer Medication Administration for a parent/guardian to administer their child’s medicine The administration of medicines at the facility should be at home. limited to: Over the counter medications, such as acetaminophen and Prescription or non-prescription medication (over- a. ibuprofen, can be just as dangerous as prescription medica - the-counter [OTC]) ordered by the prescribing health tions and can result in illness or even death when these professional for a specific child with written permission products are misused or unintentional poisoning occurs. of the parent/guardian. Written orders from the pre- Many children’s over the counter medications contain a scribing health professional should specify medical combination of ingredients. It is important to make sure need, medication, dosage, and length of time to give the child isn’t receiving the same medications in two medication; different products which may result in an overdose. b. Labeled medications brought to the child care facility Facilities should not stock OTC medications (1). by the parent/guardian in the original container (with a label that includes the child’s name, date filled, pre- Cough and cold medications are widely used for chil- scribing clinician’s name, pharmacy name and phone dren to treat upper respiratory infections and allergy number, dosage/instructions, and relevant warnings). symptoms. Recently, concern has been raised that there is no proven benefit and some of these products may be Facilities should not administer folk or homemade remedy dangerous (2,3,5). Leading organizations such as the medications or treatment. Facilities should not administer Consumer Healthcare Products Association (CHPA) a medication that is prescribed for one child in the family and the American Academy of Pediatrics (AAP) have to another child in the family. recommended restrictions on these products for No prescription or non-prescription medication (OTC) children under age six (4-7). should be given to any child without written orders from If a medication mistake or unintentional poisoning does a prescribing health professional and written permission occur, call your local poison center immediately at from a parent/guardian. Exception: Non-prescription 1-800-222-1222. sunscreen and insect repellent always require parental consent but do not require instructions from each child’s Parents/guardians should always be notified in every prescribing health professional. instance when medication is used. Telephone instructions - from a primary care provider are acceptable if the care Documentation that the medicine/agent is administered to giver/teacher fully documents them and if the parent/ the child as prescribed is required. guardian initiates the request for primary care provider or “Standing orders” guidance should include directions for child care health consultant instruction. In the event medi - facilities to be equipped, staffed, and monitored by the pri- cation for a child becomes necessary during the day or in mary care provider capable of having the special health care the event of an emergency, administration instructions plan modified as needed. Standing orders for medication from a parent/guardian and the child’s prescribing health should only be allowed for individual children with a docu - professional are required before a caregiver/teacher may mented medical need if a special care plan is provided by administer medication. the child’s primary care provider in conjunction with the TYPE OF FACILITY standing order or for OTC medications for which a primary Center, Large Family Child Care Home care provider has provided specific instructions that define the children, conditions and methods for administration of RELATED STANDARDS the medication. Signatures from the primary care provider Sun Safety Including Sunscreen 3. 4 . 5.1 and one of the child’s parents/guardians must be obtained Insect Repellent and Protection from Vector-Borne 3.4.5.2 on the special care plan. Care plans should be updated as Diseases needed, but at least yearly. Information Required for Children Who Are Ill 3.6.2.9 RATIONALE 3.6.3.2 Labeling, Storage, and Disposal of Medications - Medicines can be crucial to the health and wellness of chil dren. 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.

181 154 Caring for Our Children: National Health and Safety Performance Standards Remove medications from their original containers and c. References 1. American Academy of Pediatrics, Committee on Drugs. 2009. Policy put them in a sealable bag. Mix medications with an statement: Acetaminophen toxicity in children. Pediatrics 123:1421-22. undesirable substance such as used coffee grounds or 2. Schaefer, M. K., N. Shehab, A. Cohen, D. S. Budnitz. 2008. Adverse events kitty litter. Throw the mixture into the regular trash. from cough and cold medications in children. Pediatrics 121:783-87. 3. Centers for Disease Control and Prevention. 2007. Infant deaths associated Make sure children do not have access to the trash (1). with cough and cold medications: Two states. MMWR 56:1-4. 4. Consumer Healthcare Products Association. Makers of OTC cough and RATIONALE cold medicines announce voluntary withdrawal of oral infant medicines. Child-resistant safety packaging has been shown to signifi - http://www.chpa-info.org/10_11_07_OralInfantMedicines.aspx. cantly decrease poison exposure incidents in young chil - 5. U.S. Department of Health and Human Services, Food and Drug Administration. 2008. Public Health advisory: FDA recommends that of medications is important to dren (1). Proper disposal over-the-counter (OTC) cough and cold products not be used for infants help ensure a healthy environment for children in our and children under 2 years of age. http://www.fda.gov/NewsEvents/ communities. There is growing evidence that throwing Newsroom/PressAnnouncements/2008/ucm051137.htm 6. Vernacchio, L., J. Kelly, D. Kaufman, A. Mitchell. 2008. Cough and cold out or flushing medications into our sewer systems may medication use by U.S. children, 1999-2006: Results from the Slone Survey. have harmful effects on the environment (1-3). Pediatrics 122: e323-29. 7. American Academy of Pediatrics. 2008. AAP Urges caution in use of TYPE OF FACILITY over-the-counter cough and cold medicines. http://www.generaterecords. Center, Large Family Child Care Home net/PicGallery/AAP_CC.pdf RELATED STANDARDS 3.6.3.2 Medication Administration 3.6.3.1 Labeling, Storage, and Disposal Training of Caregivers/Teachers to Administer 3.6.3.3 of Medications Medication Any prescription medication should be dated and kept in References the original container. The container should be labeled by 1. U.S. Food and Drug Administration. 2010. Disposal by flushing of certain unused medicines: What you should know. http://www.fda.gov/Drugs/ a pharmacist with: ResourcesForYou/Consumers/BuyingUsingMedicineSafely/ The child’s first and last names; • EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ ucm186187.htm. 2. U.S. Environmental Protection Agency. 2009. Pharmaceuticals and personal The date the prescription was filled; • care products as pollutants (PPCPs). http://www.epa .gov/ppcp/. • The name of the prescribing health professional who 3. Fiene, R. 2002. 13 indicators of quality child care: Research update. wrote the prescription, the medication’s expiration date; Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ • The manufacturer’s instructions or prescription label basic-report/13-indicators-quality-child-care. with specific, legible instructions for administration, storage, and disposal; 3.6.3.3 • The name and strength of the medication. Training of Caregivers/Teachers to - Over-the-counter medications should be kept in the origi Administer Medication nal container as sold by the manufacturer, labeled by the Any caregiver/teacher who administers medication should parent/guardian, with the child’s name and specific complete a standardized training course that includes skill instructions given by the child’s prescribing health and competency assessment in medication administration. professional for administration. The trainer in medication administration should be a All medications, refrigerated or unrefrigerated, should: licensed health professional. The course should be repeated • Have child-resistant caps; according to state and/or local regulation. At a minimum, • Be kept in an organized fashion; skill and competency should be monitored annually or • Be stored away from food; - whenever medication administration error occurs. In facili Be stored at the proper temperature; • ties with large numbers of children with special health care Be completely inaccessible to children. • - needs involving daily medication, best practice would indi cate strong consideration to the hiring of a licensed health Medication should not be used beyond the date of expira - care professional. Lacking that, caregivers/teachers should tion. Unused medications should be returned to the parent/ be trained to: guardian for disposal. In the event medication cannot be returned to the parent or guardian, it should be disposed a. Check that the name of the child on the medication of according to the recommendations of the US Food and and the child receiving the medication are the same; Drug Administration (FDA) (1). Documentation should be b. Check that the name of the medication is the same as kept with the child care facility of all disposed medications. the name of the medication on the instructions to give The current guidelines are as follows: - the medication if the instructions are not on the medi cation container that is labeled with the child’s name; a. If a medication lists any specific instructions on how to c. Read and understand the label/prescription directions dispose of it, follow those directions. or the separate written instructions in relation to the b. If there are community drug take back programs, measured dose, frequency, route of administration participate in those. (ex. by mouth, ear canal, eye, etc.) and other special instructions relative to the medication;

182 155 Chapter 3: Health Promotion and Protection Observe and report any side effects from medications; d. References 1. Heschel, R. T., A. A. Crowley, S. S. Cohen. 2005. State policies regarding e. Document the administration of each dose by the time nursing delegation and administration in child care settings: A case study. and the amount given; Policy, Politics, and Nursing Practice 6:86-98. Document the person giving the administration and f. 2. Qualistar Early Learning. 2008. Colorado Medication Administration Curriculum. 5th ed. http://www.qualistar.org/medication-administration. any side effects noted; html. Handle and store all medications according to label g. 3. Fiene, R. 2002. 13 indicators of quality child care: Research update. instructions and regulations. Washington, DC: US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. http://aspe.hhs.gov/ The trainer in medication administration should be a basic-report/13-indicators-quality-child-care. Calder, J. 2004. Medication administration in child care programs. Health 4. licensed health professional: Registered Nurse, Advanced and Safety Notes. Berkeley, CA: California Childcare Health Program. Practice Registered Nurse (APRN), MD, Physician’s http://www.ucsfchildcarehealth.org/pdfs/healthandsafety/ Assistant, or Pharmacist. medadminEN102004_adr.pdf. 5. Vernacchio, L., J. P. Kelly, D. W. Kaufman, A. A. Mitchell. 2009. Medication RATIONALE use among children <12 years of age in the United States: Results from the Slone Survey. Pediatrics 124:446-54. 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, 3.6.4 mostly vitamins, but between 16% and 40% are taking anti - REPORTING ILLNESS AND DEATH pyretics/analgesics (5). Safe medication administration in child care is extremely important and training of care- 3 . 6 . 4 .1 givers/teachers is essential (1). Procedure for Parent/Guardian Notification Caregivers/teachers need to know what medication the About Exposure of Children to Infectious child is receiving, who prescribed the medicine and when, Disease for what purpose the medicine has been prescribed and Caregivers/teachers should work collaboratively with local what the known reactions or side effects may be if a child and state health authorities to notify parents/guardians - has a negative reaction to the medicine (2,3). A child’s reac about potential or confirmed exposures of their child to tion to medication can be occasionally extreme enough to an infectious disease. Notification should include the initiate the protocol developed for emergencies. The medi - following information: cation record is especially important if medications are a. The names, both the common and the medical name, of frequently prescribed or if long-term medications are the diagnosed disease to which the child was exposed, being used (4). whether there is one case or an outbreak, and the nature COMMENTS of the exposure (such as a child or staff member in a Caregivers/teachers need to know the state laws and regula - shared room or facility); tions on training requirements for the administration of b. Signs and symptoms of the disease for which the parent/ medications in out-of-home child care settings. These laws guardian should observe; may include requirements for delegation of medication c. Mode of transmission of the disease; administration from a primary care provider. Training Period of communicability and how long to watch for d. on medication administration for caregivers/teachers is signs and symptoms of the disease; available in several states. Model Child Care Health Policies , Disease-prevention measures recommended by the e. 2nd Ed. from Healthy Child Care Pennsylvania is available health department (if appropriate); at http://www.ecels-healthychildcarepa.org/publications/ Control measures implemented at the facility; f. manuals-pamphlets-policies/item/248-model-child-care- Pictures of skin lesions or skin condition may be g. health-policies and contains sample polices and forms helpful to parents/guardians (i.e., chicken pox, spots related to medication administration. on tonsils, etc.) TYPE OF FACILITY The notice should not identify the child who has the Center, Large Family Child Care Home infectious disease. RELATED STANDARDS RATIONALE Medication Administration 3.6.3.1 Effective control and prevention of infectious diseases in Labeling, Storage, and Disposal of 3.6.3.2 child care depends on affirmative relationships between Medications parents/guardians, caregivers/teachers, public health authorities, and primary care providers. 9.2.3.9 Written Policy on Use of Medications Care Plan for Children With Special Appendix O: COMMENTS Health Needs The child care health consultant can locate appropriate Medication Administration Packet Appendix AA: photographs of conditions for parent/guardian information use. Resources for fact sheets and photographs include the

183 156 Caring for Our Children: National Health and Safety Performance Standards Managing Infectious Diseases in Child current edition of 3.6.4.3 Care and Schools (1) and the Centers for Disease Control and Notification of the Facility About Prevention Website on conditions and diseases. For a sample Infectious Disease or Other Problems letter to parents notifying them of illness of their child or by Parents/Guardians other enrolled children, see Healthy Young Children, avail - Upon registration of each child, the facility should inform able from the National Association for the Education of parents/guardians that they must notify the facility within Young Children (NAEYC) at http://www.naeyc.org. twenty-four hours after their child or any member of the TYPE OF FACILITY immediate household has developed a known or suspected Center, Large Family Child Care Home infectious or vaccine-preventable disease (1). When a child has a disease that may require exclusion, the parents/ RELATED STANDARD guardians should inform the facility of the diagnosis. Infectious Disease Outbreak Control 3. 6 .1. 4 The facility should encourage parents/guardians to inform Reference the caregivers/teachers of any other problems which may 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, IL: affect the child’s behavior. American Academy of Pediatrics. RATIONALE This requirement will facilitate prompt reporting of disease 3.6.4.2 and enable the caregiver/teacher to provide better care. Infectious Diseases That Require and reporting to local health authori - Disease surveillance Parent/Guardian Notification ties is crucial to preventing and controlling diseases in the In cooperation with the child care regulatory authority and child care setting (2,3). The major purpose of surveillance health department, the facility or the health department is to allow early detection of disease and prompt imple- should inform parents/guardians if their child may have mentation of control measures. If it is known that the child been exposed to the following diseases or conditions while attends another center or facility, all facilities should be attending the child care program, while retaining the con- informed (for example, if the child attends a Head Start fidentiality of the child who has the infectious disease: program and a child care program that are separate–then both need to be notified and the notification of local health Neisseria meningitidis a. (meningitis); authority should name both facilities). b. Pertussis; c. Invasive infections; - Ascertaining whether a child who is ill is attending a facil Varicella-zoster (Chickenpox) virus; d. ity is important when evaluating childhood illnesses (2,3). e. Skin infections or infestations (head lice, scabies, Ascertaining whether an adult with illness is working in a and ringworm); facility or is a parent/guardian of a child attending a facility Infections of the gastrointestinal tract (often with f. is impor-tant when considering infectious diseases that diarrhea) and hepatitis A virus (HAV); are more commonly manifest in adults. Cases of illness in g. type B (Hib); Haemophilus influenzae family member such as infections of the gastrointestinal Parvovirus B19 (fifth disease); h. tract (with diarrhea), or infections of the liver may necessi - Measles; i. tate questioning about possible illness in the child attending Tu b e r c u l o s i s ; j. child care. Information concerning infectious disease in k. Two or more affected unrelated persons affiliated with a child care attendee, staff member, or household contact the facility with a vaccine-preventable or infectious should be communicated to public health authorities, to the disease. child care director, and to the child’s parents/guardians. RATIONALE TYPE OF FACILITY Early identification and treatment of infectious diseases are Center, Large Family Child Care Home important in minimizing associated morbidity and mortal - RELATED STANDARD ity as well as further reducing transmission (1). Notification Inclusion/Exclusion/Dismissal of Children 3. 6 .1.1 of parents/guardians will permit them to discuss with their References child’s primary care provider the implications of the expo - 1. Pennsylvania chapter of the American Academy of Pediatrics. Model sure and to closely observe their child for early signs and Child Care Health Polices. Aronson SS, ed. 5th ed. Elk Grove Village, IL: symptoms of illness. American Academy of Pediatrics; 2014. 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Children TYPE OF FACILITY in out-of-home child care. In: Red book: 2015 report of the committee on infectious diseases. 30th Ed. Elk Grove Village, IL: American Academy of Center, Large Family Child Care Home Pediatrics. RELATED STANDARD 3. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, Infectious Disease Outbreak Control 3. 6 .1. 4 IL: American Academy of Pediatrics. Reference 1. Aronson, S. S., T. R. Shope, eds. 2009. Managing infectious diseases in child care and schools: A quick reference guide. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics.

184 157 Chapter 3: Health Promotion and Protection For information on assisting families in finding a medical 3.6.4.4 home or primary care provider, consult the local chapter of List of Excludable and Reportable the American Academy of Pediatrics (AAP), the facility’s Conditions for Parents/Guardians - child care health consultant, the local public health depart The facility should give to each parent/guardian a written ment, or the American Academy of Family Physicians list of conditions for which exclusion and dismissal may (AAFP). For more information, see also the current edition be indicated (1). . Managing Infectious Diseases in Child Care and Schools of For the following symptoms, the caregiver/teacher should TYPE OF FACILITY ask parents/guardians to have the child evaluated by a Center, Large Family Child Care Home primary care provider. The advice of the primary care RELATED STANDARDS provider should be documented for the caregiver/teacher in the following situations: Inclusion/Exclusion/Dismissal of Children 3. 6 .1.1 Situations that Require Medical Attention Appendix P: a. The child has any of the following conditions: fever, R ig ht Away lethargy, irritability, persistent crying, difficult breath- ing, or other manifestations of possible severe illness; References b. The child has a rash with fever and behavioral change; 1. Aronson, S. S., T. R. Shope, eds. 2017. Managing infectious diseases in child care and schools: A quick reference guide, 4th Edition. Elk Grove Village, The child has tuberculosis that has not been evaluated; c. IL: American Academy of Pediatrics. The child has scabies; d. 2. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. Red e. The child has a persistent cough with inability to book: 2015 report of the committee on infectious diseases. 30th Ed. Elk Grove Village, IL: American Academy of Pediatrics. practice respiratory etiquette. The facility should have a list of reportable diseases pro- 3.6.4.5 vided by the health department and should provide a copy Death to each parent/guardian. Each facility should have a plan in place for responding RATIONALE to any death relevant to children enrolled in the facility Vomiting with symptoms such as lethargy and/or dry and their families. The plan should describe protocols the skin or mucous membranes or reduced urine output may program will follow and resources available for children, indicate dehydration, and the child should be medically families, and staff. evaluated. Diarrhea with fever or other symptoms usually If a facility experiences the death of a child or adult, the indicates infection. Blood and/or mucus may indicate shig - following should be done: ellosis or infection with E. coli 0157:H7, which should be evaluated. Effective control and prevention of infectious a. If a child or adult dies while at the facility: diseases in child care depend on affirmative relationships 1. The caregiver/teacher(s) responsible for any chil- between parents/guardians, caregivers, health departments, dren who observed or were in the same room where and primary care providers (2). the death occurred, should take the children to a different room, while other staff tend to appropriate COMMENTS response/follow-up. Minimal explanations should be If there is more than one case of vomiting in the facility, it provided until direction is received from the proper may indicate either contagious illness or food poisoning. authorities. Supportive and reassuring comments If a child with abdominal pain is drowsy, irritable, and should be provided to children directly affected; unhappy, has no appetite, and is unwilling to participate Designated staff should: 2. in usual activities, the child should be seen by that child’s 3. Immediately notify emergency medical personnel; primary care provider. Abdominal pain may be associated 4. Immediately notify the child’s parents/guardians or with viral, bacterial, or parasitic gastrointestinal tract ill- adult’s emergency contact; ness, which is contagious, or with food poisoning. It also 5. Notify the Licensing agency and law enforcement the may be a manifestation of another disease or illness such as same day the death occurs; kidney disease. If the pain is severe or persistent, the child 6. Follow all law enforcement protocols regarding the should be referred for medical consultation (by telephone, scene of the death: if necessary). – Do not disturb the scene; If the caregiver/teacher is unable to contact the parent/ – Do not show the scene to others; guardian, medical advice should be sought until the parents – Reserve conversation about the event until having can be located. completed all interviews with law enforcement. 7. Provide age-appropriate information for children, The facility should post the health department’s list of parents/guardians and staff; infectious diseases as a reference. The facility should inform Make resources for support available to staff, parents 8. parents/guardians that the program is required to report and children; infectious diseases to the health department.

185 158 Caring for Our Children: National Health and Safety Performance Standards For a suspected Sudden Infant Death Syndrome (SIDS) b. RELATED STANDARDS death or other unexplained deaths: Safe Sleep Practices and Sudden Unexpected 3.1. 4 .1 1. Seek support and information from local, state, or Infant Death (SUID)/SIDS Risk Reduction national SIDS resources; 3.4.4.1 Recognizing and Reporting Suspected Child 2. Provide SIDS information to the parents/guardians Abuse, Neglect, and Exploitation of the other children in the facility; 3.4.4.2 Immunity for Reporters of Child Abuse 3. Provide age-appropriate information to the other and Neglect children in the facility; Preventing and Identifying Shaken Baby 3.4.4.3 4. Provide appropriate information for staff at the Syndrome/Abusive Head Trauma facility; Care for Children Who Have Been Abused/ 3.4.4.4 If a child or adult known to the children enrolled in the c. Neglected facility dies while not at the facility: 1. Provide age-appropriate information for children, 3.4.4.5 Facility Layout to Reduce Risk of Child Abuse parents/guardians and staff; and Neglect Make resources for support available to staff, parents 2. References and children. 1. Moon, R. Y., K. M. Patel, S. J. M. Shaefer. 2000. Sudden infant death syndrome in child care settings. Pediatrics 106:295-300. Facilities may release specific information about the cir- Moon, R. Y., T. Calabrese, L. Aird. 2008. Reducing the risk of sudden infant 2. cumstances of the child or adult’s death that the authorities death syndrome in child care and changing provider practices: Lessons learned from a demonstration project. Pediatrics 122:788-98. and the deceased member’s family agrees the facility 3. Moon, R. Y., L. Kotch, L. Aird. 2006. State child care regulations regarding may share. infant sleep environment since the Healthy Child Care America – Back to Sleep Campaign. Pediatrics 118:73-83. If the death is due to suspected child maltreatment, the 4. Boston Medical Center. Good grief program. http://www.bmc.org/ caregiver/teacher is mandated to report this to child pediatrics-goodgrief.htm. protective services. 5. Rivlin, D. The good grief program of Boston Medical Center: What do children need? Boston Medical Center. http://www.wayland.k12.ma.us/ Depending on the cause of death (SIDS, suffocation or claypit_hill/GoodGrief Handout.pdf. 6. Trozzi, M. 1999. Talking with children about Loss: Words, strategies, and other infant death, injury, maltreatment etc.), there may be wisdom to help children cope with death, divorce, and other difficult times. a need for updated education on the subject for caregivers/ New York: Berkley Publishing Group. teachers and/or children as well as implementation of 7. Knapp, J., D. Mulligan-Smith, Committee on Pediatric Emergency Medicine. 2005. Death of a child in the emergency department. Pediatrics improved health and safety practices. 115 :14 32 -37. RATIONALE Following the steps described in this standard would con- stitute prudent action (1-3). Accurate information given to parents/guardians and children will help them understand the event and facilitate their support of the caregiver/ teacher (4-7). COMMENTS It is important that caregivers/teachers are knowledgeable about SIDS and that they take proper steps so that they are not falsely accused of child abuse and neglect. The licensing agency and/or a SIDS agency support group (e.g., CJ Foundation for SIDS at http://www.cjsids.org, the National Action Partnership to Promote Safe Sleep (NAPPSS) at http://nappss.org, and First Candle at http://www.firstcandle.org) can offer support and counseling to caregivers/teachers. TYPE OF FACILITY Center, Large Family Child Care Home

186 CHAPTER 4 Nutrition and Food Service

187

188 161 Chapter 4: Nutrition and Food Service providing a staff that is well-trained in the proper handling 4 .1 of human milk and feeding of breastfed infants. INTRODUCTION - Mothers who formula feed can also establish healthy attach One of the basic responsibilities of every parent/guardian ment. A mother may choose not to breastfeed her infant for and caregiver/teacher is to provide nourishing food daily reasons that may include: human milk is not available, there that is clean, safe, and developmentally appropriate for is a real or perceived inadequate supply of human milk, her children. Food is essential in any early care and education infant fails to gain weight, there is an existing medical con- setting to keep infants and children free from hunger. dition for which human milk is contraindicated, or a mother Children also need freely available, clean drinking water. desires not to breastfeed. Today there is a range of infant Feeding should occur in a relaxed and pleasant environ - formulas on the market that vary in nutrient content and ment that fosters healthy digestion and positive social address specific needs of individual infants. A primary care behavior. Food provides energy and nutrients needed by provider should prescribe the specific infant formula to be infants and children during the critical period of their used to meet the nutritional requirements of an individual growth and development. infant. When infant formula is used to supplement an infant Feeding nutritious food everyday must be accompanied by being breastfed, the mother should be encouraged to con- offering appropriate daily physical activity and play time for tinue to breastfeed or to pump human milk since her milk the healthy physical, social, and emotional development of supply will decrease if her milk production isn’t stimulated infants and young children. There is solid evidence that by breastfeeding or pumping. physical activity can prevent a rapid gain in weight which Given adequate opportunity, assistance, and age-appropriate leads to childhood obesity early in life. The early care and equipment, children learn to self-feed as age-appropriate education setting is an ideal environment to foster the goal solid foods are introduced. Equally important to self-feeding of providing supervised, age-appropriate physical activity is children’s attainment of normal physical growth, motor during the critical years of growth when health habits and coordination, and cognitive and social skills. Modeling of patterns are being developed for life. The overall benefits of healthy eating behavior by early care and education staff practicing healthy eating patterns, while being physically helps a child to develop lifelong healthy eating habits. This active daily are significant. Physical, social, and emotional period, beginning at six months of age, is an opportune time habits are developed during the early years and continue for children to learn more about the world around them by into adulthood; thus these habits can be improved in early expressing their independence. Children pick and choose childhood to prevent and reduce obesity and a range of from different kinds and combinations of foods offered. To chronic diseases. Active play and supervised structured ensure programs are offering a variety of foods, selections physical activities promote healthy weight, improved over - should be made from these groups of food: - all fitness, including mental health, improved bone develop a. Grains – especially whole grains; ment, cardiovascular health, and development of social Vegetables b. – dark, green leafy and deep yellow; skills. The physical activity standards outline the blueprint c. – deep orange, yellow, and red whole fruits, 100% Fruits for practical methods of achieving the goal of promoting fruit juices limited to no more than four to six ounces healthy bodies and minds of young children. per day for children one year of age and over; Breastfeeding sets the stage for an infant to establish d. Milk – whole milk, or reduced fat (2%) milk for children healthy attachment. The American Academy of Pediatrics, at risk for obesity or hypercholesterolemia, for children the United States Breastfeeding Committee, the Academy from one year of age up to two years of age; skim or 1% of Breastfeeding Medicine, the American Academy of for children two years or older, unsweetened low-fat Family Physicians, the World Health Organization, and the yogurt or low-fat cheese (e.g. cottage, farmer’s); United Nations Children’s Fund (UNICEF) all recommend – baked or broiled chicken, fish, lean e. Meats and Beans that women should breastfeed exclusively for about the first meats, dried peas and beans; and six months of the infant’s life, adding age-appropriate solid – vegetable. f. Oils foods (complementary foods) and continuing breastfeeding Current research supports a diet based on a variety of for at least the first year if not longer. nutrient dense foods which provide substantial amounts Human milk, containing all the nutrients to promote opti - of essential nutrients – protein, carbohydrates, oils, and mal growth, is the most developmentally appropriate food vitamins and minerals – with appropriate calories to meet for infants. It changes during the course of each feeding and the child’s needs. For children, the availability of a variety over time to meet the growing child’s changing nutritional of clean, safe, nourishing foods is essential during a period - needs. All caregivers/teachers should be trained to encour of rapid growth and development. The nutrition and food age, support, and advocate for breastfeeding. Caregivers/ service standards, along with related appendixes, address teachers have a unique opportunity to support breastfeed - age-appropriate foods and feeding techniques beginning ing mothers, who are often daunted by the prospect of with the very first food, preferably human milk and when continuing to breastfeed as they return to work. Early not possible, infant formula based on the recommendation care and education programs can reduce a breastfeeding of the infant’s primary care provider and family. As part of mother’s anxiety by welcoming breastfeeding families and their developing growth and maturity, toddlers often exhibit

189 162 Caring for Our Children: National Health and Safety Performance Standards changed eating habits compared to when they were infants. 4.2 One may indulge in eating sprees, wanting to eat the same GENERAL REQUIREMENTS food for several days. Another may become a picky eater, picking or dawdling over food, or refusing to eat a certain food because it is new and unfamiliar with a new taste, color, odor, or texture. If these or other food behaviors 4 . 2 . 0 .1 persist, parents/guardians, caregivers/teachers, and the Written Nutrition Plan primary care provider together should determine the The facility should provide nourishing and appealing reason(s) and come up with a plan to address the issue. food for children according to a written plan developed The consistency of the plan is important in helping a child by a qualified nutritionist/registered dietitian. Caregivers/ to build sound eating habits during a time when they are teachers, directors, and food service personnel should share focused on developing as an individual and often have the responsibility for carrying out the plan. The director is erratic, unpredictable appetites. Family homes and center- responsible for implementing the plan but may delegate based out-of-home early care and education settings have tasks to caregivers/teachers and food service personnel. the opportunity to guide and support children’s sound Where infants and young children are involved, the feeding eating habits and food learning experiences (1-3). plan may include special attention to supporting mothers in Early food and eating experiences form the foundation maintaining their human milk supply. The nutrition plan of attitudes about food, eating behavior, and consequently, should include steps to take when problems require rapid food habits. Responsive feeding, where the parents/ response by the staff, such as when a child chokes during guardians or caregivers/teachers recognize and respond mealtime or has an allergic reaction to a food. The com- to infant and child cues, helps foster trust and reduces pleted plan should be on file, easily accessible to staff, and overfeeding. Sound food habits are built on eating and available to parents/guardians on request. enjoying a variety of healthful foods. Including culturally If the facility is large enough to justify employment of a specific family foods is a dietary goal for feeding infants full-time nutritionist/registered dietitian or child care food and young children. Current research documents that service manager, the facility should delegate to this person a balanced diet, combined with daily and routine age- the responsibility for implementing the written plan. Some appropriate physical activity, can reduce diet-related risks children may have medical conditions that require special of overweight, obesity, and chronic disease later in life (1). dietary modifications. A written care plan from the pri- Two essentials – eating healthy foods and engaging in mary health care provider, clearly stating the food(s) to be physical activity on a daily basis – promote a healthy avoided and food(s) to be substituted, should be on file. beginning during the early years and throughout the life - This information should be updated annually if the modifi span. 2010 Dietary Guidelines for Americans and the cation is not a lifetime special dietary need. Staff should be U.S. Department of Agriculture’s ChooseMyPlate.gov are educated about a child’s dietary modification to ensure that designed to support lifestyle behaviors that promote health, no child in care ingests or has contact with foods he/she including a diet composed of a variety of healthy foods and should avoid while at the facility. The proper modifications physical activity at two years of age and older (1-2,4-7). should be implemented whether the child brings his/her TYPE OF FACILITY own food or whether it is prepared on site. The facility Center; Large Family Child Care Home; Small Family needs to inform all families and staff if certain foods, such Child Care Home as nut products (e.g., peanut butter, peanut oil), should not be brought from home because of a child’s life-threatening References 1. U.S. Department of Health and Human Services, U.S. Department of allergy. Staff should also know what procedure to follow if Agriculture. 2010. Dietary guidelines for Americans, 2010. 7th ed. ingestion or contact occurs. In addition to knowing ahead Washington, DC: U.S. Government Printing Office. http://www.health.gov/ of time what procedures to follow, staff must know their dietaryguidelines/dga2010/DietaryGuidelines2010.pdf 2. U.S. Department of Agriculture. 2011. MyPlate. http://www.choosemyplate. designated roles during an emergency. The emergency gov. plan should be dated and updated biannually. 3. Zero to Three. 2007. Healthy from the start—How feeding nurtures your young child’s body, heart, and mind. Washington, DC: Zero to Three. RATIONALE 4. Pipes, P. L., C. M. Trahms, eds. 1997. Nutrition in infancy and childhood. - Nourishing and appealing food is the cornerstone of chil 6th ed. New York: McGraw-Hill. 5. Marotz, L. R. 2008. Health, safety, and nutrition for the young child. 7th ed. dren’s health, growth, and development, as well as develop - Clifton Park, NY: Delmar Learning. mentally appropriate learning experiences (1-3). Nutrition Herr, J. 2008. Working with young children. 4th ed. Tinley Park, IL: 6. and feeding are fundamental and required in every facility. Goodheart-Willcox Company. 7. Dalton, S. 2004. Our overweight children: What parents, schools, and Because children grow and develop more rapidly during the communities can do to control the fatness epidemic. Berkeley, CA: first few years after birth than at any other time, a child’s University of California Press. home and the facility together must provide food that is adequate in amount and type to meet each child’s growth and nutritional needs. Children can learn healthy eating habits and be better equipped to maintain a healthy weight

190 163 Chapter 4: Nutrition and Food Service if they eat nourishing food while attending early care and 4.2.0.2 education settings (4). Children can self-regulate their food Assessment and Planning of Nutrition intake and are able to determine an appropriate amount of for Individual Children food to eat in any one sitting when allowed to feed them - As a part of routine health supervision by a primary selves. Excessive prompting, feeding in response to emo- health care provider, children should be evaluated for tional distress, and using food as a reward have all been nutrition- related medical problems, such as failure to shown to lead to excessive weight gain in children (5,6). The thrive, overweight, obesity, food allergy, reflux disease, obesity epidemic makes this an important lesson today. and iron-deficiency anemia (1). The nutritional standards - Meals and snacks provide the caregiver/teacher an oppor throughout this document are general recommendations tunity to model appropriate mealtime behavior and guide that may not always be appropriate for some children with the conversation, which aids in children’s conceptual and medically identified special nutrition needs. Caregivers/ sensory language development and eye/hand coordination. teachers should communicate with the child’s parent/ In larger facilities, professional nutrition staff must be - guardian and pediatrician/other physician to adapt nutri involved to ensure compliance with nutrition and food tional offerings to individual children as indicated and service guidelines, including accommodation of children medically appropriate. Caregivers/teachers should work with special health care needs. with the parent/guardian to implement individualized feeding plans developed by the child’s primary health TYPE OF FACILITY care provider to meet a child’s unique nutritional needs. Center, Large Family Child Care Home These plans could include, for instance, additional iron- RELATED STANDARDS rich foods for a child who has been diagnosed as having Assessment and Planning of Nutrition for 4.2.0.2 iron-deficiency anemia. For a child diagnosed as obese or Individual Children overweight, the plan would focus on controlling portion sizes and creating a menu plan in which calorie-dense Categories of Foods 4.2.0.4 foods, like sugar-sweetened juices, nectars, and beverages, Feeding Plans and Dietary Modifications 4.2.0.8 should not be served. Using these nutritional differences as Feeding Infants on Cue by a Consistent 4 . 3.1. 2 educational moments will help children understand why Caregiver/Teacher they can or cannot eat certain food items. Some children 4.4.0.2 Use of Nutritionist/Registered Dietitian require special feeding techniques, such as thickened foods 4 . 5 . 0 .11 Prohibited Uses of Food or special positioning during meals. Other children will Nutrition Learning Experiences for Children 4.7.0.1 require dietary modifications based on food intolerances, such as lactose or wheat (gluten) intolerance. Some chil- Food and Nutrition Service Policies and Plans 9. 2 . 3 .11 dren will need dietary modifications based on cultural or Disaster Planning, Training, and 9.2.4.3 religious preferences, such as vegan, vegetarian, or kosher Communication diets, or halal foods. Nutrition Specialist, Registered Dietitian, Appendix C: RATIONALE Licensed Nutritionist, Consultant, and The early years are a critical time for children’s growth and Food Service Staff Qualifications development. Nutritional problems must be identified and References treated during this period to prevent serious or long-term 1. US Department of Health and Human Services, Administration for Children and Families, Office of Head Start. Head Start Program medical problems. Strong evidence shows a relationship Performance Standards. Rev ed. Washington, DC: US Government Printing between preschool-aged children being presented with Office; 2016. https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii. Accessed - larger sized portions and increased energy intake, prompt September 7, 2017 2. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health ing the importance of implementing proper portion sizing Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove as soon as 2 years of age for children at risk of being over - Village, IL: American Academy of Pediatrics; 2017 weight (2). The early care and education setting may be 3. Holt K, Wooldridge N, Story M, Sofka D. Bright Futures: Nutrition. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2011 offering most of a child’s daily nutritional intake, especially 4. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, for children in full-time care. It is important that the facility IL: American Academy of Pediatrics; 2014 ensures that food offerings are congruent with nutritional 5. Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring for Infants and Toddlers in Groups: Developmentally Appropriate Practice. interventions or dietary modifications recommended by 2nd ed. Arlington, VA: Zero to Three; 2008 the child’s pediatrician/other physician, in consultation with the nutritionist/registered dietitian, to make certain NOTES the intervention is child specific. Content in the STANDARD was modified on 11/9/2017. TYPE OF FACILITY Center, Large Family Child Care Home

191 164 Caring for Our Children: National Health and Safety Performance Standards RELATED STANDARDS Meal and Snack Patterns for Toddlers and 4 . 3. 2 .1 Preschoolers 3.1. 2 .1 Routine Health Supervision and Growth Monitoring Meal and Snack Patterns for School-Age Children 4.3.3.1 4.2.0.8 Feeding Plans and Dietary Modifications References 1. US Department of Agriculture, Food and Nutrition Service. Requirements 4 . 3.1. 2 Feeding Infants on Cue by a Consistent for meals. US Government Publishing Office Web site. https://www.ecfr. Caregiver/Teacher gov/cgi-bin/text-idx?SID=9c3a6681dbf6aada3632967c4bfeb030&mc=true& node=pt7.4.226&rgn=div5#se7.4.226_120. Accessed September 7, 2017 References US Department of Agriculture, Food and Nutrition Service. Child and 2. 1. McAllister JW. Achieving a Shared Plan of Care with Children and Adult Care Food Program (CACFP). Regulations. https://www.fns.usda. Youth with Special Health Care Needs. Palo Alto, CA: Lucille Packard gov/cacfp/regulations. Updated September 7, 2017. Accessed September 7, Foundation for Children’s Health; 2014. http://www.lpfch.org/sites/default/ 2017 files/field/publications/achieving_a_shared_plan_of_care_full.pdf. 3. Lally JR, Griffin A, Fenichel E, Segal M, Szanton E, Weissbourd B. Caring Accessed September 7, 2017 . for Infants and Toddlers in Groups: Developmentally Appropriate Practice McCrickerd K, Leong C, Forde CG. Preschool children’s sensitivity to 2. 2nd ed. Arlington, VA: Zero to Three; 2008 teacher-served portion size is linked to age related differences in leftovers. US Department of Agriculture, Food and Nutrition Service. 4. Independent Appetite. 2017;114:320–328 Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://fns-prod. Additional Resource azureedge.net/sites/default/files/cacfp/Independent%20Child%20Care%20 US Department of Health and Human Services, US Department of Centers%20Handbook.pdf. Accessed September 7, 2017 Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. 5. US Department of Health and Human Services, US Department of Washington, DC: US Department of Health and Human Services; 2015. Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_ Washington, DC: US Department of Health and Human Services; 2015. Guidelines.pdf. Accessed September 7, 2017 https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_ Guidelines.pdf. Accessed September 7, 2017 NOTES 6. US Department of Agriculture, Food and Nutrition Service. Child and Content in the STANDARD was modified on 11/9/2017. 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 4.2.0.3 7. US Department of Agriculture, Healthy Meals Resource System, Team Nutrition. CACFP wellness resources for child care providers. https:// Use of US Department of Agriculture Child healthymeals.fns.usda.gov/cacfp-wellness-resources-child-care-providers. and Adult Care Food Program Guidelines Accessed September 7, 2017 All meals and snacks and their preparation, service, and Additional Resource storage should meet the requirements for meals (7 CFR US Department of Agriculture. Child and Adult Care Food Program: best practices. US Department of Agriculture, Food and Nutrition Service Web site. §226.20) of the child care component of the US Depart- https://www.fns.usda.gov/sites/default/files/cacfp/CACFP_factBP.pdf. ment of Agriculture Child and Adult Care Food Program Accessed September 7, 2017 (CACFP) (1-3). NOTES RATIONALE Content in the STANDARD was modified on 11/9/2017. The CACFP regulations, policies, and guidance materials on meal requirements provide basic guidelines for sound 4.2.0.4 nutrition and sanitation practices. The CACFP guidance for Categories of Foods meals and snack patterns ensures that the nutritional needs The early care and education program should ensure the of infants and children, including school-aged children following food groups are being served to children in care. through 12 years, are met based on the Dietary Guidelines When incorporated into a child’s diet, these food groups - for Americans (4,5) as well as other evidence-based recom make up foundational components of a healthy eating mendations (6,7). Programs not eligible for reimbursement pattern. under the regulations of CACFP should still use the CACFP food guidance. OTHER RECOMMENDATIONS COMMENTS • Trans-fatty acids (trans fat) should be avoided. • Avoid concentrated sweets such as candy, sodas, sweet - Staff should use information about the child’s growth ened caffeinated drinks, fruit nectars, and flavored and CACFP meal patterns to develop individual feeding milks. Offer foods that have little or no added sugars. pla ns (6). Limit salty foods such as chips and pretzels. When • TYPE OF FACILITY buying foods, choose no salt added, low-sodium, or Center, Large Family Child Care Home reduced sodium versions, and prepare foods without RELATED STANDARDS adding salt. Use herbs or no-salt spice mixes instead of salt, soy sauce, ketchup, barbeque sauce, pickles, olives, Routine Health Supervision and Growth 3.1. 2 .1 salad dressings, butter, stick margarine, gravy, or cream Monitoring sauce with seasonal vegetables and other dishes. Categories of Foods 4.2.0.4 • Avoid caffeine. Meal and Snack Patterns 4.2.0.5 Feeding Infants on Cue by a Consistent 4 . 3.1. 2 Caregiver/Teacher

192 165 Chapter 4: Nutrition and Food Service a Making Healthy Food Choices Food Groups/ b Ingredients USDA CFOC Guidelines for Young Children • Eat a variety of whole fruits. Whole Fruits Fruits • Whole fruit, mashed or pureed, for infants. Includes fresh, frozen, canned (packed in water or • Do not serve juice to infants younger than 12 months. 100% fruit juice), and dried varieties that include good • No more than 4 oz of juice per day for 1- to 3-year-olds. sources of potassium (eg, bananas, dried plums) • No more than 4–6 oz of juice per day for 4- to 6-year-olds. Fruit Juice • No more than 8 oz of juice per day for 7- to 12-year-olds. 100% juice (ie, without added sugars) Vegetables • Include a variety of vegetables from the vegetable subgroups. Includes fresh, frozen, canned, and dried varieties • Select low-sodium options when serving canned vegetables. Vegetable Subgroups • Dark green • Red and orange Beans and peas (legumes) • Starchy vegetables • Other vegetables Grains • Limit the amount of refined grains. Whole Grains • Make half the grains served whole grains or whole-grain products. Contain the entire grain kernel (eg, whole wheat flour, bulgur, oatmeal, brown rice) Refined Grains Enriched grains that have been milled, processed, and stripped of vital nutrients Protein Foods Includes food from animal and plant sources • Fish, poultry, lean meat, eggs. (Meat and Meat (eg, seafood, lean meat, poultry, eggs, yogurt, • Unsalted nuts and seeds (if developmentally and age appropriate). Alternatives) cheese, soy products, nuts and seeds, • Legumes (beans and peas) may also be considered a protein source. cooked [mature] beans and peas) • Limit processed meats and poultry. • Avoid fried fish and poultry. Dairy Fat-free or low-fat (1%) milk or soy milk • Human milk and/or iron-fortified infant formula for infants 0–12 months of age. • Unflavored whole milk for children 1–2 years of age. • 2% (reduced-fat) milk for those children at risk for obesity or hypocholesteremia. • Unflavored low-fat (1%) or fat-free milk for children 2 years and older. • Nondairy milk substitutes that are nutritionally equivalent to milk. • Yogurt must not contain more than 23 g of sugar per ounce. Abbreviations: CFOC, Caring for Our Children: National Health and Safety Performance Standards; USDA, US Department of Agriculture. a All foods are assumed to be in nutrient-dense forms, lean or low-fat, and prepared without added fats, sugars, or salt. Solid fats and added sugars may be included up to the daily maximum limit identified in the 2015–2020 Dietary Guidelines for Americans. b The USDA recommends finding a balance between food and physical activity. ADDITIONAL RESOURCES RATIONALE American Academy of Pediatrics. American Academy of Pediatrics 2015–2020 Dietary Guidelines for Americans and The The recommends no fruit juice for children under 1 year. https://www.aap.org/ Surgeon General’s Call to Action to Support Breastfeeding en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics- Recommends-No-Fruit-Juice-For-Children-Under-1-Year.aspx. Published May support patterns of healthy eating to promote a healthy 22, 2017. Accessed September 19, 2017 weight and lifestyle that, in turn, prevent the onset of over - Holt K, Wooldridge N, Story M, Sofka D. Bright Futures: Nutrition . 3rd ed. Elk weight and obesity in children (1,2). Incorporating each of Grove Village, IL: American Academy of Pediatrics; 2011 the food groups by providing children with appropriate US Department of Agriculture. ChooseMyPlate.gov. Children. http://www. meals and snacks helps set the stage for a lifetime of healthy choosemyplate.gov/children. Updated August 26, 2015. Accessed September - eating behaviors. Research reinforces the following sugges 19, 2017 tions as being a practical approach to selecting foods high US Department of Health and Human Services. 2008 Physical Activity in essential nutrients and moderate in calories/energy: . Washington, DC: US Department of Health and Guidelines for Americans Human Services; 2008. http://www.health.gov/paguidelines/guidelines/default. aspx. Accessed September 19, 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 19, 2017

193 166 Caring for Our Children: National Health and Safety Performance Standards Centers for Disease Control and Prevention. Healthy schools. The buzz on 4. • Meals and snacks planned based on the food groups energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. in the Making Healthy Food Choices Table promote Updated March 22, 2016. Accessed September 19, 2017 normal growth and development of children as well as NOTES reduce children’s risk of overweight, obesity, and related Content in the STANDARD was modified on 2/2012 chronic diseases later in life. Age-specific guidance for and 11/16/2017. meals and snacks is outlined in the US Department of Agriculture Child and Adult Care Food Program (CACFP) guidelines (3). 4.2.0.5 • Early care and education settings provide the oppor- Meal and Snack Patterns tunity for children to learn about the food they eat, to The facility should ensure that the following meal and develop and strengthen their fine and gross motor skills, snack pattern occurs: and to engage in social interaction at mealtimes. a. Children in care for 8 or fewer hours in 1 day should “Energy” or sports beverages are typically high in added • be offered at least 1 meal and 2 snacks or 2 meals and sugars and, therefore, not recommended for consump - 1 snack (1). tion. They contain many nonnutritive stimulants, such b. A nutritious snack should be offered to all children as caffeine, that have a history of harmful effects on a in midmorning (if they are not offered a breakfast child’s developing heart, brain, and nervous system (4). on-site that is provided within 3 hours of lunch) COMMENTS and in mid-afternoon. Early care and education settings should encourage mothers Children should be offered food at intervals at least c. to breastfeed their infants. Scientific evidence documents 2 hours apart but not more than 3 hours apart unless and supports the nutritional and health contributions of the child is asleep. Some very young infants may need 2 For more information on portion sizes and human milk. to be fed at shorter intervals than every 2 hours to 3 types of food, see the CACFP guidelines. meet their nutritional needs, especially breastfed infants being fed expressed human milk. Lunch may need to be TYPE OF FACILITY served to toddlers earlier than preschool-aged children Center, Large Family Child Care Home because of their need for an earlier nap schedule. Chil- RELATED STANDARDS dren must be awake prior to being offered a meal/snack. Meal and Snack Patterns 4.2.0.5 d. Children should be allowed time to eat their food and 100% Fruit Juice 4.2.0.7 not be rushed during the meal or snack service. They should not be allowed to play during these times. Feeding Plans and Dietary Modifications 4.2.0.8 e. Caregivers/teachers should discuss breastfed infants’ Feeding Infants on Cue by a Consistent 4 . 3.1. 2 feeding patterns with their parents/guardians because Caregiver/Teacher the frequency of breastfeeding at home can vary. For Preparing, Feeding, and Storing Human Milk 4.3.1.3 example, some infants may still be feeding frequently Preparing, Feeding, and Storing Infant 4 . 3.1. 5 at night, while others may do the bulk of their feeding Formula during the day. Knowledge about infants’ feeding 4 . 3.1.7 Feeding Cow’s Milk patterns over 24 hours will help caregivers/teachers assess infants’ feeding schedules during their time Meal and Snack Patterns for Toddlers 4 . 3. 2 .1 together. and Preschoolers 4.3.3.1 Meal and Snack Patterns for School-Age RATIONALE Children Children younger than 6 years need to be offered food every 2 to 3 hours. Appetite and interest in food varies from Nutrition Learning Experiences for Children 4.7.0.1 one meal or snack to the next. Appropriate timing of meals 4.7.0.2 Nutrition Education for Parents/Guardians and snacks prevents children from snacking throughout the Appendix Q: Getting Started with MyPlate day and ensures that children maintain healthy appetites Choose MyPlate: 10 Tips to a Great Plate Appendix R: during mealtimes (2,3). Snacks should be nutritious, as References they often are a significant part of a child’s daily intake. 1. US Department of Health and Human Services, US Department of Children in care for longer than 8 hours need additional 2015–2020 Dietary Guidelines for Americans. 8th ed. Agriculture. food because this period represents most of a young child’s Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_ waking hours. Guidelines.pdf. Accessed September 19, 2017 COMMENTS The Surgeon General’s Call 2. US Department of Health and Human Services. to Action to Support Breastfeeding . Washington, DC: US Department of Caloric needs vary greatly from one child to another. A Health and Human Services, Office of the Surgeon General; 2011. https:// child may require more food during growth spurts (4). www.cdc.gov/breastfeeding/promotion/calltoaction.htm. Updated April 12, 2017. Accessed September 19, 2017 Some states have regulations that indicate suggested 3. US Department of Agriculture, Food and Nutrition Service. Child and times for meals and snacks. By regulation, under the US Adult Care Food Program (CACFP). https://www.fns.usda.gov/cacfp/ Department of Agriculture Child and Adult Care Food child-and-adult-care-food-program. Published March 29, 2017. Accessed September 19, 2017

194 167 Chapter 4: Nutrition and Food Service out mouthing the fixture. They should not be allowed Program (CACFP), centers and family child care homes may be approved to claim up to 2 reimbursable meals to have water continuously in hand in a sippy cup or bottle. (breakfast, lunch, or supper) and 1 snack, or 2 snacks Permitting toddlers to suck continuously on a bottle or sippy - and 1 meal, for each eligible participant, each day. Many cup filled with water, to soothe themselves, may cause nutri after-school programs provide before-school care or full- tional or, in rare instances, electrolyte imbalances. When toothbrushing is not done after a feeding, children should day care when elementary school is out of session. Many of these programs offer breakfast and/or a morning snack. be offered water to drink to rinse food from their teeth. After-school care programs may claim reimbursement for RATIONALE serving each child one snack, each day. In some states after- When children are thirsty between meals and snacks, school programs also have the option of providing supper. water is the best choice. Drinking water during the day can These are reimbursed by CACFP if they meet certain reduce extra caloric intake if the water replaces high-caloric guidelines and time frames (5). beverages, such as fruit drinks/nectars and sodas, which are TYPE OF FACILITY associated with overweight and obesity (2). Drinking water Center, Large Family Child Care Home helps maintain a child’s hydration and overall health. Water can also decrease the likelihood of early childhood caries if RELATED STANDARDS consumed throughout the day, especially between meals 4 . 3.1. 2 Feeding Infants on Cue by a Consistent and snacks (3,4). Personal and environmental factors, such Caregiver/Teacher as age, weight, gender, physical activity level, outside air Meal and Snack Patterns for Toddlers and 4 . 3. 2 .1 temperature, heat, and humidity, can affect individual Preschoolers water needs (5). 4.3.3.1 Meal and Snack Patterns for School-Age Children COMMENTS References Having clean, small pitchers of water and single-use paper 1. US Department of Agriculture, Food and Nutrition Service. Independent cups available in classrooms and on playgrounds allows Child Care Centers: A Child and Adult Care Food Program Handbook. children to serve themselves water when they are thirsty. Washington, DC: US Department of Agriculture; 2014. https://www.fns. usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20 Drinking fountains should be kept clean and sanitary Centers%20Handbook.pdf. Published May 2014. Accessed September 19, and maintained to provide adequate drainage. 2017 Shield JE, Mullen M. When should my kids snack? Academy of Nutrition 2. TYPE OF FACILITY and Dietetics Web site. http://www.eatright.org/resource/food/nutrition/ Center, Large Family Child Care Home dietary-guidelines-and-myplate/when-should-my-kids-snack. Published February 13, 2014. Accessed September 19, 2017 RELATED STANDARDS 3. Kleinman RE, Greer FR, eds. . 7th ed. Elk Grove Village, Pediatric Nutrition IL: American Academy of Pediatrics; 2014 Playing Outdoors 3.1.3.2 4. American Academy of Pediatrics Committee on Nutrition. Childhood Preparing, Feeding, and Storing Human Milk 4.3.1.3 nutrition. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/ 4 . 3.1. 5 Preparing, Feeding, and Storing Infant Formula Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed September 19, 2017 US Department of Agriculture, Food and Nutrition Service. Child and Testing for Lead and Copper Levels in Drinking 5.2.6.3 Adult Care Food Program (CACFP). Why CACFP is important. https:// Water www.fns.usda.gov/cacfp/why-cacfp-important. Published September 22, 2014. Accessed September 19, 2017 References 1. Centers for Disease Control and Prevention. Increasing Access to Drinking NOTES Water and Other Healthier Beverages in Early Care and Education Settings. Atlanta, GA: US Department of Health and Human Services; 2014. https:// Content in the STANDARD was modified on 11/9/2017. www.cdc.gov/obesity/downloads/early-childhood-drinking-water-toolkit- final-508reduced.pdf. Accessed September 19, 2017 Muckelbauer R, Sarganas G, Grüneis A, Müller-Nordhorn J. Association 2. 4.2.0.6 between water consumption and body weight outcomes: a systematic review. Availability of Drinking Water Am J Clin Nutr. 2013;98(2):282–299 3. Kleinman RE, Greer FR, eds. Pediatric Nutrition. 7th ed. Elk Grove Village, Clean, sanitary drinking water should be readily available, IL: American Academy of Pediatrics; 2014 in indoor and outdoor areas, throughout the day (1). Water 4. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd should not be a substitute for milk at meals or snacks where ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide.pdf. milk is a required food component unless recommended by Accessed September 19, 2017 the child’s primary health care provider. 5. Mullen M, Shield JE. Water: how much do kids need? Academy of Nutrition and Dietetics Web site. http://www.eatright.org/resource/fitness/sports-and- On hot days, infants receiving human milk in a bottle can performance/hydrate-right/water-go-with-the-flow. Published May 2, 2017. be given additional human milk in a bottle but should not Accessed September 19, 2017 be given water, especially in the first 6 months after birth NOTES - (1). Infants receiving formula and water can be given addi Content in the STANDARD was modified on 11/9/2017. tional formula in a bottle. Toddlers and older children will need additional water as physical activity and/or hot temperatures cause their needs to increase. Children should - learn to drink water from a cup or drinking fountain with

195 168 Caring for Our Children: National Health and Safety Performance Standards References 4.2.0.7 1. Heyman MB, Abrams SA; American Academy of Pediatrics Section on 100% Fruit Juice Gastroenterology, Hepatology, and Nutrition and Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Fruit or vegetable juice may be served once per day during a Pediatrics. 2017;139(6):e20170967 scheduled meal or snack to children 12 months or older (1). American Academy of Pediatrics. Fruit juice and your child’s diet. 2. All juices should be pasteurized and 100% juice without American Academy of Pediatrics HealthyChildren.org Web site. https:// www.healthychildren.org/English/healthy-living/nutrition/Pages/ added sugars or sweeteners. Fruit-Juice-and-Your-Childs-Diet.aspx. Updated May 22, 2017. Accessed September 19, 2017 (1) Maximum Allowed Age 3. American Academy of Pediatrics. Starting solid foods. American Academy of Pediatrics HealthyChildren.org Web site. https://www.healthychildren. Do not offer juices to infants younger than 12 months. 0–12 mo org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid- Limit consumption to 4 oz/day (½ cup). 1–3 y Foods.aspx. Updated April 7, 2017. Accessed September 19, 2017 US Department of Health and Human Services, US Department of 4. Limit consumption to 4–6 oz/day (½–¾ cup). 4–6 y Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th ed. 7–18 y Limit consumption to 8 oz/day (1 cup). Washington, DC: US Department of Health and Human Services; 2015. https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_ Guidelines.pdf. Accessed September 19, 2017 100% juice should be offered in an age-appropriate cup 5. Casamassimo P, Holt K, eds. Bright Futures: Oral Health Pocket Guide. 3rd instead of a bottle (2). These amounts include any juices ed. Washington, DC: National Maternal and Child Oral Health Resource Center; 2016. https://www.mchoralhealth.org/PDFs/BFOHPocketGuide. consumed at home. Caregivers/teachers should ask parents/ pdf. Accessed September 19, 2017 guardians if any juice is provided at home when deciding Crowe-White K, O’Neil CE, Parrott JS, et al. Impact of 100% fruit juice 6. if and when to serve fruit juice to children in care. Whole consumption on diet and weight status of children: an evidence-based review. Crit Rev Food Sci Nutr . 2016;56(5):871–884 fruit, mashed or pureed, is recommended for infants begin - 7. Shefferly A, Scharf RJ, DeBoer MD. Longitudinal evaluation of 100% fruit ning at 4 months of age or as developmentally ready (3). juice consumption on BMI status in 2–5-year-old children. Pediatr Obes. 2016;11(3):221–227 RATIONALE 8. US Food and Drug Administration. Talking about juice safety: what you While 100% fruit juice can be included in a healthy eating need to know. https://www.fda.gov/food/resourcesforyou/consumers/ ucm110526.htm. Updated September 19, 2017. Accessed September 19, 2017 pattern, whole fruit is more nutritious and provides many 9. Centers for Disease Control and Prevention. Healthy schools. The buzz on nutrients, including dietary fiber, not found in juices (4). energy drinks. https://www.cdc.gov/healthyschools/nutrition/energy.htm. Updated March 22, 2016. Accessed September 19, 2017. Limiting overall juice consumption and encouraging children to drink water in-between meals will reduce acids NOTES produced by bacteria in the mouth that cause tooth decay. Content in the STANDARD was modified on 11/9/2017. The frequency of exposure and liquids being pooled in the mouth are important in determining the cause of tooth 4.2.0.8 decay in children (5). Beverages labeled as “fruit punch,” Feeding Plans and Dietary Modifications “fruit nectar”, or “fruit cocktail” contain less than 100% Before a child enters an early care and education facility, fruit juice and may be higher in overall sugar content. Rou- the facility should obtain a written history that contains tine consumption of fruit juices does not provide adequate any special nutrition or feeding needs for the child, includ - amounts of vitamin E, iron, calcium, and dietary fiber—all ing use of human milk or any special feeding utensils. The essential in the growth and development of young children staff should review this history with the child’s parents/ (6). Continuous consumption of fruit juice may be associ - guardians, clarifying and discussing how the parents’/ ated with decreased appetite during mealtimes, which may guardians’ home feeding routines may differ from the lead to inadequate nutrition, feeding issues, and increases facility’s planned routine. The child’s primary health care in a child’s body mass index—all of which are considered provider should provide written information to the parent/ risk factors that may contribute to childhood obesity (7). guardian about any dietary modifications or special feeding Serving pasteurized juice protects against the possible techniques that are required at the early care and education outbreak of foodborne illness because the process destroys program so they can be shared with and implemented by any harmful bacteria that may have been present (8). the program. Drinks high in sugar and caffeine should be avoided If dietary modifications are indicated, based on a child’s because they can contribute to childhood obesity, tooth medical or special dietary needs, caregivers/teachers should decay, and poor nutrition (9). modify or supplement the child’s diet to meet the individ - TYPE OF FACILITY ual child’s specific needs. Dietary modifications should be Center, Large Family Child Care Home made in consultation with the parents/guardians and the child’s primary health care provider. Caregivers/teachers RELATED STANDARDS can consult with a nutritionist/registered dietitian. Routine Oral Hygiene Activities 3.1. 5.1 A child’s diet may be modified because of food sensitivity, 3.1. 5. 3 Oral Health Education a food allergy, or many other reasons. Food sensitivity Categories of Foods 4.2.0.4 includes a range of conditions in which a child exhibits an Availability of Drinking Water 4.2.0.6 adverse reaction to a food that, in some instances, can be 4 . 3.1.11 Introduction of Age-Appropriate Solid Foods life-threatening. Modification of a child’s diet may also be to Infants

196 169 Chapter 4: Nutrition and Food Service related to a food allergy, an inability to digest or to tolerate Some children have difficulty with slow weight gain and need their caloric intake monitored and supplemented. certain foods, a need for extra calories, a need for special Others, such as those with diabetes, may need to have their positioning while eating, diabetes and the need to match food with insulin, food idiosyncrasies, and other identified diet matched to their medication (e.g., insulin, if they are on a fixed dose of insulin). Some children are unable to tolerate feeding issues, including celiac disease, phenylketonuria, certain foods because of their allergy to the food or their diabetes, and severe food allergy (anaphylaxis). In some cases, a child may become ill if he/she is unable to eat, so inability to digest it. The 8 most common foods to cause anaphylaxis in children are cow’s milk, eggs, soy, wheat, missing a meal could have a negative consequence, espe - fish, shellfish, peanuts, and tree nuts (3). Staff members cially for children with diabetes. must know ahead of time what procedures to follow, as For a child with special health care needs who requires well as their designated roles, during an emergency. dietary modifications or special feeding techniques, writ- As a safety and health precaution, staff should know in ten instructions from the child’s parent/guardian and the child’s primary health care provider should be provided advance whether a child has food allergies, inborn errors in the child’s record and carried out accordingly. Dietary of metabolism, diabetes, celiac disease, tongue thrust, or - special health care needs related to feeding, such as requir - modifications should be recorded. These written instruc ing special feeding utensils or equipment, nasogastric or tions must identify gastric tube feedings, or special positioning. These situa - The child’s full name and date of instructions a. tions require individual planning prior to the child’s entry The child’s special health care needs b. into an early care and education program and on an Any dietary restrictions based on those special needs c. ongoing basis (2). Any special feeding or eating utensils d. In some cases, dietary modifications are based on religious Any foods to be omitted from the diet and any foods to e. or cultural beliefs. Detailed information on each child’s be substituted special needs, whether stemming from dietary, feeding Any other pertinent information about the child’s f. equipment, or cultural needs, is invaluable to the facility special health care needs staff in meeting the nutritional needs of all the children What, if anything, needs to be done if the child is g. in their care. exposed to restricted foods COMMENTS The written history of special nutrition or feeding needs should be used to develop individual feeding plans and, Close collaboration between families and the facility is collectively, to develop facility menus. Health care providers necessary for children on special diets. Parents/guardians with experience in disciplines related to special nutrition - may have to provide food on a temporary, or even perma - needs, including nutrition, nursing, speech therapy, occu nent, basis, if the facility, after exploring all community pational therapy, and physical therapy, should participate resources, is unable to provide the special diet. when needed and/or when they are available to the facility. Programs may consider using the American Academy of If available, the nutritionist/registered dietitian should Pediatrics (AAP) Allergy and Anaphylaxis Emergency Plan, approve menus that accommodate needed dietary which is included in the AAP clinical report, Guidance on modifications. Completing a Written Allergy and Anaphylaxis Emergency The feeding plan should include steps to take when a situa - Pla n (4). tion arises that requires rapid response by the staff, such as TYPE OF FACILITY a child choking during mealtime or a child with a known Center, Large Family Child Care Home history of food allergies demonstrating signs and symptoms of anaphylaxis (severe allergic reaction), such as difficulty RELATED STANDARDS breathing and severe redness and swelling of the face or 3. 5. 0.1 Care Plan for Children with Special Health mouth. The completed plan should be on file and accessible Care Needs to staff and available to parents/guardians on request. Written Nutrition Plan 4 . 2 . 0.1 RATIONALE Assessment and Planning of Nutrition for 4.2.0.2 Children with special health care needs may have individ - Individual Children ual requirements related to diet and swallowing, involving 4 . 2 . 0.12 Vegetarian/Vegan Diets special feeding utensils and feeding needs that will necessi - 4 . 3.1. 2 Feeding Infants on Cue by a Consistent tate the development of an individual plan prior to their Caregiver/Teacher entry into the facility (1). Many children with special health Foods that Are Choking Hazards 4 . 5. 0.10 care needs have difficulty with feeding, including delayed attainment of basic chewing, swallowing, and independent - feeding skills. Food, eating style, food utensils, and equip ment, including furniture, may have to be adapted to meet the developmental and physical needs of individual children (2,3,).

197 170 Caring for Our Children: National Health and Safety Performance Standards COMMENTS References . 4th ed. Sunbury, MA: Jones and Pediatric Nutrition 1. Samour PQ, King K. Caregivers/teachers should be aware that new foods may Bartlett Learning; 2010 need to be offered between 8 and 15 times before they Pediatric Nutrition Kleinman RE, Greer FR, eds. . 7th ed. Elk Grove Village, 2. IL: American Academy of Pediatrics; 2014 may be accepted (2,4). Sample menus and menu planning 3. Kaczkowski CH, Caffrey C. Pediatric nutrition. In: Blanchfield DS, ed. templates are available from most state health departments . The Gale Encyclopedia of Children’s Health: Infancy Through Adolescence and the US Department of Agriculture (5) and its Child Vol 3. 3rd ed. Farmington Hills, MI: Gale; 2016:2063–2066 Wang J, Sicherer SH; American Academy of Pediatrics Section on 4. and Adult Care Food Program (6). Allergy and Immunology. Guidance on completing a written allergy Pediatrics. 2017;139(3):e20164005 and anaphylaxis emergency plan. Good communication between caregivers/teachers and parents/guardians is essential for successful feeding, in NOTES general, including when introducing age-appropriate solid Content in the STANDARD was modified on 11/9/2017. foods (complementary foods). The decision to feed specific foods should be made in consultation with the parents/ 4.2.0.9 guardians. It is recommended that caregivers/teachers be Written Menus and Introduction of given written instructions on the introduction and feeding of foods from the parents/guardians and the infants’ New Foods primary health care providers. Facilities should develop, at least one month in advance, written menus that show all foods to be served during that TYPE OF FACILITY month and should make the menus available to parents/ Center, Large Family Child Care Home guardians. The facility should date and retain these menus RELATED STANDARDS for 6 months, unless the state regulatory agency requires a General Plan for Feeding Infants 4 . 3.1.1 longer retention time. The menus should be amended to reflect any and all changes in the food actually served. 4 . 3.1.11 Introduction of Age-Appropriate Solid Foods Any substitutions should be of equal nutrient value. to Infants Experience with Familiar and New Foods 4.5.0.8 Caregivers/teachers should use or develop a take-home sheet for parents/guardians on which caregivers/teachers References 1. Benjamin SE, Copeland KA, Cradock A, et al. Menus in child care: a record the food consumed each day or, for breastfed infants, . J Am Diet Assoc comparison of state regulations with national standards. the number of times they are fed and other important 2009;109(1):109–115 notes. Caregivers/teachers should continue to consult with 2. Coulthard H, Sealy A. Play with your food! Sensory play is associated . with tasting of fruits and vegetables in preschool children. Appetite each infant’s parent/guardian about foods they have intro - 2017;113:84–90 duced and are feeding to the infant. In this way, caregivers/ 3. Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: teachers can follow a schedule of introducing new foods one . 2007;35(1):22–34 J Law Med Ethics conception to adolescence. 4. US Department of Agriculture. Menu planning tools for child care at a time and more easily identify possible food allergies or providers. https://healthymeals.fns.usda.gov/menu-planning/menu- - intolerances. Caregivers/teachers should let parents/guard planning-tools/menu-planning-tools-child-care-providers. Accessed ians know what and how much their infants eat each day. September 20, 2017 5. US Department of Agriculture, Food and Nutrition Service. Child and To avoid problems of food sensitivity in infants younger Adult Care Food Program (CACFP). https://www.fns.usda.gov/cacfp/ than 12 months, caregivers/teachers should obtain from child-and-adult-care-food-program. Published March 29, 2017. Accessed September 20, 2017 infants’ parents/guardians a list of foods that have already 6. American Academy of Pediatrics Committee on Nutrition. Childhood been introduced (without any reaction) and serve those nutrition. American Academy of Pediatrics HealthyChildren.org Web items when appropriate. As new foods are considered for site. https://www.healthychildren.org/English/healthy-living/nutrition/ Pages/Childhood-Nutrition.aspx. Updated March 3, 2016. Accessed serving, caregivers/teachers should share and discuss these September 20, 2017 foods with parents/guardians prior to their introduction. NOTES RATIONALE Content in the STANDARD was modified on 11/9/2017. Planning menus in advance helps to ensure that food will be on hand. Posting menus in a prominent area and distrib - 4 . 2 . 0 .10 uting them to parents/guardians helps to inform parents/ guardians about proper nutrition Parents/guardians need Care for Children with Food Allergies to be informed about food served in the facility to know When children with food allergies attend an early care and how to complement it with the food they serve at home. education facility, here is what should occur. If a child has difficulty with any food served at the facility, a. Each child with a food allergy should have a care plan parents/guardians can address this issue with appropriate prepared for the facility by the child’s primary health staff members. Some regulatory agencies require menus as care provider, to include a part of the licensing and auditing process (1). 1. A written list of the food(s) to which the child is - Consistency between home and the early care and educa allergic and instructions for steps that need to be tion setting is essential during the period of rapid change taken to avoid that food. when infants are learning to eat age-appropriate solid 2. A detailed treatment plan to be implemented in the fo o d s (1-3). event of an allergic reaction, including the names,

198 171 Chapter 4: Nutrition and Food Service Food sharing between children must be prevented by doses, and methods of administration of any medi - cations that the child should receive in the event of a careful supervision and repeated instruction to children reaction. The plan should include specific symptoms about this issue. Exposure may also occur through contact that would indicate the need to administer one or between children or by contact with contaminated surfaces, more medications. such as a table on which the food allergen remains after eating. Some children may have an allergic reaction just b. Based on the child’s care plan, the child’s caregivers/ teachers should receive training, demonstrate compe from being in proximity to the offending food, without - actually ingesting it. Such contact should be minimized tence in, and implement measures for by washing children’s hands and faces and all surfaces that 1. Preventing exposure to the specific food(s) to which the child is allergic were in contact with food. In addition, reactions may occur when a food is used as part of an art or craft project, such Recognizing the symptoms of an allergic reaction 2. 3. Treating allergic reactions as the use of peanut butter to make a bird feeder or wheat c. Parents/guardians and staff should arrange for the to make modeling compound. facility to have the necessary medications, proper RATIONALE storage of such medications, and the equipment and Food allergy is common, occurring in between 2% and training to manage the child’s food allergy while the 8% of infants and children (1). Allergic reactions to food child is at the early care and education facility. can range from mild skin or gastrointestinal symptoms to d. Caregivers/teachers should promptly and properly severe, life-threatening reactions with respiratory and/or administer prescribed medications in the event of an cardiovascular compromise. Hospitalizations from food allergic reaction according to the instructions in the allergy are being reported in increasing numbers, especially care plan. among children with asthma who have one or more food The facility should notify parents/guardians immedi- e. sensitivities (2). A major factor in death from anaphylaxis ately of any suspected allergic reactions, the ingestion has been a delay in the administration of lifesaving emer - of the problem food, or contact with the problem food, gency medication, particularly epinephrine (3). Intensive even if a reaction did not occur. efforts to avoid exposure to the offending food(s) are, there - f. The facility should recommend to the family that the fore, warranted. The maintenance of detailed care plans child’s primary health care provider be notified if the and the ability to implement such plans for the treatment child has required treatment by the facility for a food of reactions are essential for all children with food allergic reaction. a l lerg ies (4). g. The facility should contact the emergency medical COMMENTS services (EMS) system immediately if the child has any serious allergic reaction and/or whenever epinephrine Successful food avoidance requires a cooperative effort that (eg, EpiPen, EpiPen Jr) has been administered, even if must include the parents/guardians, child, child’s primary the child appears to have recovered from the allergic health care provider, and early care and education staff. In reaction. some cases, especially for a child with multiple food aller - h. Parents/guardians of all children in the child’s class gies, parents/guardians may need to take responsibility for should be advised to avoid any known allergens in class providing all the child’s food. In other cases, early care and treats or special foods brought into the early care and education staff may be able to provide safe foods as long as education setting. they have been fully educated about effective food Individual child’s food allergies should be posted prom- i. avoidance. inently in the classroom where staff can view them and/ Effective food avoidance has several facets. Foods can be or wherever food is served. listed on an ingredient list under a variety of names; for The written child care plan, a mobile phone, and a list j. example, milk could be listed as casein, caseinate, whey, of the proper medications for appropriate treatment if and/or lactoglobulin. the child develops an acute allergic reaction should be Some children with a food allergy will have mild reactions routinely carried on field trips or transport out of the and will only need to avoid the problem food(s). Others will early care and education setting. need to have antihistamine or epinephrine available to be For all children with a history of anaphylaxis (severe used in the event of a reaction. allergic reaction), or for those with peanut and/or tree For more information on food allergies, contact Food nut allergy (whether or not they have had anaphylaxis), Allergy Research & Education (FARE) at www.foodallergy. epinephrine should be readily available. This will usually org. Some early care and education/school settings require be provided as a premeasured dose in an auto-injector, that all foods brought into the classroom are store-bought - such as EpiPen or EpiPen Jr. Specific indications for admin and in their original packaging so that a list of ingredients istration of epinephrine should be provided in the detailed is included, to prevent exposure to allergens. However, care plan. Within the context of state laws, appropriate packaged foods may mistakenly include allergen-type personnel should be prepared to administer epinephrine ingredients. Alerts and ingredient recalls can be found when needed. on the FARE Web site (5).

199 172 Caring for Our Children: National Health and Safety Performance Standards harmful residues in the facility to reduce children’s expo - TYPE OF FACILITY sure. Pica involves the recurrent ingestion of substances Center, Large Family Child Care Home that do not provide nutrition. Pica is most prevalent among RELATED STANDARDS children between the ages of 1 and 3 years (3). Among chil - Care Plan for Children with Special Health 3. 5. 0.1 - dren with intellectual developmental disability and concur Care Needs rent mental illness, the incidence exceeds 25% (3). 4.2.0.2 Assessment and Planning of Nutrition for Children who have iron deficiency anemia regularly ingest Individual Children nonnutritive substances. Dietary intake plays an impor- Feeding Plans and Dietary Modifications 4.2.0.8 tant role because certain nutrients, such as those ingested Situations that Require Medical Attention Appendix P: with a diet high in fat or lecithin, increase the absorption of R ig ht Away lead, which can result in toxicity (3). Lead, when present in the gastrointestinal tract, is absorbed in place of calcium. References 1. Bugden EA, Martinez AK, Greene BZ, Eig K. Safe at School and Ready to Children will absorb more lead than an adult. Whereas an Learn: A Comprehensive Policy Guide for Protecting Students with adult absorbs approximately 10% of ingested lead, a toddler 2nd ed. Alexandria, VA: National School Life-threatening Food Allergies. absorbs approximately 30% to 50% of ingested lead. Chil- Boards Association; 2012. http://www.nsba.org/sites/default/files/reports/ Safe-at-School-and-Ready-to-Learn.pdf. Accessed September 20, 2017 dren who ingest paint chips or contaminated soil can 2. Caffarelli C, Garrubba M, Greco C, Mastrorilli C, Povesi Dascola C. develop lead toxicity, which can lead to developmental Asthma and food allergy in children: is there a connection or interaction? delays and neurodevelopmental disability. Currently, there Front Pediatr. 2016;4:34 3. Tsuang A, Demain H, Patrick K, Pistiner M, Wang J. Epinephrine use and is consensus that repeated ingestion of some nonfood items training in schools for food-induced anaphylaxis among non-nursing staff. J results in an increased lead burden of the body (3,4). Early Allergy Clin Immunol Pract. 2017;5(5):1418–1420.e3 detection and intervention in nonfood ingestion can pre- 4. Wang J, Sicherer SH; American Academy of Pediatrics Section on Guidance on completing a written allergy Allergy and Immunology. vent nutritional deficiencies and growth/developmental and anaphylaxis emergency plan. Pediatrics. 2017;139(3):e20164005 disabilities. Eating soil or drinking contaminated water 5. Food Allergy Research & Education. Allergy alerts. https://www. could result in an infection with a parasite. foodallergy.org/alerts. Accessed September 20, 2017 COMMENTS Additional Resources Centers for Disease Control and Prevention. Healthy schools. Food allergies in - Common sources of lead include lead-based paint (in build schools. https://www.cdc.gov/healthyschools/foodallergies/index.htm. ings constructed before 1978 or constructed on properties Reviewed May 9, 2017. Accessed September 20, 2017 that were formerly the site of buildings constructed before Centers for Disease Control and Prevention. Voluntary Guidelines for 1978); contaminated drinking water (from public water Managing Food Allergies in Schools and Early Care and Education Programs. https:// Washington, DC: US Department of Health and Human Services; 2013. systems, supply pipes, or plumbing fixtures); contaminated www.cdc.gov/healthyschools/foodallergies/pdf/13_243135_A_Food_Allergy_ soil (from old exterior paint); the storage of acidic foods Web_508.pdf. Accessed September 20, 2017 in open cans or ceramic containers/pottery with a lead NOTES glaze; certain types of art supplies; some imported toys Content in the STANDARD was modified on 11/9/2017. and inexpensive play jewelry; and polyvinyl chloride (PVC) vinyl products (eg, beach balls, soft PVC-containing dolls, rubber ducks, chew toys, nap mats). These sources and 4 . 2 . 0 .11 - others should be addressed concurrently with a nutrition Ingestion of Substances that Do Not ally adequate diet as a prevention strategy. It is important to Provide Nutrition reduce exposure to possible lead sources, promote a healthy All children should be monitored to prevent them from and balanced diet, and encourage blood lead level (BLL) eating substances that do not provide nutrition (often testing of children. If a child’s BLL is 5 mcg/dL or greater, it referred to as pica) (1,2). The parents/guardians of chil- is important to identify and remove the child’s source of dren who repeatedly place nonnutritive substances in lead exposure. their mouths should be notified and informed of the RELATED STANDARDS importance of having their children visit their primary Testing for Lead and Copper Levels in 5.2.6.3 health care provider or a local health department. In Drinking Water collaboration with the child’s parent/guardian, an assessment of the child’s eating behavior and dietary Testing for Lead 5. 2 . 9.13 intake, along with any other health issues, should References occur to begin an intervention strategy. 1. Centers for Disease Control and Prevention. Gateway to health com- munication & social marketing practice. Pica behavior and contaminated RATIONALE soil. https://www.cdc.gov/healthcommunication/toolstemplates/ entertainmented/tips/pica.html. Updated September 15, 2017. The occasional ingestion of nonnutritive substances can Accessed September 20, 2017 be a part of everyday living and is not necessarily a con- 2. Miao D, Young SL, Golden CD. A meta-analysis of pica and micronutrient cern. For example, ingestion of nonnutritive substances can status. Am J Hum Biol. 2015;27(1):84–93 3. McNaughten B, Bourke T, Thompson A. Fifteen-minute consultation: the occur from mouthing, placing dirty hands in the mouth, child with pica. Arch Dis Child Educ Pract Ed. May 2017;edpract-2016-312121 or eating dropped food. However, because of this normal Moya J, Bearer CF, Etzel RA. 4. Children’s behavior and physiology and how behavior it is that much more important to minimize it affects exposure to environmental contaminants. Pediatrics. 2004;113(4 Suppl 3):996–1006

200 173 Chapter 4: Nutrition and Food Service (1). Sensitivity to cultural factors, including beliefs and NOTES practices of a child’s family, should be maintained. Content in this standard was modified on August 23, 2016 and November 10, 2017. Changing lifestyles and convictions and beliefs about food and religion, including what is eaten and what foods are restricted or never consumed, have some families with 4 . 2 . 0 .12 infants and children practicing several levels of vegetarian Vegetarian/Vegan Diets diets. Some parents/guardians indicate they are vegetarians, Infants and children, including school-aged children from semi-vegetarian, or strict vegetarians because they do not families practicing a vegetarian diet, can be accommodated or seldom eat meat. Others label themselves lacto-ovo vege - in an early care and education environment when there is: tarians, eating or drinking foods such as eggs and dairy a. Written documentation from parents/guardians with a products. Still others describe themselves as vegans who detailed and accurate dietary history of food choices— restrict themselves to ingesting only plant-based foods, foods eaten, levels of limitations/restrictions to foods, avoiding all and any animal products. and frequency of foods offered; TYPE OF FACILITY b. A current health record of the child available to the Center, Large Family Child Care Home caregivers/teachers, including information about height and rate of weight gain, or consistent poor appetite RELATED STANDARDS (warning signs of growth deficiencies); 3.1. 2 .1 Routine Health Supervision and Growth Sharing of updated information on the child’s health c. Monitoring with the parents/guardians and the early care and Assessment and Planning of Nutrition for 4.2.0.2 education staff by the child care health consultant and Individual Children the nutritionist/registered dietitian; and 4 . 3.1. 6 Use of Soy-Based Formula and Soy Milk Sharing sound health and nutrition information that is d. Use of Nutritionist/Registered Dietitian 4.4.0.2 culturally-relevant to the family to ensure that the child receives adequate calories and essential nutrients. References 1. Kleinman RE, Greer FR, eds. . 7th ed. Elk Grove Village, Pediatric Nutrition RATIONALE IL: American Academy of Pediatrics; 2014 - Infants and young children are at highest risk for nutri Hayes D. Feeding vegetarian and vegan infants and toddlers. Academy of 2. Nutrition and Dietetics Web site. http://www.eatright.org/resource/food/ tional deficiencies for energy levels and essential nutrients, nutrition/vegetarian-and-special-diets/feeding-vegetarian-and-vegan- including protein, calcium, iron, zinc, vitamins B and B, infants-and-toddlers. Published May 4, 2015. Accessed September 20, 2017 and vitamin D (1-3). The younger the child, the more criti - 3. Mangels R, Driggers J. The youngest vegetarians. Vegetarian infants and toddlers. Infant Child Adolesc Nutr. 2012;4(1):8–20 cal it is to know about family food 6 12 choices, limitations, Maternal versus infant vitamin D 4. Hollis BW, Wagner CL, Howard CR, et al. and restrictions because the child is dependent on family supplementation during lactation: a randomized controlled trial. Pediatrics. food (2). 2015;136(4):625–634 5. US Department of Agriculture, Food and Nutrition Service. Independent Also, it is important that a child’s diet consist of a variety Child Care Centers: A Child and Adult Care Food Program Handbook. Washington, DC: US Department of Agriculture; 2014. https://www.fns. of nourishing food to support the critical period of rapid usda.gov/sites/default/files/cacfp/Independent%20Child%20Care%20 growth in the early years after birth. All children who are Centers%20Handbook.pdf. Accessed September 20, 2017 vegetarian/vegan should receive multivitamins, especially Additional Resources vitamin D (400 IU of vitamin D is recommended from US Department of Agriculture. 10 tips: healthy eating for vegetarians. 6 months of age to adulthood unless there is certainty of ChooseMyPlate.gov Web site. https://www.choosemyplate.gov/ having the daily allowance met by foods); infants younger ten-tips-healthy-eating-for-vegetarians. Updated July 25, 2017. Accessed September 20, 2017 than 6 months who are exclusively or partially breastfed US Department of Agriculture, US Department of Health and Human and who receive less than 16 oz of formula per day should Services. Meat and meat alternates: build a healthy plate with protein. In: receive 400 IU of vitamin D (4). If the facility participates Nutrition and Wellness Tips for Young Children: Provider Handbook for the in the US Department of Agriculture Child and Adult Care . Alexandria, VA: US Department of Child and Adult Care Food Program Agriculture; 2012. https://www.fns.usda.gov/sites/default/files/protein.pdf. Food Program, guidance for meals and snack patterns Accessed September 20, 2017 must be followed for any child consuming a vegetarian or vegan diet (5). NOTES Content in this standard was modified on November 10, COMMENTS 2 017. For older children who have more choice about what they eat and drink, effort should be made to provide accurate nutrition information so they make the wisest food choices for themselves. Both the early care and education program/ school and the caregiver/teacher have an opportunity to inform, teach, and promote sound eating practices, along with the consequences when poor food choices are made

201 174 Caring for Our Children: National Health and Safety Performance Standards several objectives, including increasing the proportion of 4.3 mothers who breastfeed their infants and increasing the REQUIREMENTS FOR SPECIAL duration of breastfeeding and exclusive breastfeeding (4). GROUPS OR AGES OF CHILDREN Incidences of common childhood illnesses, such as diarrhea, respiratory disease, bacterial meningitis, botulism, urinary 4 . 3 .1 tract infections, sudden infant death syndrome, insulin- NUTRITION FOR INFANTS dependent diabetes, ulcerative colitis, and ear infections, and overall risk for childhood obesity are significantly 4 . 3 .1.1 - decreased in breastfed children (5,6). Similarly, breastfeed General Plan for Feeding Infants ing, when paired with other healthy parenting behaviors, The facility should keep records detailing whether an infant has been directly related to increased cognitive development is breastfed or formula fed, along with the type of formula in infants (7). Breastfeeding also has added benefits to the being served. An infant feeding record of human (breast) mother: it decreases risk of diabetes, breast and ovarian milk and/or all formula given to the infant should be com- cancers, and heart disease (8). pleted daily. Infant meals and snacks should follow the Mothers who want to supplement their breast milk with meal and snack patterns of the Child and Adult Care Food formula may do so, as the infant will continue to receive - Program. Food should be appropriate for the infant’s indi breastfeeding benefits (4,5,7). Iron-fortified infant formula is vidual nutrition requirements and developmental stage an acceptable alternative to human milk as a food for infant as determined by written instructions obtained from the feeding even though it lacks any anti-infective or immuno - child’s parent/guardian or primary health care provider. logical components. Regardless of feeding preference, an The facility should encourage breastfeeding by providing adequately nourished infant is more likely to achieve healthy - accommodations and continuous support to the breastfeed physical and mental development, which will have long-term ing mother. Facilities should have a designated place set positive effects on health (9). aside for breastfeeding mothers who want to visit the class - COMMENTS room during the workday to breastfeed, as well as a private The ways to help a mother breastfeed successfully in the area (not a bathroom) with an outlet for mothers to pump early care and education facility are (2,6,8): their breast milk (1,2). The private area also should have access to water or hand hygiene. A place that parents/ a. If she wishes to breastfeed her infant or child when she guardians feel they are welcome to breastfeed, pump, or comes to the facility, offer or provide her a bottle-feed can create a positive and supportive environ - 1. Quiet, comfortable, and private place to breastfeed ment for the family. (This helps her milk to let down.) Place to wash her and her infant’s hands before and 2. Infants may need a variety of special formulas, such as after breastfeeding soy-based formula or elemental formulas, that are easier 3. Pillow to support her infant on her lap while nursing to digest and less allergenic. Elemental or special hypo- Nursing stool or step stool for her feet so she doesn’t 4. allergenic formulas should be specified in the infant’s care have to strain her back while nursing plan. Age-appropriate solid foods other than human milk 5. Glass of water or other liquid to help her stay complementary or infant formula (ie, foods) should be hydrated introduced no sooner than 6 months of age or as indicated Encourage her to get the infant used to being fed her b. by the individual child’s nutritional and developmental expressed human milk by another person before the needs. Please refer to standards 4.3.1.11 and 4.3.1.12 for infant starts in early care and education, while continu - more information. ing to breastfeed directly herself. RATIONALE c. Discuss with her the infant’s usual feeding pattern and Human milk, as an exclusive food, is best suited to meet the benefits of feeding the infant based on the infant’s the entire nutritional needs of an infant from birth until hunger and satiety cues rather than on a schedule; ask 6 months of age, with the exception of recommended vita - her if she wishes to time the infant’s last feeding so that - min D supplementation. In addition to nutrition, breast the infant is hungry and ready to breastfeed when she feeding supports optimal health and development. Human arrives; and ask her to leave her availability schedule with milk is also the best source of milk for infants for at least the early care and education program as well as to call if the first 12 months of age and, thereafter, for as long as she is planning to miss a feeding or is going to be late. mutually desired by mother and child. Breastfeeding Encourage her to provide a backup supply of frozen or d. protects infants from many acute and chronic diseases refrigerated expressed human milk; properly label the and has advantages for the mother, as well (3). infant’s full name, date, and time on the bottle or other clean storage container in case the infant needs to eat - Research overwhelmingly shows that exclusive breastfeed more often than usual or the mother’s visit is delayed. ing for 6 months, and continued breastfeeding for at least a year or longer, dramatically improves health outcomes for children and their mothers. Healthy People 2020 outlines

202 175 Chapter 4: Nutrition and Food Service 4. Healthy People 2020. Maternal, infant, and child health. HealthyPeople.gov e. Share with her information about other places or people Web site. https://www.healthypeople.gov/2020/topics-objectives/topic/ in the community who can answer her questions and maternal-infant-and-child-health/objectives. Accessed January 11, 2018 concerns about breastfeeding, such as local lactation 5. Furman L. Breastfeeding: what do we know, and where do we go from here? Pediatrics. 2017;139(4):e20170150 consultants. 6. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding 1. Provide culturally appropriate breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841 materials, including community resources for 7. Gibbs BG, Forste R. Breastfeeding, parenting, and early cognitive development. J Pediatr. 2014;164(3):487–493 parents/guardians that include appropriate lan- 8. 8. Binns C, Lee M, Low WY. The long-term public health benefits of guage and pictures of multicultural families to breastfeeding. Asia Pac J Public Health. 2016;28(1):7–14 assist families in identifying with them. 9. 9. Danawi H, Estrada L, Hasbini T, Wilson DR. Health inequalities and breastfeeding in the United States of America. Int J Childbirth Educ. f. Ensure that all staff receive training in breastfeeding 2 016 ; 31(1) support and promotion. NOTES g. Ensure that all staff are trained in the proper handling, storing, and feeding of each milk product, including Content in the STANDARD was modified on 05/30/2018. human milk or infant formula. ADDITIONAL RESOURCES 4 . 3 .1. 2 Breastfeeding, US Department of Health and Human Services Office on Feeding Infants on Cue by a Consistent Women’s Health (https://www.womenshealth.gov/printables-and-shareables/ Caregiver/Teacher health-topic/breastfeeding) Caregivers/teachers should feed infants on cue unless Feeding Infants: A Guide for Use in the Child Nutrition Programs, US Department of Agriculture (USDA) Food and Nutrition Service (https://www. the parent/guardian and the child’s primary health care fns.usda.gov/tn/feeding-infants-guide-use-child-nutrition-programs) provider give written instructions stating otherwise (1). Infant Meal Pattern, USDA (https://fns-prod.azureedge.net/sites/default/files/ Caregivers/teachers should be gentle, patient, sensitive, cacfp/CACFP_infantmealpattern.pdf) and reassuring when responding appropriately to the Strategy 6, Support for Breastfeeding in Early Care and Education, Centers for infant’s feeding cues (2). Responsive feeding is most suc- Disease Control and Prevention (https://www.cdc.gov/breastfeeding/pdf/ - cessful when caregivers/teachers learn how infants exter strategy6-support-breastfeeding-early-care.pdf ) nally communicate hunger and fullness. Crying alone is Updated Child and Adult Care Food Program Meal Patterns: Infant Meals, USDA (https://fns-prod.azureedge.net/sites/default/files/cacfp/CACFP_ not a cue for hunger unless accompanied by other cues, InfantMealPattern_FactSheet_V2.pdf ) such as opening the mouth, making sucking sounds, rooting, fast breathing, clenched fingers/fists, and flexed TYPE OF FACILITY arms/legs (1,2). Whenever possible, the same caregiver/ Center, Large Family Child Care Home, Small Family teacher should feed a specific infant for most of that infant’s Child Care Home feedings (3). Caregivers/teachers should not feed infants RELATED STANDARDS - beyond satiety; just as hunger cues are important in initiat 4.2.0.9 Written Menus and Introduction of New ing feedings, observing satiety cues can limit overfeeding. Foods An infant will communicate fullness by shaking the head 4.3.1.3 Preparing, Feeding, and Storing Human Milk or turning away from food (1,4,5). 4 . 3.1. 5 Preparing, Feeding, and Storing Infant A pacifier should not be offered to an infant prior to Formula being fed. 4 . 3.1.11 Introduction of Age-Appropriate Solid Foods RATIONALE to Infants Responsive feeding meets the infant’s nutritional and 4 . 3.1.12 Feeding Age-Appropriate Solid Foods to emotional needs and provides an immediate response to Infants the infant, which helps ensure trust and feelings of security Our Child Care Center Supports Appendix JJ: (6). A caregiver/teacher is more likely to understand how a Breastfeeding particular infant communicates hunger/satiety when con- sistent, reliable feedings and interactions are done regularly References 1. Centers for Disease Control and Prevention. Strategies to Prevent Obesity - over time. Early relationships between an infant and care and Other Chronic Diseases: The CDC Guide to Strategies to Support givers/teachers involving feeding set the stage for an infant Breastfeeding Mothers and Babies. Atlanta, GA: US Department of Health to develop eating patterns for life (1-5). Responsive feeding and Human Services; 2013. http://www.cdc.gov/breastfeeding/pdf/ BF-Guide-508.pdf. Accessed January 11, 2018 may help prevent childhood obesity (5-7). 2. Special Supplemental Nutrition Program for Women, Infants, and Children TYPE OF FACILITY (WIC); US Department of Agriculture Food and Nutrition Service. Breastfeeding Policy and Guidance. https://www.fns.usda.gov/sites/default/ Center, Large Family Child Care Home, Small Family files/wic/WIC-Breastfeeding-Policy-and-Guidance.pdf. Published July Child Care Home 2016. Accessed January 11, 2018 3. Darmawikarta D, Chen Y, Lebovic G, Birken CS, Parkin PC, Maguire JL. RELATED STANDARDS Total duration of breastfeeding, vitamin D supplementation, and serum levels of 25-hydroxyvitamin D. Am J Public Health. 2016;106(4):714–719 4 . 3.1.1 General Plan for Feeding Infants 4 . 3.1. 8 Techniques for Bottle Feeding

203 176 Caring for Our Children: National Health and Safety Performance Standards filled, labeled containers of human milk should be kept References 1. Blaine RE, Davison KK, Hesketh K, Taveras EM, Gillman MW, Benjamin refrigerated. Human milk containers with significant Neelon SE. Child care provider adherence to infant and toddler feeding amount of contents remaining (greater than one ounce) recommendations: findings from the Baby Nutrition and Physical Activity may be returned to the mother at the end of the day as Self-Assessment for Child Care (Baby NAP SACC) Study. Child Obes. 2015;11(3):30 4 –313 long as the child has not fed directly from the bottle. Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the Robert Wood 2. Johnson Foundation HER Expert Panel on Best Practices for Promoting Frozen human milk may be transported and stored in Healthy Nutrition, Feeding Patterns, and Weight Status for Infants and single use plastic bags and placed in a freezer (not a com- Toddlers From Birth to 24 Months. Feeding Guidelines for Infants and partment within a refrigerator but either a freezer with a Young Toddlers: A Responsive Parenting Approach. Guidelines for Health Professionals. Durham, NC: Healthy Eating Research; 2017. separate door or a standalone freezer). Human milk should http://healthyeatingresearch.org/wp-content/uploads/2017/02/ be defrosted in the refrigerator if frozen, and then heated her_feeding_guidelines_brief_021416.pdf. Published February 2017. briefly in bottle warmers or under warm running water Accessed November 14, 2017 3. Zero to Three. How to care for infants and toddlers in groups. 4. Continuity so that the temperature does not exceed 98.6°F. If there of care. https://www.zerotothree.org/resources/77-how-to-care-for-infants- is insufficient time to defrost the milk in the refrigerator and-toddlers-in-groups#chapter-38. Published February 8, 2010. Accessed before warming it, then it may be defrosted in a container November 14, 2017 4. US Department of Agriculture, Special Supplemental Nutrition Program of running cool tap water, very gently swirling the bottle for Women, Infants, and Children. Infant hunger and satiety cues. periodically to evenly distribute the temperature in the https://wicworks.fns.usda.gov/wicworks/WIC_Learning_Online/support/ milk. Some infants will not take their mother’s milk unless job_aids/cues.pdf. Updated October 2016. Accessed November 14, 2017 5. Buvinger E, Rosenblum K, Miller AL, Kaciroti NA, Lumeng JC. Observed - it is warmed to body temperature, around 98.6°F. The care infant food cue responsivity: associations with maternal report of infant giver/teacher should check for the infant’s full name and eating behavior, breastfeeding, and infant the date on the bottle so that the oldest milk is used first. weightgain. Appetite. 2017;112:219–226 6. Early Head Start National Resource Center. Observation: The Heart of After warming, bottles should be mixed gently (not shaken) Individualizing Responsive Care. Washington, DC: Early Head Start and the temperature of the milk tested before feeding. National Resource Center; 2013. https://eclkc.ohs.acf.hhs.gov/sites/default/ files/pdf/ehs-ta-paper-15-observation.pdf. Accessed November 14, 2017 Expressed human milk that presents a threat to an infant, 7. 7. Redsell SA, Edmonds B, Swift JA, et al. Systematic review of randomised such as human milk that is in an unsanitary bottle, is controlled trials of interventions that aim to reduce the risk, either directly curdled, smells rotten, and/or has not been stored follow- or indirectly, of overweight and obesity in infancy and early childhood. Matern Child Nutr. 2016;12(1):24–38 ing the storage guidelines of the Academy of Breastfeeding Medicine as shown later in this standard, should be NOTES returned to the mother. Content in the STANDARD was modified on 05/30/2018. Some children around six months to a year of age may be developmentally ready to feed themselves and may want 4.3.1.3 to drink from a cup. The transition from bottle to cup can Preparing, Feeding, and Storing Human Milk come at a time when a child’s fine motor skills allow use Expressed human milk should be placed in a clean and of a cup. The caregiver/teacher should use a clean small cup sanitary bottle with a nipple that fits tightly or into an without cracks or chips and should help the child to lift equivalent clean and sanitary sealed container to prevent and tilt the cup to avoid spillage and leftover fluid. The spilling during transport to home or to the facility. Only caregiver/teacher and mother should work together on cleaned and sanitized bottles, or their equivalent, and cup feeding of human milk to ensure the child is receiving nipples should be used in feeding. The bottle or container adequate nourishment and to avoid having a large amount should be properly labeled with the infant’s full name and of human milk remaining at the end of feeding. Two to the date and time the milk was expressed. The bottle or three ounces of human milk can be placed in a clean container should immediately be stored in the refrigerator cup and additional milk can be offered as needed. Small on arrival. amounts of human milk (about an ounce) can be discarded. The mother’s own expressed milk should only be used for Human milk can be stored using the following guidelines her own infant. Likewise, infant formula should not be from the Academy of Breastfeeding Medicine: used for a breastfed infant without the mother’s written RATIONALE permission. Labels for containers of human milk should be resistant Avoid bottles made of plastics containing bisphenol A to loss of the name and date/time when washing and (BPA) or phthalates, sometimes labeled with #3, #6, or #7 handling. This is especially important when the frozen (1). Use glass bottles with a silicone sleeve (a silicone bottle bottle is thawed in running tap water. There may be jacket to prevent breakage) or those made with safer plastics several bottles from different mothers being thawed such as polypropylene or polyethylene (labeled BPA-free) or and warmed at the same time in the same place. plastics with a recycling code of #1, #2, #4, or #5. By following this standard, the staff is able, when necessary, Non-frozen human milk should be transported and stored to prepare human milk and feed an infant safely, thereby in the containers to be used to feed the infant, identified reducing the risk of inaccuracy or feeding the infant un- with a label which will not come off in water or handling, sanitary or incorrect human milk (2,3). Written guidance bearing the date of collection and child’s full name. The

204 177 Chapter 4: Nutrition and Food Service Guidelines for Storage of Human Milk Temperature Duration Comments Location Containers should be covered and kept as cool as Room temperature 6-8 hours Countertop, table (up to 77°F or 25°C) possible; covering the container with a cool towel may keep milk cooler. Insulated cooler bag 5°F – 39°F or 24 hours Keep ice packs in contact with milk containers at all times, limit opening cooler bag. -15°C – 4°C 39°F or 4°C 5 days Store milk in the back of the main body of the refrigerator. Refrigerator 2 weeks Store milk toward the back of the freezer, where 5°F or -15°C Freezer compartment of a refrigerator temperature is most constant. Milk stored for longer 3-6 months 0°F or -18°C Freezer compartment of refrigerator durations in the ranges listed is safe, but some of the with separate doors lipids in the milk undergo degradation resulting in 6-12 months Chest or upright deep freezer -4°F or -20°C lower quality. Source: Academy of Breastfeeding Medicine Protocol Committee. 2010. Clinical protocol #8: Human milk storage information for home use for healthy full term infants, revised. Breastfeeding Med 5:127-30. http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf. From the Centers for Disease Control and Prevention Website: Proper handling and storage of human milk – Storage duration of fresh human milk for use with healthy full term infants. http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm. for both staff and parents/guardians should be available to 4 . 3.1. 8 Techniques for Bottle Feeding determine when milk provided by parents/guardians will 4 . 3.1. 9 Warming Bottles and Infant Foods not be served. Human milk cannot be served if it does not Plastic Containers and Toys 5.2.9.9 meet the requirements for sanitary and safe milk. References Although human milk is a body fluid, it is not necessary to 1. Harley, K.G., Gunier, R.B., Kogut, K., Johnson, C., et al. 2013. Prenatal and wear gloves when feeding or handling human milk. Unless early childhood bisphenol a concentrations and behavior in school-aged . 126: 43-50. children. Environ Res there is visible blood in the milk, the risk of exposure to United States Cooperative Expansion System. 2015. Guidelines for child care 2. infectious organisms either during feeding or from milk providers to prepare and feed bottles to infants. 2015. http://articles. that the infant regurgitates is not significant. extension.org/pages/25404/guidelines-for-child-care-providers-to-prepare- and-feed-bottles-to-infants. Returning unused human milk to the mother informs 3. Centers for Disease Control and Prevention. 2016. Proper handling and storage of human milk. Atlanta, GA. https://www.cdc.gov/breastfeeding/ her of the quantity taken while in the early care and recommendations/handling_breastmilk.htm. education program. 4. La Leche League International. (2014). Storage guidelines: LLLI guidelines for storing breastmilk. http://www.llli.org/faq/milkstorage.html. Excessive shaking of human milk may damage some of 5. Boué, G., Cummins, E., Guillou, S., Antignac, J., Bizec, B., & Membré, J. the cellular components that are valuable to the infant. It 2016. Public health risks and benefits associated with breast milk and infant is difficult to maintain 0°F consistently in a freezer com- Critical Reviews in Food Science and Nutrition . Feb formula consumption. 6:1-20. partment of a refrigerator or freezer, so caregivers/teachers Binns, C. 2016. The long-term public health benefits of breastfeeding. 6. should carefully monitor, with daily log sheets, temperature . 2 8 (1):7. Asia-Pacific Journal of Public Health of freezers used to store human milk using an appropriate NOTES working thermometer. Human milk contains components Content in the STANDARD was modified on 8/23/2016. - that are damaged by excessive heating during or after thaw ing from the frozen state (4). Currently, there is nothing in the research literature that states that feedings must be 4 . 3 .1. 4 warmed at all prior to feeding. Frozen milk should never Feeding Human Milk to Another be thawed in a microwave oven as 1) uneven hot spots in Mother’s Child the milk may cause burns in the infant and 2) excessive Because parents/guardians may express concern about the heat may destroy beneficial components of the milk. likelihood of transmitting diseases through human milk, By following safe preparation and storage techniques, this issue is addressed in detail to assure there is a very nursing mothers and caregivers/teachers of breastfed small risk of such transmission occurring. infants and children can maintain the high quality of If a child has been mistakenly fed another child’s bottle of expressed human milk and the health of the infant (5,6). expressed human milk, the possible exposure to infectious TYPE OF FACILITY diseases should be treated just as if an unintentional expo - Center, Large Family Child Care Home sure to other body fluids had occurred. RELATED STANDARDS The early care and education program should (1): 4 . 3.1.1 General Plan for Feeding Infants a. Inform the mother who expressed the human milk 4 . 3.1. 4 Feeding Human Milk to Another Mother’s Child about the mistake and when the bottle switch occurred, and ask: 4 . 3.1.7 Feeding Cow’s Milk

205 178 Caring for Our Children: National Health and Safety Performance Standards 1. When the human milk was expressed and how it was References 1. U.S. Centers for Disease Control and Prevention. 2016. What to do if an handled prior to being delivered to the caregiver/ infant or child is mistakenly fed another woman’s expressed breast milk. teacher or facility; http://www.cdc.gov/breastfeeding/recommendations/ Whether the mother has ever had a Human 2. other_mothers_milk.htm. 2. U.S. Centers for Disease Control and Prevention. 2016. Hepatitis B FAQs Immunodeficiency Virus (HIV) blood test and, if so, for the public. https://www.cdc.gov/hepatitis/hbv/bfaq.htm#bFAQ13. the date of the test and would she be willing to share 3. U.S. Centers for Disease Control and Prevention. 2016. Hepatitis C FAQs the results with the parents/guardians of the child for the public. https://www.cdc.gov/hepatitis/hcv/cfaq.htm#cFAQ37. 4. Kimberlin, D.W., Brady, M.T., Jackson, M.A., Long, S.S., eds. 2015. who was fed her child’s milk; 30th Ed. Red Book: 2015 Report of the Committee on Infectious Diseases. 3. If she does not know whether she has ever been Elk Grove Village, IL: American Academy of Pediatrics. tested for HIV, ask her if would she be willing to NOTES contact her primary health care provider and find Content in the STANDARD was modified on 8/24/2017. out if she has been tested; and 4. If she has never been tested for HIV, would she be willing to be tested and share the results with the 4 . 3 .1. 5 parents/guardians of the other child. Preparing, Feeding, and Storing Infant Formula b. Discuss the mistake with the parents/guardians of the Formula provided by parents/guardians or by the facility child who was fed the wrong bottle: should come in a factory-sealed container. The formula 1. Inform them that their child was given another should be of the same brand that is served at home and child’s bottle of expressed human milk and the date should be of ready-to-feed strength or liquid concentrate it was given; to be diluted using cold water from a source approved by Inform them that the risk of transmission of HIV 2. the health department. Powdered infant formula, though it is low; is the least expensive formula, requires special handling in 3. Encourage the parents/guardians to notify the mixing because it cannot be sterilized. The primary source child’s primary health care provider of the potential for proper and safe handling and mixing is the manufac- exposure; and turer’s instructions that appear on the can of powdered 4. Provide the family with information including the formula. Before opening the can, hands should be washed. time at which the milk was expressed and how the The can and plastic lid should be thoroughly rinsed and milk was handled prior to its being delivered to the - dried. Caregivers/teachers should read and follow the manu caregiver/teacher so that the parents/guardians may facturer’s directions. Caregivers/teachers should only use the inform the child’s primary health care provider. scoop that comes with the can and not interchange the scoop Assess why the wrong milk was given and develop a c. from one product to another, since the volume of the scoop prevention plan to be shared with the parents/guardians may vary from manufacturer to manufacturer and product as well as the staff in the facility. - to product. Also, a scoop can be contaminated with a poten tial allergen from another type of formula. If instructions are RATIONALE - not readily available, caregivers/teachers should obtain infor Hepatitis B and C are not spread through breastfeeding mation from their local WIC program or the World Health (2,3). Organization’s Safe Preparation, Storage and Handling of The risk of HIV transmission from expressed human Powdered Infant Formula Guidelines at: http://www.who.int/ milk consumed by another child is believed to be foodsafety/publications/micro/pif_guidelines.pdf (1). low because: Formula mixed with cereal, fruit juice, or any other foods Transmission of HIV from a single human milk a. should not be served unless the child’s primary care provider exposure has never been documented (1); provides written documentation that the child has a medical Chemicals present in human milk stored in cold b. reason for this type of feeding. temperatures, act to destroy the HIV present in Iron-fortified formula should be refrigerated until immedi - expressed human milk; and ately before feeding. For bottles containing formula, any In the United States, women who know they are HIV- c. contents remaining after a feeding should be discarded. positive are advised NOT to breastfeed their infants and to refrain from breastfeeding if they are hepatitis C- Bottles of formula prepared from powder or concentrate positive or have cracked or bleeding nipples. [However, or ready-to-feed formula should be labeled with the child’s the transmission of hepatitis C by breastfeeding has not full name and time and date of preparation. Any prepared been documented (4). formula must be discarded within one hour after serving to an infant. Prepared powdered formula that has not been TYPE OF FACILITY given to an infant should be covered, labeled with date and Center, Large Family Child Care Home time of preparation and child’s full name, and may be stored RELATED STANDARD in the refrigerator for up to twenty-four hours. An open Preparing, Feeding, and Storing Human Milk 4.3.1.3 container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, labeled with date of opening

206 179 Chapter 4: Nutrition and Food Service and child’s full name, and discarded at forty-eight hours Diluted formula may interfere with an infant’s growth and health because it provides inadequate calories and nutrients if not used (2). The caregiver/teacher should always follow and can cause water intoxication. Water intoxication can manufacturer’s instructions for mixing and storing of occur in breastfed or formula-fed infants or children over any formula preparation. Some infants will require spe- one year of age who are fed an excessive amount of water. cialized formula because of allergy, inability to digest Water intoxication can be life-threatening to an infant or certain formulas, or need for extra calories. The appro- young child (6).If a child has a special health problem, such priate formula should always be available and should be as reflux, or inability to take in nutrients because of delayed fed as directed. For those infants getting supplemental development of feeding skills, the child’s primary care pro- calories, the formula may be prepared in a different way vider should provide a written plan for the staff to follow so - from the directions on the container. In those circum stances, either the family should provide the prepared that the child is fed appropriately. Some infants are allergic formula or the caregiver/teacher should receive special to milk and soy and need to be fed an elemental formula training, as noted in the infant’s care plan, on how to which does not contain allergens. Other infants need prepare the formula. Formula should not be used supplemental calories because of poor weight gain. beyond the stated shelf life period (3). Infants should not be fed a formula different from the one the parents/guardians feed at home, as even minor differ - Parents/guardians should supply enough clean and steril - ences in formula can cause gastrointestinal upsets and ized bottles to be used throughout the day. The bottles must other problems (7). be sanitary, properly prepared and stored, and must be the same brand in the early care and